scholarly journals The effects of cervical cerclage practice on perinatal and neonatal outcomes according to the indications

2020 ◽  
Vol 28 (3) ◽  
pp. 164-169
Author(s):  
Serdar Kaya ◽  
Fatma Ceren Güner ◽  
Mehmet Şimşek ◽  
Selahattin Kumru
Keyword(s):  
Preterm Labor ◽  
Previous History ◽  
Cervical Length ◽  
Neonatal Outcomes ◽  
Cervical Insufficiency ◽  
Singleton Pregnancy ◽  
Cervical Cerclage ◽  
Significant Difference ◽  
Prophylactic Cerclage ◽  
The Mean

Objective: The aim was to investigate the perinatal and neonatal outcomes in the cases which underwent cervical cerclage, and to compare the elective and emergency cerclage cases. Methods: The cases that underwent cervical cerclage in the Hospital of the Faculty of Medicine at Akdeniz University between January 2014 and December 2019 were assessed retrospectively, and separated into 3 categories as the prophylactic, elective and emergency groups. The demographic characteristics and perinatal and neonatal outcomes were recorded and they were compared between the groups. Results: A total of 92 cases with singleton pregnancy between 12 and 24 weeks of gestation were included in the study. The prophylactic cerclage group consisted of 48 cases, the elective cerclage group consisted of 21 cases and the emergency cerclage group consisted of 23 cases. The rate of the cases delivered at term (≥37 weeks of gestation) was found significantly lower in the emergency cerclage group than the rates of the cases in the prophylactic and elective cerclage groups (26.1%, 70.8% and 66.7%; respectively). While there was no significant difference between the prophylactic and elective cerclage groups in terms of premature preterm labor (<32 weeks of gestation), the rate of premature preterm labor was significantly higher in the emergency cerclage group than two other groups (10.4%, 9.5% and 43.5%, respectively; p=0.005). The mean delivery week of the emergency cerclage cases was significantly higher than the prophylactic and elective cerclage groups (31.7, 36.7 and 36.5 weeks, respectively; p<0.001). The mean duration between the cerclage procedure and the delivery week was the highest in the prophylactic cerclage cases and the lowest in the emergency cerclage cases (22.8 and 9.7 weeks, respectively; p<0.001). The mortality rate of the newborns was higher in the emergency cerclage cases than the other groups, which was statistically significant (p=0.002). Conclusion: We concluded that the perinatal and neonatal outcomes of the emergency cerclage procedure carried out in the advanced stage of cervical changes in the cases with cervical insufficiency is less successful than the prophylactic and elective cerclage procedures. The early detection of cervical insufficiency by the previous history, the physical examination and the measurement of transvaginal cervical length and responding at the early weeks of gestation may improve the perinatal and neonatal outcomes.

scholarly journals Evaluation of uterine cervix with transvaginal ultrasonography in women with threatened preterm labor and or preterm labor

2018 ◽  
Vol 7 (2) ◽  
pp. 704 ◽  
Author(s):  
Akila Shree ◽  
Chitra A. K.
Keyword(s):  
Positive Predictive Value ◽  
Negative Predictive Value ◽  
Preterm Delivery ◽  
Predictive Value ◽  
Preterm Labor ◽  
Cervical Length ◽  
Transvaginal Ultrasonography ◽  
Singleton Pregnancy ◽  
Significant Difference ◽  
A Prospective Study

Background: Preterm delivery can be associated with substantial perinatal morbidity and mortality. Nearly in 5 to 13% of pregnancies, happening deliveries are preterm before 37 weeks' gestation. Thus, prediction of preterm labor in parturient can provide a window of opportunity to prevent these complications and to be better prepared to deal with them. Hence the current study has been conducted with an objective to assess the efficiency of cervical length and funneling as assessed by transvaginal ultrasonography in predicting preterm labor.Methods: The current study was a prospective study, conducted in the Department of Obstetrics Emergencies, Dhanalakshmi Srinivasan Medical College and Hospital between November 2015 to April 2017. The study population included 60 women with singleton pregnancy of gestational age between 28 + 0 and 36 + 6 weeks and with painful and regular contractions (>1/10 min for at least 1 hour). Cervical length, funnelling length measured at presentation and after 48 hours were considered as predictor variables. The outcomes of interest were delivery within 1 week, delivery before 37 weeks and delivery before 34 weeks.Results: There was a statistically significant difference in cervical length and funnelling length between term and preterm groups at the time of diagnosis and after 48 hours (P <0.001). The positive predictive value increased from 33.3% to 100% with cervical length ≤ 40 mm to ≤ 20 mm. The negative predictive value decreased from 100% to 79.2% with cervical length ≤40 mm to ≤20 mm. To predict a preterm delivery in threatened preterm delivery patients, the sensitivity of a cervical length of ≤25 mm was 77.7%, specificity was 95.2%, the positive predictive value was 87.5% and negative predictive value is 90.9%.Conclusions: Cervical length and funnelling as assessed by transvaginal ultrasonography are efficient in predicting preterm labor.

