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Obstetrical brachial plexus palsy (OBP) complicates a small proportion of births. The incidence is believed to be 0.35 to 5 cases per 1000 live births. Risk factors of OBP included: 1/ large birth weight, 2/ shoulder dystocia and prolonged second stage of labour , 3/ instrumental vaginal delivery (forceps delivery, vacuum extraction), 4/ diabetes mellitus and mother's obesity, 5/ breech presentation, 6/ delivery an infant with OBP in an antecedent delivery. Historically, the cause of OBP was excessive lateral traction applied to the fetal head at delivery, in association with anterior shoulder dystocia. Not all cases of brachial plexus palsy are attributable to traction. Brachial plexus injury may be occurring in the absence of shoulder dystocia, in the posterior arm of infants with anterior shoulder dystocia and can be associated with cesarean delivery. Intrauterine factors may play some role in the etiology of the OBP. Many strategies have been proposed to prevent the occurrence of OBP--control of the birth weight, induction of labour, cesarean delivery, intensified management of gestational diabetes. About 10-20% of patients with injuries of the brachial plexus require surgical intervention for optimal results.
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PMID:[Obstetrical brachial plexus palsy--etiopathogenesis, risk factors, prevention, prognosis]. 1558 15

Shoulder dystocia and brachial plexus injury occur in 0.5% to 1.5% of all births. Risk factors for both include maternal obesity, excessive prenatal weight gain, maternal diabetes, protracted labor, and fetal macrosomia. These factors are involved in only about 50% of births complicated by shoulder dystocia or brachial plexus injury. Shoulder dystocia has a low recurrence rate (9.8%-16.7%), although history of previous shoulder dystocia is the most reliable predictor of occurrence. Brachial plexus injury is the most common morbidity associated with shoulder dystocia, but 50% of newborns who present with this injury were not subject to shoulder dystocia at birth. Most brachial plexus injuries are transient, although 5% to 22% become permanent. Shoulder dystocia followed by permanent brachial plexus injury or mental impairment is one of the leading causes of malpractice allegations. Prompt assessment and management of shoulder dystocia and preparation to maximize the efficiency of shoulder dystocia maneuvers are critical. Documentation of the appropriate use of maneuvers to relieve shoulder dystocia demonstrates standard of care practice, thereby decreasing the potential for successful malpractice allegations.
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PMID:Shoulder dystocia: etiology, common risk factors, and management. 1626 Mar 63

Fetal macrosomia (birth weight >/=4,500 g) is known to increase a number of adverse maternal and perinatal outcomes. Although there is a clear association between maternal diabetes mellitus and fetal macrosomia, the majority of macrosomic infants are born to non-diabetic mothers. We wished to determine the recurrence rate of macrosomia in non-diabetic pregnancy and to see if a history of multiple prior macrosomic infants confers additional risk. A retrospective analysis of 14,461 term, singleton, infants born to non-diabetic mothers in 1997 and 1998 was performed, using a computerised hospital database. Among 14,461 term pregnancies, 529 infants (3.7%) were macrosomic, and the incidence was significantly higher in parous women (4.6%) compared with nulliparas (2.4%, p < 0.0001). Over the next 5 years, 164 of these women returned for another delivery. Women with a history of one macrosomic infant are at significantly increased risk of another macrosomic infant in a subsequent pregnancy (OR 15.8, 95% CI 11.45 - 21.91, p < 0.0001). For women with two or more macrosomic infants, the risk is even greater (OR 47.4, 95% CI 19.9 - 112.89, p < 0.0001). Macrosomia was associated with increased rates of instrumental delivery and anal sphincter injury regardless of parity, and additionally with increased rates of caesarean delivery and shoulder dystocia among nulliparas. Overall, 88% of women who laboured with a macrosomic infant achieved vaginal delivery.
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PMID:Recurrence of fetal macrosomia in non-diabetic pregnancies. 1765 89

Shoulder dystocia has no consensus definition or management algorithm. Its incidence ranges from 0.2% to 3% and its occurrence is unpredictable. Risk factors for shoulder dystocia may include macrosomia, maternal diabetes, operative vaginal delivery, history of macrosomic infant or shoulder dystocia, labor abnormalities, post-term pregnancy, maternal obesity, advanced maternal age, fetal anthropometric variations, and male fetal gender. Once identified, multiple maneuvers can be applied in a stepwise fashion in an attempt to alleviate the dystocia. While training clinicians to manage shoulder dystocia is difficult because of its rare occurrence and lack of standardized management, all clinicians must be able to manage shoulder dystocia at any time.
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PMID:Shoulder dystocia: an update. 1792 Oct 12

