OBJECTIVEThe Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study found strong associations between higher levels of maternal glucose at 24–32 weeks, within what is currently considered normoglycemia and adverse pregnancy outcomes. Our aim was to evaluate the associations between first-trimester fasting plasma glucose level and adverse pregnancy outcomes.RESEARCH DESIGN AND METHODSCharts of all patients who delivered at our hospital between June 2001 and June 2006 were reviewed. Only subjects with singleton pregnancy and a recorded first-trimester fasting glucose level were included. Women with pregestational diabetes, fasting glucose level >105 mg/dl, or delivery <24 weeks were excluded. Fasting glucose levels were analyzed in seven categories, similar to the HAPO study. The main outcomes were development of gestational diabetes mellitus (GDM), large-for-gestational-age (LGA) neonates and/or macrosomia, and primary cesarean section. Multivariate logistic regression analysis was used; significance was <0.05.RESULTSA total of 6,129 women had a fasting glucose test at median of 9.5 weeks. There were strong, graded associations between fasting glucose level and primary outcomes. The frequency of GDM development increased from 1.0% in the lowest glucose category to 11.7% in the highest (adjusted odds ratio 11.92 [95% CI 5.39–26.37]). The frequency of LGA neonates and/or macrosomia increased from 7.9 to 19.4% (2.82 [1.67–4.76]). Primary cesarean section rate increased from 12.7 to 20.0% (1.94 [1.11–3.41]).CONCLUSIONSHigher first-trimester fasting glucose levels, within what is currently considered a nondiabetic range, increase the risk of adverse pregnancy outcomes. Early detection and treatment of women at high risk for these complications might improve pregnancy outcome.

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Objective  To investigate the factors associated with caesarean delivery and the relationship between mode of delivery and mortality in singleton vertex‐presenting very low birthweight (≤1500 g) live born infants. Design  Observational population‐based study. Setting  Data collected from all 28 neonatal departments comprise the Israel National Very Low Birth Weight Infant Database. Population  2955 singleton vertex‐presenting very low birthweight infants registered in the database from 1995 to 2000, and born at 24–34 weeks of gestation. Methods  The demographic, obstetric and perinatal factors associated with caesarean delivery and subsequent mortality were studied. The independent effect of the mode of delivery on mortality was tested by multiple logistic regression. Main outcome measure  Mortality was defined as death prior to discharge. Results  Caesarean delivery rate was 51.7%. Caesarean delivery was directly associated with increasing maternal age and gestational age, small for gestational age infants, maternal hypertensive disorders and antepartum haemorrhage, and was inversely related to premature labour and prolonged rupture of membranes. Factors associated with increased survival were increasing gestational age, antenatal corticosteroid therapy, maternal hypertensive disorders and no amnionitis. Mortality rate prior to discharge was lower after caesarean delivery (13.2%vs 21.8%), but in the multivariate analysis, adjusting for the other risk factors associated with mortality, delivery mode had no effect on infant survival (OR 1.00, 95% CI 0.74–1.33). In a subgroup with amnionitis, a protective effect of caesarean delivery was found. Conclusions  Caesarean delivery did not enhance survival of vertex‐presenting singleton very low birthweight babies. Caesarean delivery cannot be routinely recommended, unless there are other obstetric indications.

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Our aim was to investigate the risk factors associated with severe perineal tears defined as either third- or forth-degree tears and, ultimately, find strategies for prevention. We carried a retrospective analysis of a computerized perinatal database, collected prospectively, from a single county hospital between January 1, 1993 and June 30, 1998. Singleton vaginal vertex deliveries were analyzed for potential risk factors using univariate and multiple logistic regression analysis including all two-way interactions. Severe perineal tear occurred in 1905 (8.2%) of 23,244 vaginal deliveries. In the multiple logistic regression analysis, the following factors carried a significantly higher risk for severe laceration: midline episiotomy, primary vaginal delivery, use of pudendal block, forceps deliveries, and birth weight more than 4000 g. The study of interactions demonstrated that mediolateral episiotomy was associated with an increased risk for severe tear only during the first vaginal delivery, but not during a repeat vaginal delivery. Our data suggest that primary vaginal delivery, fetal weight above 4000 g, and the use of pudendal analgesia can help identify in advance patients at highest risk for severe perineal tear. During the delivery of these patients usage of vacuum (instead of forceps) and restricting the use of midline episiotomy might reduce the incidence of severe perineal tear. In cases where episiotomy seems crucial, the use of a mediolateral episiotomy may reduce the likelihood of severe perineal tear.