scholarly journals Cervical Insufficiency and Cerclage Treatment of Pregnant Syrian Refugees

2021 ◽  
Vol 3 (2) ◽  
pp. 15-19
Author(s):  
İlkan Kayar ◽  
Aliye Nigar Serin ◽  
Özer Birge
Keyword(s):  
Cervical Length ◽  
Transvaginal Sonography ◽  
Cervical Insufficiency ◽  
Syrian Refugees ◽  
Cervical Cerclage ◽  
Healthy Pregnancy ◽  
Significant Difference ◽  
Term Delivery ◽  
Pregnancy And Delivery ◽  
Second Trimester Pregnancy

Objective: We aimed to evaluate the cervical cerclage treatment among the Syrian refugees with cervical insufficiency. Material and Methods: Retrospective data of 42 Syrian pregnant women who had cervical cerclage suture due to cervical insufficiency between 2015 and 2017 scanned and analyzed with SPSS 22. Results: The mean age of the cases included in the study was 27.4±6.8. 12 cases (28.6%) had spontaneous pregnancy losses twice in the 2nd trimester. 24 cases (57.1%) gave birth via spontaneous vaginal delivery, whereas 18 cases (42.9%) gave birth via cesarean section. A statistically significant difference was determined between pre-cerclage and post-cerclage cervical length. Whilst no difference was detected in pre-cerclage cervical length for deliveries at week 37, a significant difference was detected in post-cerclage length. Conclusıon: Increased miscarriages and second-trimester pregnancy losses seen in the first years of the war especially due to the use of chemical weapons and the stress suffered thereafter as well as the increased reproductive interest after the war bring together a greater desire for a healthy pregnancy and delivery. We believe that cervical-length measurement using transvaginal sonography during post-cerclage checks is important and that measurement of a cervical length equal to or above 30 mm may increase the probability of term delivery and decrease maternal, and most importantly, neonatal complications associated with preterm labor.

scholarly journals Effect of Bacterial Vaginozis and cervikal length on preterm delivery in second trimester

2019 ◽  
Vol 6 (11) ◽  
pp. 305-309
Author(s):  
Hacı Öztürk Şahin ◽  
Ahmet Gülkılık
Keyword(s):  
Preterm Birth ◽  
Bacterial Vaginosis ◽  
Pregnant Women ◽  
Preterm Delivery ◽  
Preterm Labor ◽  
Cervical Length ◽  
Delivery Rate ◽  
Significant Difference ◽  
Detailed Medical History ◽  
The Mean

Objective: Preterm birth is one of the major cause of perinatal morbidity and mortality. Clinical studies have pointed out the association between preterm birth and bacterial vaginosis (BV) infection. Our aim is to discover the incidence of BV and search for the mean cervical length and parameters for the prediction of preterm delivery. Materials and Methods: 130 pregnant woman between the 16th and 24th gestational week were included in our study. A detailed medical history was obtained from all of the women, and patients with a history of preterm delivery and the Vaginal Ph values and cervical length measurement were evaluated. Vaginal samples were analyzed, gram staining was performed, and a bacterial vaginosis diagnosis was made with Nugent’s criteria. Results:  Of 130 woman that we included in our study,  only 19 had bacterial vaginosis (14.6 %), and the mean cervical length was measured as 41.79 mm. Preterm birth occurred in nine of the pregnant women (6.9%), and no statistically significant difference was found between BV and shortened cervical length or preterm labor. When we excluded the known preterm birth risk factors from our study, we could not find a significant difference between preterm labor and BV. Conclusion:  We concluded that BV by itself is not a preterm risk factor. The frequency of BV in the pregnant women in our study group according to the preterm delivery rate and the mean cervical length were similar to those in international studies in which the relationship between cervical length and preterm delivery has been established. We did not come to a significant conclusion in our research; nevertheless, we can relate this result to the preterm delivery rate that is found to be lower than expected.