Shoulder dystocia is a birth emergency that occurs in approximately 1% of all births. Shoulder dystocia can be followed by broken clavicle or humerus, brachial plexus injury, fetal hypoxia, or death. Although risk factors for shoulder dystocia include previous birth complicated by shoulder dystocia, maternal obesity, excessive prenatal weight gain, fetal macrosomia, gestational diabetes, and instrumental delivery, shoulder dystocia is not predictable. Perinatal nurses can reduce the risk for shoulder dystocia by teaching mothers about optimal weight gain in pregnancy and assisting mothers with diabetes to prevent hyperglycemia through diet management and medication use. During childbirth preparation or early labor, nurses can educate mothers about position changes and maneuvers used for shoulder dystocia. Nurses play a vital role in obtaining assistance during a shoulder dystocia, keeping time, assisting with maneuvers such as suprapubic pressure, and documenting the dystocia management. Nurses can assist mothers and families to review the shoulder dystocia and any newborn injuries in the postpartum period, thereby reducing confusion and anxiety. Regular drills and case reviews help build nursing shoulder dystocia management skills.
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PMID:Shoulder dystocia: nursing prevention and posttrauma care. 1828 97

The significant threshold values for the 75-g oral glucose tolerance test (oGTT) during pregnancy have yet to be conclusively determined. This study aimed to identify the risk significance of various set thresholds for the oGTT result. Women undergoing a 75-g oGTT during the third trimester of pregnancy were classified into three groups: mild gestational impaired glucose tolerance (GIGT; 2-h postload glucose, 8.0-8.5 mmol/l; n=75), moderate-severe GIGT (8.6-10.9 mmol/l; n=167), and GDM (> or =11.0 mmol/l; n=76). Outcome indicators of these three groups of women were compared to the parameters of the women with a presumed normal carbohydrate metabolism (n=12,185). The results show that with increasing oGTT thresholds, there was an increasing risk of maternal morbidity in the form of hypertensive disorders complicating pregnancy, as well as obstetric intervention such as induction of labor, cesarean delivery, and preterm delivery. The infant was also at increasing risk with increasing oGTT thresholds from respiratory distress, macrosomia, and associated shoulder dystocia. It would appear, therefore, that abnormal glucose tolerance in pregnancy, even as defined by the World Health Organization criteria, has proportionate risks to both mother and child.
J Diabetes Complications
PMID:Significant thresholds for the 75-g oral glucose tolerance test in pregnancy. 1841 21

Obesity is a global health problem that is increasing in prevalence. The World Health Organization characterizes obesity as a pandemic issue, with a higher prevalence in females than males. Thus, many pregnant patients are seen with high body mass index (BMI). Obesity during pregnancy is considered a high-risk state because it is associated with many complications. Compared with normal-weight patients, obese patients have a higher prevalence of infertility. Once they conceive, they have higher rate of early miscarriage and congenital anomalies, including neural tube defects. Besides the coexistence of preexisting diabetes mellitus and chronic hypertension, obese women are more likely to have pregnancy-induced hypertension, gestational diabetes, thromboembolism, macrosomia, and spontaneous intrauterine demises in the latter half of pregnancy. Obese women also require instrument or Cesarean section delivery more often than average-weight women. Following Cesarean section delivery, obese women have a higher incidence of wound infection and disruption. Irrespective of the delivery mode, children born to obese mothers have a higher incidence of macrosomia and associated shoulder dystocia, which can be highly unpredictable. In addition to being large at birth, children born to obese mothers are also more susceptible to obesity in adolescence and adulthood. Prevention is the best way to prevent this problem. As pregnancy is the worst time to lose weight, women with a high BMI should be encouraged to lose weight prior to conceiving. During preconception counseling, they should be educated about the complications associated with high a BMI. Obese women should also be screened for hypertension and diabetes mellitus. In early pregnancy, besides being watchful about the higher association of miscarriage, obese women should be screened with ultrasound for congenital anomalies around 18 to 22 weeks. The ultrasound should be repeated close to term to check on the estimated fetal weight to rule out macrosomia. Obese pregnant women are screened for gestational diabetes around 24 to 28 weeks. During the second half of pregnancy, one needs to closely watch for signs and symptoms of pregnancy-induced hypertension. Once in labor, an early anesthesia consultation is highly recommended irrespective of delivery mode. When Cesarean section is performed, many obstetricians prefer an incision above the pannus to avoid skin infection. However, the incision should be decided upon the discretion of the surgeon. Peripartum, special attention is given to avoid thromboembolism by using compression stockings and early ambulation.
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PMID:Maternal obesity and pregnancy. 1882 17

