妊娠期甲状腺疾病诊断及治疗的研究进展

妊娠期妇女体内激素水平会发生变化,使妊娠妇女甲状腺激素水平的测定和判断存在一定的困难,应选择适用于妊娠妇女的甲状腺激素水平特异值,进而正确评估甲状腺功能状态及对母体和胎儿的影响。孕前及妊娠期测定促甲状腺素和游离甲状腺激素有很大的必要性,因为甲状腺疾病以及单纯性甲状腺抗体阳性会导致多种妊娠不良结局,尤其是甲状腺功能减退对胎儿智力发育和认知功能具有非常大的影响。孕期甲状腺激素的监测对评估甲状腺功能状态及疾病预后具有非常大的作用,可以提示临床医师是否给予药物干预及如何调整药量。对于孕期甲状腺激素补充治疗后应达到的目标值以及甲状腺抗体阴性的亚临床甲状腺功能降低的妊娠患者是否给予干预,目前仍有异议。     

胰岛素对不同孕期妊娠糖尿病患者血糖水平及妊娠结局的影响

目的:探讨胰岛素对不同孕期妊娠合并糖尿病孕产妇血糖水平及妊娠结局的影响。方法:选择2011年7月-2015年4月在我院接受治疗的妊娠期糖尿病患者200例,均采用胰岛素治疗。检测患者血糖变化、妊娠期并发症的发生情况,并分析孕期对胰岛素治疗效果的影响。结果:治疗后产妇空腹血糖及餐后2 h血糖均低于治疗前,差异具有统计学意义(P0.05);孕期32周的产妇治疗后空腹血糖及餐后2 h血糖均低于孕期≥32周的产妇,差异具有统计学意义(P0.05)。孕期32周的产妇妊娠高血压及产后出血的发生率均低于孕期≥32周的产妇,但早产及剖宫产的发生率高于孕期≥32周的产妇,差异具有统计学意义(P0.05)。结论:胰岛素治疗能够有效控制妊娠期糖尿病产妇的血糖水平,改善妊娠结局,早期干预效果较好。     

妊娠期高血压疾病发病危险因素及对妊娠结局的影响

目的:探讨妊娠期高血压疾病(HDCP)发病的危险因素及其对妊娠结局的影响,以期为HDCP的诊断和早期预防提供一定的临床依据。方法:选择2011年11月到2014年11月在我院接受治疗的120例HDCP患者,设为实验组,同期选择120例正常孕产妇作为对照组。自制调查问卷调查受试者的临床资料以及妊娠结局,分析HDCP的危险因素,对比观察两组妊娠结局的差异。结果:(1)单因素分析显示,HDCP发病的危险因素可能有:年龄、体质指数(BMI)、月收入、高血压家族史、孕期并发症、负面情绪、文化程度(均P0.05)。(2)进一步行多因素非条件Logistic回归分析显示,HDCP发病的危险因素有:BMI、高血压家族史、负面情绪及文化程度。(3)实验组患者胎儿窘迫、低体重儿、新生儿窒息、围产儿死亡及胎儿畸形的发生率均明显高于对照组,具有显著性差异(P0.05)。结论:导致HDCP发病的危险因素较多,主要有BMI、高血压家族史、负面情绪及文化程度等,这些因素极易导致不良妊娠结局。     

妊娠期糖尿病及时诊治对妊娠结局的影响分析

目的评价分析妊娠期糖尿病及时诊治对妊娠结局的影响。方法将2015年4月~2016年3月我院收治的75例妊娠期糖尿病患者作为研究对象,根据确诊治疗时间不同分为两组,实验组37例在妊娠24周以前确诊并治疗,对照组38例在妊娠24周以后确诊并治疗,比较不同诊治时间对妊娠结局的影响。结果与对照组患者比较,实验组患者的血糖控制效果较佳,经阴道分娩率高,妊娠结局改善良好,组间数据比较差异具有统计学意义(P0.05)。结论早期及时进行妊娠期糖尿病的诊断、治疗,对改善妊娠结局有积极意义,临床需引以重视。     

破骨细胞分化因子与乳腺发育

破骨细胞分化因子 (RANKL)可以促进乳腺在妊娠中后期形成正常的小叶 腺泡结构 ,其作用机制为RANKL与其特异性受体RANK结合 ,通过IKKα促进乳腺上皮细胞CyclinD1蛋白的表达 ,从而促进乳腺上皮细胞的增生。RANKL在乳腺上皮细胞的表达受催乳素、孕激素等性激素和PTHrP的调节。而且RANKL在妊娠期骨质疏松和乳腺癌骨转移中也有重要作用 ,于是在骨代谢调节中起重要作用的RANKL就成为乳腺与骨之间的新的桥梁。     