Ultrasonographic Transabdominal Measurement of Uterine Cervical Length for the Prediction of a Midtrimester Short Cervix

2020 ◽  
Author(s):  
Paul Guerby ◽  
Annie Beaudoin ◽  
Geneviève Marcoux ◽  
Mario Girard ◽  
Jean-Charles Pasquier ◽  
...  
Keyword(s):  
Roc Curve ◽  
False Positive Rate ◽  
Cervical Length ◽  
Ultrasound Measurement ◽  
Singleton Pregnancy ◽  
Short Cervix ◽  
Nulliparous Women ◽  
Key Points ◽  
Positive Rate ◽  
The Mean

Objective This study was aimed to estimate the value of transabdominal (TA) ultrasound measurement of cervical length (CL), as an alternative of transvaginal (TV) ultrasound, for universal screening of short cervix in the midtrimester. Study Design We conducted a prospective cohort study of nulliparous women with singleton pregnancy at 20 to 24 weeks of gestation. All participants underwent TA ultrasound followed by TV ultrasound with acquisitions of images and videos of the uterine cervix. A second sonographer, blinded to the participants' data and pregnancy outcomes, measured the CL using TA and TV images and videos. Pearson's correlation test and receiver operating characteristic (ROC) curve analyses were performed. Results A total of 805 participants were recruited, including 780 (97%) where TA CL measurement was feasible. We observed a strong correlation of CL between TA and TV (correlation coefficient: 0.57; p < 0.0001) with a mean TA measurement being 4 mm (95% confidence interval [CI]: −6 to 14 mm) below the mean TV measurement (mean of differences: 5 ± 4 mm). We observed that a TA CL <30 mm was highly predictive of a short cervix defined as a TV CL ≤25 mm (area under the ROC curve: 0.97; 95% CI: 0.95–0.99; p < 0.0001) with a sensitivity of 100% and a false-positive rate of 22%. Conclusion Universal short cervix screening in nulliparous women could be performed using TA ultrasound, which could allow the avoidance of TV ultrasound in more than three quarter of women. In low-risk population, TV ultrasound could be reserved to women with TA CL <30 mm. Key Points

scholarly journals Ambispective study on Mac Donald suturing in pregnant ladies with cervical incompetence in Dhulikhel Hospital

2012 ◽  
Vol 8 (3) ◽  
pp. 321-324
Author(s):  
S R Tamrakur ◽  
C D Chawla
Keyword(s):  
Pregnant Women ◽  
Pregnancy Outcomes ◽  
Previous History ◽  
Cervical Length ◽  
University Teaching ◽  
Third Trimester ◽  
Cervical Cerclage ◽  
Trimester Abortion ◽  
Cervical Incompetence ◽  
History Of

Background Cervical incompetence is one of the main contributors to repeated pregnancy loss, accounting for approximately 25% of the cases. Typically it results in progressive cervical dilatation, leading to a painless second- or early-third-trimester abortion. Objectives The main objective of the study was to explore the benefit from cervical cerclage in pregnant women with anatomical cervical incompetence Methods In a review of the operation and labour registers from January 2006 till January 2010, a total of 38 cervical cerclage procedures were performed at Dhulikhel Hospital (DH). In the study caste, parity, gestational age, diagnostic criteria, postoperative complications and pregnancy outcomes of the cases were analyzed. Results Two of the 38 cases didn’t come for delivery at Dhulikhel Hospital (Kathmandu University Teaching Hospital). Four women haven’t delivered at the time of data analysis. So pregnancy outcomes were analyzed among 32 cases while rests of the variables were analyzed among 38 cases. Of them 18 cases (47%) were Brahmin, 22 cases (58%) were between 20-25 years old and 32 cases (84%) were from Kavre district.  All cases were booked cases (they had antenatal care in the hospital) and 14 patients (37%) were third gravida. Most cases had 2 to 4 antenatal visits prior to suturing. Two cases were diagnosed with a bicornuate uterus. 21 cases (55%) had a previous history of at least one dilatation and evacuation.  33 cases (87%) were diagnosed with cervical incompetence clinically and confirmed by ultrasound. The remaining 13% were assessed, in the absence of a history of mid-trimester abortion, of having a high suspicion of cervical incompetence after mid-trimester scan with measurement of cervical length. In 18 cases (47%), cervical cerclage were done at 15 to 20 weeks of gestation. The postoperative period was uneventful in all 38 cases.  All cases (32) delivered in DH were assisted by consultant obstetricians. 19 out 32 cases (59%) were delivered vaginally at term. Conclusions38 cases were included in the study. Pregnancy outcomes were analyzed among 32 cases while rests of the variables were analyzed among 38 cases. 31 out 32 cases were delivered with good foetal weight. It clearly shows pregnant women with anatomical cervical incompetence were benefitted from cervical cerclage. The authors recommend an early trans vaginal scan in any patient with a history of mid trimester abortion or preterm labour. The cervical cerclage procedure therefore should be available more widely to benefit those patients with proven or strongly suspected cervical incompetence.DOI: http://dx.doi.org/10.3126/kumj.v8i3.6222 Kathmandu Univ Med J 2010;8(3):321-24 

