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Background: Women with gestational diabetes mellitus (GDM) and gestational glucose intolerance (GGI, abnormal initial GDM screening test) and their infants have an increased risk of adverse perinatal outcomes including large for gestational age birth weight (LGA), pregnancy-related hypertension, neonatal intensive care unit (NICU) admission, and cesarean delivery. We expanded a prior analysis defining physiologic subtypes of GGI categorized by insulin resistance, insulin deficiency, or mixed pathophysiology. We aimed to determine if GGI subtypes are at differential risk for adverse outcomes. Methods: We applied homeostasis model assessment (HOMA2) to fasting glucose and insulin levels at 16–20 weeks’ gestation to assess insulin resistance and deficiency, defined using the 50th percentile in 220 women with a normal glucose loading test (GLT) at 24–30 weeks’ gestation. We defined GGI as GLT 1-hr glucose ≥140 mg/dL (n=245) and normal glucose tolerance (NGT) as GLT 1-hr glucose <140 mg/dL (n=1538). We classified women with GGI into subtypes according to the presence of insulin resistance and/or deficiency. We compared odds of adverse outcomes in each subtype to odds in women with NGT using logistic regression with adjustment for age, race/ethnicity, marital status, and 1st trimester BMI, plus infant sex in LGA models. Results: Of women with GGI, 49.0% had the insulin resistant subtype (IR, n=120), 30.6% had the insulin deficient subtype (ID, n=75), 15.9% had mixed pathophysiology (MP, n=39), and 4.5% had no evidence of IR or ID (n=11). GLT results and GDM diagnosis were similar among GGI subtypes. We found increased odds of LGA (primary outcome) in women with IR compared to women with NGT (OR 1.97 [1.17–3.32], p=0.01) in an unadjusted model; this was attenuated in an adjusted model with BMI (adjusted OR 1.43 [0.82–2.49], p=0.21). There was a trend toward increased odds of LGA in women with ID (adjusted OR 1.87 [0.92–3.80], p=0.09) and no increased odds in women with MP (adjusted OR 1.33 [0.50–3.57], p=0.57) compared to NGT. The odds of pregnancy-related hypertension in the IR subtype were increased (adjusted OR 1.68 [1.02–2.77], p=0.04) compared to women with NGT; women with ID (adjusted OR 0.91 [0.44–1.88], p=0.79) or MP (adjusted OR 1.13 [0.48–2.67], p=0.78) did not have increased odds. Neither infants of women with IR nor ID had increased odds of NICU admission overall, yet among women with BMI <25, infants of those with IR had increased odds of NICU admission compared to those of women with NGT (adjusted OR 3.37 [1.04–10.96], p=0.02); odds of NICU admission were not increased in infants of women with ID and BMI <25 (adjusted OR 0.50 [0.07–3.83], p=0.50). There was no difference in cesarean delivery across subtypes. Conclusion: Insulin resistant GGI is a high-risk subtype for adverse perinatal outcomes. Using HOMA2 to delineate subtypes may provide opportunities for a personalized approach to GGI/GDM.

Anticoagulation for stroke prevention in atrial fibrillation (AF) is effective. Pivotal trials RE-LY, ROCKET AF, ARISTOTLE, and ENGAGE-AF TIMI 48 tested novel agents against warfarin (W). In RE-LY, an open-label trial, dabigatran 150 mg BID (D150) was superior (35%) and 110 mg BID (D110) was noninferior to W. D150 reduced ischemic strokes by 25% and intracerebral bleeds by 74%, but increased major GI bleeds by 0.5 % per year. In ROCKET AF, a double-blind study, rivaroxaban 20 mg daily, downtitrated to 15 mg daily (if CrCl was <49) was noninferior for efficacy and safety, with an increase in GI bleeds. In ARISTOTLE, a double-blind study, apixaban 5 mg BID (downtitrated to 2.5 mg BID if two of the following were present: age, >80; weight, <60 kg; or serum creatinine, >1.5 mg) was superior for safety (31%), efficacy (21%), and all-cause mortality (11%). In ENGAGE-AF TIMI 48, edoxaban 60 mg once daily (30 mg once daily if CrCl 30-50 ml/min, weight <60 kg, or concomitant verapamil or quinidine) was noninferior to W for efficacy, but reduced major bleeding (20%). To translate clinical trials to practice, understanding the disease and each anticoagulant is essential. For all novel agents, rapid anticoagulation, absence of monitoring, and a short half-life differentiate them from W. Bleed rates were either noninferior or lower than for W, without an antidote. Patient compliance is critical. Knowledge of renal function is essential and maintaining patients on therapy is key.

Objective To evaluate maternal and neonatal outcomes following management of preterm premature rupture of membranes (PPROM) by two fetal assessment strategies. Methods In a retrospective cohort study performed at two hospitals in Philadelphia, Pennsylvania between July 2010 and June 2015, data were reviewed from 180 singleton pregnancies with PPROM at 230–336 weeks of gestation that underwent expectant management. Outcomes were compared between continuous electronic fetal heart monitoring (EFM) with daily biophysical profile (BPP) (“continuous monitoring”) and non‐stress test (NST) three times per day (“periodic monitoring”) using Mann‐Whitney U and Fisher exact tests. Results Overall, 119 (66.1%) pregnancies were assessed by continuous monitoring and 61 (33.9%) by periodic monitoring. There was no difference in frequency of intrauterine death between the continuous monitoring (1, 0.8%) and periodic monitoring (3, 4.9%) groups (OR, 0.16; 95% CI, 0.02–1.61). The continuous monitoring group was more likely to have an interventional (OR, 2.17; 95% CI, 1.06–4.44) or cesarean (OR 3.30, 95% CI 1.70–6.38) delivery. Conclusion Continuous EFM with daily BPP was associated with higher rates of intervention and cesarean delivery compared with periodic NST, but there was no difference in intrauterine or perinatal mortality.