妊娠期糖尿病患者妊娠前超重对血糖水平及巨大儿的影响

目的探讨妊娠期糖尿病患者妊娠前超重对血糖水平及巨大儿的影响。方法选取2015年9月～2017年6月在我院进行产检和分娩的妊娠期糖尿病患者94例,均为单胎妊娠,依据妊娠前体重指数(BMI)分为对照组(非超重)和观察组(超重)各47例,比较两组患者的血糖情况及新生儿出生体重,并分析巨大儿的影响因素。结果与对照组比较,观察组的血糖控制达标率低,而OGTT空腹血糖、服糖后1h血糖及新生儿出生体重均较高,差异均有统计学意义(P0.05)。妊娠期糖尿病患者分娩巨大儿的影响因素分别为妊娠期超重、妊娠期每周平均增重和OGTT空腹血糖。结论妊娠前超重者一旦诊断为妊娠期糖尿病,应及时有效控制血糖,避免妊娠期超重,减少巨大儿发生的风险,有利于确保母婴安全。     

燕麦β-葡聚糖对妊娠期糖尿病患者血糖调节及妊娠结局影响的临床研究

摘要 目的：研究燕麦β-葡聚糖对妊娠期糖尿病患者血糖调节及妊娠结局的影响。方法：选取2020年08月至2021年01月在本院产科门诊规律产检并确诊为GDM的孕妇,按照是否服用燕麦β-葡聚糖随机分为观察组和对照组,两组均采取医学营养治疗,观察组为自愿服用燕麦β-葡聚糖的患者,观察两组患者在不同时间段的空腹血糖变化以及胰岛素需求量、孕期BMI增加量、分娩方式、新生儿出生体重、母婴不良妊娠结局之间的差异。结果：两组患者观察期间平均空腹血糖水平整体呈下降趋势;两组患者在不同时间段空腹血糖水平的差异,治疗4周时P>0.05,治疗8周后P<0.05;观察组患者孕期BMI增加量（4.56±2.00 Kg/m²）显著低于对照组（5.34±2.21 Kg/m²,P<0.05）;观察组患者剖宫产率（64.62 %）低于对照组（70.77 %）,两组患者的剖宫产率、新生儿出生体重、胰岛素需求量无明显差异,P>0.05;两组患者的母婴不良围产期结局无明显差异（P>0.05）。结论：燕麦β-葡聚糖可以降低妊娠期糖尿病患者的空腹血糖水平,控制孕期体重增长的同时不影响胎儿正常的生长发育,对母婴不良妊娠结局无改善作用,不会产生除已知结局之外的其他不良结局。     

妊娠梅毒孕期治疗及产后随访管理的体会

目的:探讨妊娠梅毒的治疗对妊娠结局的影响。方法:回顾性分析了2011年5月至2014年12月在我院管理随访的90例妊娠合并梅毒患者治疗对妊娠结局的影响。结果:90例中足月产74例,早产4例,在孕4例,自然流产1例,终止妊娠7例,妊娠成功率91.1%。结论:妊娠合并梅毒威胁着孕妇和胎儿的健康,认真做好孕期梅毒筛查,早发现,早治疗有助于提高干预效率。     

孕期规范化综合营养干预对妊娠期糖尿病孕妇妊娠结局的改善作用

目的：观察妊娠期糖尿病孕妇的妊娠结局,探讨规范化综合营养干预对改善妊娠期糖尿病孕妇妊娠结局的临床意义。方法：选取326例确诊为妊娠期糖尿病的患者,按就诊先后顺序,将其分为观察组和干预组,每组163例。观察组患者定期门诊产检,干预组患者孕期给予规范化综合营养干预,比较两组产妇营养干预前后体重指数,观察两组产妇剖宫产率、早产率、巨大儿发生率、胎儿窘迫发生率、产后出血发生率及产褥感染发生率。结果：观察组产妇的体重指数（BMI）明显高于干预组,差异具有统计学意义（P＜0.05）。观察组产妇剖宫产率、早产率、巨大胎儿发生率明显高于干预组,差异具有统计学意义（P＜0.05）。两组产妇胎儿窘迫发生率比较差异无统计学意义（P＞0.05）。观察组产妇产后出血、产褥感染发生率高于干预组,差异具有统计学意义（P＜0.05）。结论：规范化综合营养干预能够指导产妇在孕期合理饮食,保持良好的体重指数,并能够降低产妇剖宫产、早产率,降低巨大儿、胎儿窘迫发生率,并能够减少产后出血的发生率,减少产褥感染,对促进孕期母婴健康具有重要意义。     