scholarly journals Sildenafil Citrate Versus Nifedipine and Dydrogesreone in Prevention of Preterm Labor with Short Cervix

2018 ◽  
Vol 2 (1) ◽  
pp. 01-05
Author(s):  
Abd El-Naser Abd El-Gaber Ali ◽  
Khaled M Abdallah ◽  
Ahmed Abdelhamid
Keyword(s):  
Pregnant Women ◽  
Preterm Labor ◽  
Cervical Length ◽  
Sildenafil Citrate ◽  
Health Concern ◽  
P Value ◽  
Short Cervix ◽  
Group I ◽  
Significant Difference ◽  
Group Ii

Background: Prevention of the premature birth occurrence remains is considered one of the most tough challenges for obstetricians worldwide, mainly to avoid neonatal prematurity complications leading to short and long term morbidities additionally prematurity prevention will reduce premature neonatal mortality rates which is considered a major health concern of obstetricians, neonatologists and families. Objective: To compare and contrast the efficacy of Sildenafil citrate, Nifedipine and Dydrogesrone in prevention of premature labor in gestations with short cervix. Setting: Obstetrics & Gynecology Departments, Faculties of medicine, south Valley and Al-Azhar (Asyut) Universities, Egypt. Duration: from September 2014 to March 2018. Patients And Methds: the study was conducted on 300 pregnant women who randomly divided into three groups: Group I included 100 cases received Sildenafil citrate (Respatio tablet 20mg twice daily orally), Group II included 100 cases received Nifedipine (Epilat retard tablets 20mg twice daily orally) and Group III included 100 pregnant women received dydrogesreone 10 mg (Duphaston) twice daily orally. Results: incidence of preterm labor was (9.37, 8.51 and 14.28) in (Group I, Group II and Group II) respectively. Mean ± SD of cervical length at 32 weeks of gestation was mildly statistically significant among groups (p value <0.05) but no significance in neonatal outcome (p value >0.05) except birth weight which had a highly statistically significant difference (p value < 0.001). There was a highly statistically significant difference among studied groups as regard to drug side effects in (p value <0.001). Conclusion: Sildenafil citrate was as effective as Nifedipine and better than oral Dydrogesterone on myometrial relaxation and prevention of preterm birth in pregnant women who had short cervix.

scholarly journals Rescue Adjuvant Vaginal Progesterone May Improve Outcomes in Cervical Cerclage Failure

2018 ◽  
Vol 78 (08) ◽  
pp. 785-790 ◽  
Author(s):  
Alina Roman ◽  
Fabricio Da Silva Costa ◽  
Edward Araujo Júnior ◽  
Penelope Sheehan
Keyword(s):  
Transvaginal Ultrasound ◽  
Prospective Trial ◽  
Intervention Group ◽  
Clinical Pathology ◽  
Cervical Length ◽  
Singleton Pregnancy ◽  
Retrospective Case ◽  
Cervical Cerclage ◽  
Vaginal Progesterone ◽  
Length Measurements

