1424 Correspondence

of the oral glucose tolerance test. Diabetes 1965;14: 473-80.

4. O'Sullivan JB, Mahan CM. Prospective study of 352 pa­tients with chemical diabetes, N EnglJ Med 1968;278: 1 038-41.

5. McDonald GW, Burnham CE, Lewish FW. Reproducibility of glucose tolerance in 101 nondiabetic women. Public Health Reports 1969;84:no. 4.

Reply To the Editors:

Dr. Hunter can take some comfort in knowing that I have not missed "his" point. Rather, J reject it. Dr. Hunter believes the best approach to gestational dia­betes is sporadic investigation of fasting or postprandial glucose in those patients suspected of having overt di­abetes that appears for the first time during pregnancy. That time has passed. Surprisingly, we have areas of agreement. 1. The glucose tolerance test (GTT) is a poor test from

the standpoint of reproducibility, especially when the preparation is inadequate. But it is also the gold standard; in the kingdom of the blind, the one-eyed man rules.

2. The applicability of the original O'Sullivan study to modern day obstetrics is unclear. I have questioned the modern obstetric risk of true gestational diabetes and I have reasoned that if the medical cost was unclear, the financial costs should be minimized. Thus our move was made into capillary glucose testing. I,2

3. It is unlikely that glucose is the sole predictor or cause of perinatal morbidity and mortality in women with gestational diabetes. Though the information was unavailable to Dr. Hunter at the time his letter was written, an experience at the University of Iowa' clearly supports this conclusion. However, in that same study, a breakdown of the morbid events (in­trauterine growth retardation, low Apgar scores, re­spiratory distress syndrome, nonelective operative delivery, and failure to be discharged with the mother) failed to reveal any significant correlation with maternal age. And though this study does not duplicate O'Sullivan's work, it does reflect the ex­perience of a single large academic institution that uses modern obstetric techniques. Gestational dia­betes remains a source of increased perinatal mor­bidity, and there is no magic maternal age in­volved.

Though I believe Dr. Hunter's statements are some­what regressive, we are not that far apart in some as­pects. Costs should be minimized as a rule, especially when the effects of treatment are unclear. We should not pat ourselves on the back for improvements in out­come that may have nothing to do with our treatment. The time has long come and gone for a prospective, randomized trial of various therapies for women with gestational diabetes. But, the time has also come and

November 1989 Am J Dbstet Gynecol

gone in which we can limit ourselves to a magic age for screening.

Carl P. Weiner, MD Director, Maternal-Fetal Medicine Department of Obstetrics and Gynecology The University of Iowa College of Medicine Iowa City, IA 52242

REFERENCES I. Weiner CP, Faustich MW, Burns J, Fraser M, Whitaker L,

Klugman M. The relationship between capillary and ve­nous glucose concentration during pregnancy. AM J OB­STET GVNECOL 1986;155:61-4.

2. Weiner CP, Faustich MW, Burns J, Fraser M, Whitaker L, Klugman M. Diagnosis of gestational diabetes by capillary blood samples and a portable reflectance meter: derivation of threshold values and prospective validation. AM J OB­STET GVNECOL 1987;156:1085-9.

3. Weiner CPo Effect of varying degrees of "normal" glucose metabolism on maternal and perinatal outcome. AM J OB­STET GVNECOL 1988; 159:862-70.

Antepartum infection as a result of Streptococcus pneumoniae and sepsis in neonate

To the Editors: Although neonatal infection as a result of Streptococ­

cus pneumoniae is thought to be uncommon, H in this letter we document the concurrence of pneumococcal sepsis in the newborn and pneumococcal antepartum infection in the mother.

During a 5-year period, seven women with presumed infection had positive cultures for S. pneumoniae in the 24 hours before delivery. Cultures of the vaginal or en­docervical exudates had been performed because of preterm labor, premature rupture of the membranes, or intrapartum fever with leukocytosis (chorioamnioni­tis). Maternal swabs were placed in a transport medium (Amies) and were sent immediately to the laboratory. Blood, cerebrospinal fluid, and throat, nasal, or exter­nal auditory canal cultures were obtained in infants in whom infection was suspected. Blood cultures were placed in biphasic (Castaneda) and thioglycollate media. Human blood agar was used for initial isolation of S. pneumoniae. All organisms were identified with the use of standard media on the basis of colonial morphology, alpha hemolysis, Gram stain, and sensitivity to the Op­tochin disk. Serotyping was not performed. Four par­turient women had ampicillin coverage while in labor. All infants were vaginally delivered. Three infants had respiratory distress and signs of infection in the first hours of life (after 15 minutes, 2 hours, and 13 hours of birth, respectively). Two of these infants with bacte­riologically confirmed (positive blood-cerebrospinal fluid culture) pneumococcal sepsis and meningitis or pneumonia were delivered from mothers who did not receive antibiotics. The third infant with respiratory dis­tress had negative cultures for S. pneumoniae and was de­livered from a woman who received antibiotic therapy. Each of the three neonates recovered after treatment.