营养治疗对妊娠糖尿病患者母婴妊娠结局的影响

目的：观察个体化营养治疗（IMNT）对妊娠糖尿病（GDM）患者母婴妊娠结局的影响。方法：经我科会诊以及门诊55名GDM患者进行全程IMNT干预,同时选取同期未进行正规营养治疗的48名GDM患者作为对照组,观察IMNT对GDM患者血糖水平、孕期增重以及母婴结局的影响。结果：合理的营养治疗可明显降低试验组患者血糖、孕期增重值;与对照组相比,试验组妊娠高血压、早产、感染、羊水过多、巨大儿、低血糖、高胆红素血症、低钙血症、畸形等并发症的患病率明显下降（P<0.05）,而剖宫产、胎儿窘迫发生率无明显差异（P>0.05）。结论：对GDM患者实施积极的IMNT干预可良好控制血糖和体重增长,并明显减少母婴并发症发病率。     

Nominations sought for Mindel C. Sheps Award

Abstract

The relationship between early fetal wastage or stillbirth and pregnancy spacing was examined in a population characterized by prolonged lactation, minimal nutrition, and high fertility and mortality. The highest risk of early fetal death was found among those pregnancies conceived less than twelve months after the birth of a surviving breast‐fed infant. Lactation as a possible causal factor is discussed. A significant inverse relationship was apparent for second trimester fetal deaths and pregnancy intervals, but not for third trimester deaths. This finding is surprising when one considers that fetal weight gain, and presumably nutrient demand, increases most rapidly during the third trimester.     

Pregnancy-Associated Breast Cancer in Taiwanese Women: Potential Treatment Delay and Impact on Survival

This study investigated the clinicopathologic characteristics and survival of women diagnosed with pregnancy-associated breast cancer (PABC) in Taiwan. PABC is defined as breast cancer diagnosed during pregnancy or within 1 year after obstetric delivery. Our sample of PABC patients (N = 26) included all patients diagnosed at a major medical center in northern Taiwan from 1984 through 2009. Among these patients, 15 were diagnosed during pregnancy and 11 were diagnosed within 1 year after delivery. The comparison group included 104 patients within the same age range as the PABC patients and diagnosed with breast cancer not associated with pregnancy from 2004 through 2009 at the same hospital. Patients'' initiating treatment delayed, 5-year and 10-year overall survival were delineated by stratified Kaplan-Meier estimates. Patients'' characteristics were associated with initiating treatment delayed was evaluated with multivariate proportional hazards modeling. Antepartum PABC patients were younger and had longer time between diagnosis and treatment initiation than postpartum PABC patients. The predictor of treatment delayed was including birth parity, cancer stage, and pregnancy. The PABC group had larger tumors, more advanced cancer stage, and tumors with less progesterone receptor than the comparison group. The antepartum PABC patients had higher mortality than postpartum PABC and comparison groups within 5 years after diagnosis. Based on these results, we confirmed that pregnant women with breast cancer were more likely to delay treatment. Therefore, we recommend that breast cancer screening should be integrated into the prenatal and postnatal routine visits for early detection of the women''s breast problems.     