Abstract Introduction Aim of the study was to evaluate the effect of rescue adjuvant vaginal progesterone in women with ongoing, transvaginal ultrasound (TVUS)-confirmed cervical shortening despite cervical cerclage. Materials and Methods A retrospective case control study was performed of women undergoing cervical surveillance following either history- or ultrasound-indicated cervical cerclage. We compared women managed with cervical cerclage and vaginal progesterone to women managed with cervical cerclage alone. Women with a singleton pregnancy who underwent cervical cerclage were identified from a database. Data on the concurrent use of vaginal progesterone, cervical length measurements, interventions and birth outcomes were collected from patient notes and clinical pathology notes. Patients from each intervention group were matched, based on exact shortest cervical length measurements obtained during surveillance and age of gestation when the measurement was obtained. Results 66 women were matched and included in the study, based on exact shortest cervical length measurements. Each group had an identical mean shortest cervical length of 12.09 mm. The outcomes of 33 women who received both cervical cerclage and vaginal progesterone were compared to the outcomes of 33 women who were treated with cervical cerclage alone. The administration of vaginal progesterone to women with ongoing cervical shortening despite cervical cerclage was found to significantly prolong the pregnancy (36.36 weeks vs. 32.63 weeks; p = 0.0036) compared to women treated with cerclage alone. This use of rescue adjuvant vaginal progesterone was also associated with higher birth weights (2829 g vs. 2134 g; p = 0.0065) compared to women who had cervical cerclage alone; however, there was no difference in Apgar scores, composite neonatal morbidity or neonatal intensive care admission. Conclusion Women with cervical shortening despite the presence of cervical cerclage may benefit from further TVUS cervical length surveillance and the administration of vaginal progesterone if further cervical shortening occurs. Despite both groups having clinically significant shortened cervical lengths and cervical cerclage in situ, adjunct vaginal progesterone treatment resulted in older gestational age at birth and higher birth weight. Further investigation and confirmation of this finding in a larger prospective trial is warranted to explore this potential benefit for the management of preterm birth in future.

scholarly journals Preoperative Anxiety and Fear of Anesthesia in Patients admitted in Tertiary Care Hospitals of Rawalpindi

2020 ◽  
Vol 24 (1) ◽  
pp. 52-58
Author(s):  
Zahra Mariyam ◽  
Laibah Safdar ◽  
Shafaq Fatima ◽  
Jawad Zaheer
Keyword(s):  
Formal Education ◽  
Tertiary Care ◽  
Previous History ◽  
Female Gender ◽  
Preoperative Anxiety ◽  
Cross Sectional ◽  
Significant Difference ◽  
History Of ◽  
History Of Anesthesia ◽  
The Mean

Background: Preoperative apprehension is a widespread global problem. This anxiety and apprehension can significantly affect all aspects of anesthesia and surgery. Thus, it is essential to detect and address the patient's anxiety to assist in recovery after surgery and improve the patient's outcome. Materials and Methods: This is a cross-sectional study conducted over one year in the allied hospitals of Rawalpindi Medical University (RMU). Our sample size was 380 preoperative patients, who were selected by convenience sampling. The Amsterdam Preoperative Anxiety and Information Scale (APAIS) was used.Results: The overall prevalence of anxiety was 30.5%, while the prevalence of information requirement was 33.2%. The mean total APAIS was 12.73±8.56, the mean anxiety subscore was 8.25±5.58, and the mean need for information subscore was 4.48±3.16. A statistically significant difference was found in the scores of the patients based on age, gender, education, type of anesthesia, and type of surgery (p< 0.05). The previous history of anesthesia and the presence of comorbidities did not bring a significant difference in the scores of the patients (p>0.05). Postoperative pain was the most important concern, found in 32% of the patients. Conclusion: Younger age group, female gender, having no formal education, surgery under regional anesthesia, and undergoing C-section, IOL implantation and septoplasty are associated with higher preoperative anxiety, while the presence of comorbidities and previous history of anesthesia are factors that do not significantly affect preoperative anxiety in our population.

scholarly journals Steroids for All

2020 ◽  
Vol 3 ◽  
Author(s):  
Alexandra McKinzie ◽  
Ziyi Yang ◽  
Joanne Daggy ◽  
Robert Tepper ◽  
Sarah Quinney ◽  
...  
Keyword(s):  
Preterm Labor ◽  
Neonatal Intensive Care ◽  
Neonatal Outcomes ◽  
Hypertensive Disorder ◽  
Antenatal Corticosteroids ◽  
Maternal Characteristics ◽  
Admission Rates ◽  
Threatened Preterm Labor ◽  
The Mean ◽  
Nicu Admission