The prevalence of both obesity and gestational diabetes mellitus (GDM) is rising worldwide. The complications of diabetes affecting the mother and fetus are well known. Maternal complications include preterm labor, pre-eclampsia, nephropathy, birth trauma, cesarean section, and postoperative wound complications, among others. Fetal complications include fetal wastage from early pregnancy loss or congenital anomalies, macrosomia, shoulder dystocia, stillbirth, growth restriction, and hypoglycemia, among others. The presence of obesity among diabetic patients compounds these complications. The above-mentioned short-term complications can be mediated by achieving the desired level of glycemic control during pregnancy. However, GDM during pregnancy is associated with increased risk of early obesity, type 2 diabetes during adolescence and the development of metabolic syndrome in early childhood. Additionally, GDM is a marker for the development of overt type 2 diabetes and metabolic syndrome for the mother in the early future.
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PMID:Obesity, gestational diabetes and pregnancy outcome. 1892 84

We compared perinatal outcomes in pregnancies in which insulin glargine was used in the management of patients with pregnancies in which standard insulin therapy was used at a single institution. A retrospective analysis of 114 pregnant patients with diabetes (pregestational or gestational) managed at a single center between January 2004 and August 2006 was undertaken. Sixty-five patients managed with insulin glargine were compared with 49 patients managed with neutral protamine Hagedorn (NPH) insulin. Both groups were also treated with short-acting insulin (either regular, lispro, or aspart insulin). Maternal age, parity, prepregnancy weight, body mass index, duration of diabetes, hemoglobin A (1C) (at entry and final recorded) and gestational age at entry were similar for each group (glargine and NPH). Thirty patients had gestational diabetes (18 glargine and 12 NPH); there were no differences in numbers of patients in higher-order White's classification between the two groups. Cesarean section for obstetric reasons included labor abnormalities, malpresentation, fetal distress, and suspected macrosomia. There were no differences in gestational age at delivery, birth weight, preeclampsia, or frequency of cesarean section (total or for obstetric reasons). The frequency of shoulder dystocia was higher in the NPH group. Regarding neonatal outcomes, gestational age at delivery, birth weight, Apgar scores, admission to the neonatal intensive care unit, respiratory distress syndrome, hypoglycemia, and congenital anomalies were similar between the two groups. From this retrospective analysis, no adverse maternal or neonatal effects were seen from maternal administration of insulin glargine. A larger multicenter study is needed to confirm these findings. This preliminary report suggests that use of insulin glargine during pregnancy can be considered if maternal metabolic control is suboptimal using the standard split-mix regimen.
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PMID:Perinatal outcomes in pregnancies managed with antenatal insulin glargine. 1937 May 12

Gestational diabetes occurs in 5 to 9 percent of pregnancies in the United States and is growing in prevalence. It is a controversial entity, with conflicting guidelines and treatment protocols. Recent studies show that diagnosis and management of this disorder have beneficial effects on maternal and neonatal outcomes, including reduced rates of shoulder dystocia, fractures, nerve palsies, and neonatal hypoglycemia. Diagnosis is made using a sequential model of universal screening with a 50-g one-hour glucose challenge test, followed by a diagnostic 100-g three-hour oral glucose tolerance test for women with a positive screening test. Treatment consists of glucose monitoring, dietary modification, exercise, and, when necessary, pharmacotherapy to maintain euglycemia. Insulin therapy is the mainstay of treatment, although glyburide and metformin may become more widely used. In women receiving pharmacotherapy, antenatal testing with nonstress tests and amniotic fluid indices beginning in the third trimester is generally used to monitor fetal well-being. The method and timing of delivery are controversial. Women with gestational diabetes are at high risk of subsequent development of type 2 diabetes. Lifestyle modification should therefore be encouraged, along with regular screening for diabetes.
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PMID:Diagnosis and management of gestational diabetes mellitus. 1962 46


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