Prenatal diagnosis--principles of diagnostic procedures and genetic counseling

The frequency of inherited malformations as well as genetic disorders in newborns account for around 3-5%. These frequency is much higher in early stages of pregnancy, because serious malformations and genetic disorders usually lead to spontaneous abortion. Prenatal diagnosis allowed identification of malformations and/or some genetic syndromes in fetuses during the first trimester of pregnancy. Thereafter, taking into account the severity of the disorders the decision should be taken in regard of subsequent course of the pregnancy taking into account a possibilities of treatment, parent's acceptation of a handicapped child but also, in some cases the possibility of termination of the pregnancy. In prenatal testing, both screening and diagnostic procedures are included. Screening procedures such as first and second trimester biochemical and/or ultrasound screening, first trimester combined ultrasound/biochemical screening and integrated screening should be widely offered to pregnant women. However, interpretation of screening results requires awareness of both sensitivity and predictive value of these procedures. In prenatal diagnosis ultrasound/MRI searching as well as genetic procedures are offered to pregnant women. A variety of approaches for genetic prenatal analyses are now available, including preimplantation diagnosis, chorion villi sampling, amniocentesis, fetal blood sampling as well as promising experimental procedures (e.g. fetal cell and DNA isolation from maternal blood). An incredible progress in genetic methods opened new possibilities for valuable genetic diagnosis. Although karyotyping is widely accepted as golden standard, the discussion is ongoing throughout Europe concerning shifting to new genetic techniques which allow obtaining rapid results in prenatal diagnosis of aneuploidy (e.g. RAPID-FISH, MLPA, quantitative PCR).     

The architect and the bee: some reflections on postmortem pregnancy

Do physicians have a duty to sustain the pregnancies of women who die during the first or second trimester? Physicians cannot simply assume that the woman would have wished the pregnancy to continue, nor (in the U. S., at any rate) is it clear that the state has any interest in fetal life before viability. The conditions for beneficence-based duties of fetal rescue will often be unmet, both because sustaining the pregnancy is not always a clear gain to the born child and because it may impose a substantial burden on the benefactor. And duties of special relationship cannot readily be applied in these cases, as it is difficult to see how the relationship between someone who no longer exists and someone who does not yet exist can breed special duties. Further, to draw on Marx's distinction between the architect, who builds purposefully, and the bee, who cannot help what she is doing, I argue that human pregnancy is in a number of respects purposeful, creative, and deliberate, and that postmortem pregnancy, which follows the model of the bee, is a destructive icon that undercuts women's agency.     

Angiotensin II receptor antagonist treatment during pregnancy

Angiotensin II (A-II) is the main effector of the renin-angiotensin system. A-II functions by binding its type 1 (AT1) receptors to cause vasoconstriction and retention of sodium and fluid. Several AT1 receptor antagonists-a group of drugs collectively called "sartans"-have been marketed during the past few years for treatment of hypertension and heart failure. At least 15 case reports describe oligohydramnios, fetal growth retardation, pulmonary hypoplasia, limb contractures, and calvarial hypoplasia in various combinations in association with maternal losartan, candesartan, valsartan, or telmisartan treatment during the second or third trimester of pregnancy. Stillbirth or neonatal death is frequent in these reports, and surviving infants may exhibit renal damage. The fetal abnormalities, which are strikingly similar to those produced by maternal treatment with angiotensin-converting enzyme (ACE) inhibitors during the second and third trimesters of pregnancy, are probably related to extreme sensitivity of the fetus to the hypotensive action of these drugs. Very little information is available regarding the outcome of human pregnancies in which the mother was treated with an AT1 receptor antagonist during the first trimester, but animal studies have not demonstrated teratogenic effects after maternal treatment with large doses of AT1 receptor antagonists during organogenesis. We conclude that pharmacological suppression of the fetal renin-angiotensin system through ACE inhibition or AT1 receptor blockade seems to disrupt fetal vascular perfusion and renal function. We recommend that maternal treatment with AT1 receptor antagonists be avoided during the second and third trimesters of pregnancy and that women who become pregnant while taking one of these medications be changed to an antihypertensive drug of a different class as soon as the pregnancy is recognized.     

Photon-beam radiotherapy in pregnant patients: Can the fetal dose be limited to 10 cGy or less?

PurposeTo estimate fetal dose and its components from three-dimensional conformal radiotherapy for several malignancies presented during pregnancy.Materials and methodsFetal dose was measured from radiotherapy for Hodgkin's lymphoma and for tumors in the region of nasopharynx, breast and lung. Anthropomorphic phantoms were used to simulate an average pregnant patient at the first, second and third trimesters of gestation. Thermoluminescent dosemeters (TLD) were employed for fetal dose measurements. Phantom exposures were also performed to estimate fetal dose due to head leakage, scatter from collimators and beam modifiers and scatter generated inside the phantom (D_in). All treatments were delivered for 6 MV photon beams.ResultsRadiotherapy of Hodgkin's lymphoma resulted in a fetal dose of 5.6–57.9 cGy depending upon the gestational age and the distance between the fetal level and the field edge. The corresponding dose ranges for treatment of nasopharyngeal, breast and lung cancer was 4.0–17.1 cGy, 3.9–24.8 cGy and 5.7–74.3 cGy, respectively. The D_in at the first trimester of gestation was always smaller than 10 cGy for all examined malignancies. Pregnancy progression resulted in D_in values above or below 10 cGy depending upon the treatment site and gestational age.ConclusionThis study provides data about the fetal exposure and the contribution of D_in to the total fetal dose from conformal radiation therapy. The D_in knowledge prior to patient's irradiation enables radiation oncologists and medical physicists to decide whether fetal dose may be limited to 10 cGy or less with or without the introduction of special shielding materials.     