Background: Due to difficulties estimating the risk of preterm labor, many women diagnosed with threatened preterm delivery and given antenatal corticosteroids to improve neonatal outcomes do not deliver until term. Our objective was to compare the short-term outcomes of infants born at term to women who received betamethasone (BMZ) for threatened preterm labor to infants who were not exposed to BMZ in utero.     Methods: We performed a retrospective cohort study of infants born at or after 37 weeks’ gestational age (GA) to mothers diagnosed with threatened preterm labor during pregnancy. Controlling for covariates, the primary neonatal outcomes of interest, including transient tachypnea of the newborn (TTN), neonatal intensive care unit (NICU) admission, and birthweight, were evaluated for their association with BMZ exposure.     Results: Of 5330 women, 1459 (27.5%) women received BMZ at a mean GA of 32.2±3.3 weeks. The mean age of women was 27±5.9 years-old and the mean GA at delivery was 38.9±1.1 weeks. Women receiving BMZ had higher rates of maternal comorbidities (P<0.001 for diabetes, asthma, and hypertensive disorder) and were more likely to self-identify as white (P=0.022). BMZ-exposed neonates had lower birth weights and increased rates of oxygen usage, TTN, hyperbilirubinemia, hypoglycemia, and NICU admission rates (all P-values <0.05).  Controlling for maternal characteristics and GA at delivery, BMZ exposure was not significantly associated with diagnosis of TTN [OR 1.09 (95% CI 0.80-1.50)], though it was associated with more NICU admissions [1.49 (1.19-1.86)] and lower birthweight by 91.5 (-122.3 to -60.6) grams.      Conclusions: Compared to women evaluated for preterm labor that did not receive BMZ, women receiving BMZ had infants with higher rates of NICU admission and lower birthweights, though the rate of TTN diagnosis was similar between the two groups. While the benefits of BMZ to infants born preterm are clear, there may be negative impacts for infants delivered at term. 

scholarly journals Investigation the Effects of Metformin versus Insulin on Neonatal and Maternal Outcomes in Women with Gestational Diabetes Mellitus: A Randomized Clinical Trail

2016 ◽  
Vol 9 (4) ◽  
pp. 272 ◽  
Author(s):  
Mahin Najafian ◽  
Mojgan Barati ◽  
Sara Masihi ◽  
Ailin Fardipor
Keyword(s):  
Diabetes Mellitus ◽  
Gestational Diabetes ◽  
Gestational Diabetes Mellitus ◽  
Neonatal Outcomes ◽  
Neonatal Hypoglycemia ◽  
Singleton Pregnancy ◽  
Insulin Group ◽  
Metformin Group ◽  
Maternal And Neonatal Outcomes ◽  
The Mean

The aim of this study was to evaluate the effectiveness of metformin versus insulin in the glycemic control and to investigate the maternal and neonatal outcomes in in women with gestational diabetes mellitus. Pregnant women with gestational diabetes were randomized to either receive metformin (n=70) or insulin (n=70). Inclusion criteria were singleton pregnancy, following healthy diet and performing exercise for at least one week without satisfactory blood glucose level, no risk factor contributing to lactic acidosis, and no anatomic and/or chromosome anomalies. Two patients were excluded from the study due to lost to follow-up. The mean score of BMI and FBS after treatment was similar between two groups. But, the mean score of 2 hours blood sugar in insulin group (104.38±7.06 mg/dl) was significantly higher than metformin group (97.5±5.98 mg/dl) (P&lt;0.0001). The weight gain in metformin group was slightly lower than insulin group. (P=0.123). The proportion of neonatal hypoglycemia in insulin group was higher than metformin group (20 vs 3, P=0.002). Other neonatal outcomes such as IUGR, IUFD, fetal anomaly, polyhydramnios, macrosomia, oligohydramnios, and NICU stay did not differ significantly between two groups. In conclusion, metformin had compatible effect with insulin in decreasing adverse maternal and neonatal outcomes even in some parameters such as neonatal hypoglycemia it works better. Totally, metformin is safe and effectiveness in controlling the gestational diabetes mellitus.

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