Maternal perception of fetal motor activity.

A technique using real-time ultrasound for comprehensive recording of fetal motor activity was used in 20 subjects in the third trimester of pregnancy. Maternal awareness of fetal movement correlated with the number of fetal parts contributing to the movement but not with maternal parity or obesity, gestational age, placental site, or duration of the fetal movement. Some subjects recorded fetal breathing, passive fetal displacement, and Braxton Hicks''s contractions as fetal movement. Most of our subjects were consistent and accurate in their perception of major fetal movements, but a few were inconsistent and one was completely unaware of major fetal movements. These results suggest that kick counts kept by most mothers will be accurate. Low counts of fetal movement should be an indication for fetal monitoring by other means and not, unconfirmed, for intervention.     

Monoamniotic twins: what should be the optimal antenatal management?

Monoamniotic twinning is a rare event with an incidence of 1% of all monozygotic twins and associated with a high fetal morbidity and mortality. Confident early diagnosis is possible, but optimal management is not yet established. This article presents the experience of a single centre in managing all monoamniotic twins diagnosed during 1994-2000. Seven pairs of monoamniotic twins were identified for analysis. All were managed in accord with a unit protocol that involved early diagnosis, serial ultrasound examination and elective early delivery. In four cases, the detection of monoamnionicity was made during a first trimester nuchal scan. Discordance for structural abnormality was found in three cases where the co-twin was normal. Cord entanglement was detected antenatally in four cases. Two pairs of twins died before 20 weeks. One of these had early onset twin-twin transfusion syndrome. In five cases, the pregnancy continued beyond 20 weeks. A live birth rate of 90% and intact survival of 70% were achieved in this group. We believe that ultrasound is reliable in diagnosing monoamniotic twins and the detection of cord entanglement. Timing of elective delivery is a balance between the risks of preterm birth at a specific gestational age in an individual centre compared with the unquantifiable risks of fetal death if an expectant policy were pursued. The decision to deliver and at which gestational age should combine input from the parents, neonatologist, fetal medicine consultant and the obstetrician.     

Is there an embryopathy associated with first-trimester exposure to angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists? A critical review of the evidence

Drugs that interfere with the renin-angiotensin system, such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), are widely used to manage hypertension and heart failure. Adequate functioning of the RAS is essential for normal fetal kidney development. The potential for ACEIs and ARBs to impair fetal and neonatal renal function if taken after the first trimester of pregnancy has been well documented. Although these drugs were not found to be teratogenic in animals, until recently little was known about the teratogenic effects of ACEIs and ARBs in humans when exposure was limited to the first trimester of pregnancy. New evidence from epidemiologic studies indicates that there may be an elevated teratogenic risk when these drugs are taken during the first trimester of pregnancy. However, this elevated risk does not appear to be specific to ACEIs and ARBs, but is instead related to maternal factors and diseases that typically coexist with hypertension in pregnancy, such as diabetes, advanced maternal age, and obesity. Women who become pregnant while being treated with an ACEI or ARB should be advised to avoid exposure to these drugs during the second and third trimesters of pregnancy by switching to a different class of antihypertensive drugs between weeks 8 and 10 after conception. Birth Defects Research (Part A) 94:576-598, 2012. ? 2012 Wiley Periodicals, Inc.     

Identifying and treating pregnant patients at risk from alcohol.

Heavy alcohol consumption during pregnancy has been associated with retardation of fetal growth and abnormal fetal development. Pregnant women whose offspring are at risk because of alcohol abuse can be identified and counselled by health professional providing prenatal care. Offspring born to women who had been drinking heavily and subsequently abstained from or reduced their intake of alcohol before the third trimester demonstrated improvements in growth and in regulation of sleep-awake states. The existing health care delivery system can be modified in a cost-effective manner to treat pregnant women who are problem drinkers. Physicians'' attitudes and behaviour are critical for the success of this strategy.