Graves Hyperthyroidism and Pregnancy: A Clinical Update

ObjectiveTo provide a clinical update on Graves’ hyperthyroidism and pregnancy with a focus on treatment with antithyroid drugs.MethodsWe searched the English-language literature for studies published between 1929 and 2009 related to management of hyperthyroidism in pregnancy. In this review, we discuss differential diagnosis of hyperthyroidism, management, importance of early diagnosis, and importance of achieving proper control to avoid maternal and fetal complications.ResultsDiagnosing hyperthyroidism during pregnancy can be challenging because many of the signs and symptoms are similar to normal physiologic changes that occur in pregnancy. Patients with Graves disease require prompt treatment with antithyroid drugs and should undergo frequent monitoring for signs of fetal and maternal hyperthyroidism and hypothyroidism. Rates of maternal and perinatal complications are directly related to control of hyperthyroidism in the mother. Thyroid receptor antibodies should be assessed in all women with hyperthyroidism to help predict and reduce the risk of fetal or neonatal hyperthyroidism or hypothyroidism. The maternal thyroxine level should be kept in the upper third of the reference range or just above normal, using the lowest possible antithyroid drug dosage. Hyperthyroidism may recurin the postpartum period as Graves disease or postpartum thyroiditis; thus, it is prudent to evaluate thyroid function 6 weeks after delivery. Preconception counseling, a multidisciplinary approach to care, and patient education regarding potential maternal and fetal complications that can occur with different types of treatment are important.ConclusionPreconception counseling and a multifaceted approach to care by the endocrinologist and the obstetric team are imperative for a successful pregnancy in women with Graves hyperthyroidism. (Endocr Pract. 2010;16:118-129)     

Radiation oncologists role,training and perceptions in palliative care: a systematic review

AimTo assess the educational needs, role and perceptions in palliative care issues of radiation oncologists (ROs) and trainees.Background1/3 of radiotherapy patients are treated with palliative intent. Conversely, education and role that ROs have in the palliative care process are not well established, neither in terms of how they perceive their competence nor whether it is important to improve training, research and attention in palliative care issues at radiotherapy congresses.Material and MethodsLiterature systematic review in National Library of Medicine and Cochrane databases with 11 relevant issues to be identified. One doctor made first selection of articles, a second one confirmed their eligibility.Results722 articles reviewed, 19 selected. 100% recognize the importance of palliative care in radiotherapy, 89.4% the need of training in palliative care for ROs, 68.4% the necessity of improving the resident programs, 63.1% the importance of skilled ROs in palliative care, 63.1% the need of better communication skills and pain management (47.3%), 52.6%, the perception of inadequate training in palliative care, 36.8% the lack of research and palliative care topics in radiotherapy meetings, 21% the absence of adequate guidelines regarding palliative care approaches, 42.1% the importance of the ROs in palliative care teams and 26.3% the lack of their involvement.ConclusionPalliative care has an important role in radiotherapy but it seems ROs still need more training. It is necessary to improve training programs, increment palliative care research in radiotherapy, giving more attention to palliative care themes at radiotherapy congresses. This could lead to a better integration of radiotherapists in multidisciplinary palliative care teams in the future.     

Value of routine ultrasound scanning at 19 weeks: a four year study of 8849 deliveries.

OBJECTIVE--To evaluate the effectiveness of routine ultrasound scanning at 19 weeks'' gestation in an unselected population in terms of accuracy of detection of fetal structural abnormality and the effect on obstetric and neonatal care. DESIGN--Prospective study over four years. Scans performed by radiographers with overall supervision by a radiologist. SETTING--Ultrasound department of district general hospital. SUBJECTS--All pregnant women were offered scans; 8523 of 8849 (96%) accepted. MAIN OUTCOME MEASURES--Information obtained from hospital records, genetic analysis, and post-mortem findings. RESULTS--166 fetal anomalies occurred; 140 were detected at 19 weeks (sensitivity 85%; specificity 99.9%). In 27 cases fetuses were shown to have severely crippling or lethal abnormalities; termination of pregnancy was requested in 25. Early diagnosis influenced timing and place of delivery in babies with severe cardiac or gastrointestinal anomalies. CONCLUSION--Scanning at 19 weeks with availability of termination can reduce perinatal morbidity and mortality. Scanning can be performed in a general ultrasound department with adequate counselling facilities and close cooperation between radiographers, midwives, obstetricians, paediatricians, and the radiologist.     

How Outpatient Palliative Care Teleconsultation Facilitates Empathic Patient-Professional Relationships: A Qualitative Study

Objective

The problems and needs of advanced cancer patients and proxies normally increase as the disease progresses. Home-based advanced cancer patients and their proxies benefit from collaborations between primary care physicians and hospital-based palliative care specialists when confronted with complex problems in the last phase of life. Telemedicine might facilitate direct, patient-centered communication between patients and proxies, primary care physicians, and specialist palliative care teams (SPCTs). This study focuses on the impact of teleconsultation technologies on the relationships between home-based palliative care patients and hospital-based palliative care specialists.

Methods

This work consists of a qualitative study among patients, family members, and caregivers that utilizes long-term direct observations, semi-structured interviews, and open interviews following the observations.

Results

The analysis of the empirical data resulted in three key concepts that describe the impact of teleconsultation on the patient-professional relationship in palliative homecare: transcending the institutional walls of home and hospital; transparency of teleconsultation technology; and technologized, intimate patient-professional relationships. Teleconsultation offers (1) condensed encounters between home-based palliative care patients and distant professionals, (2) a unique insight into the patients’ daily lives for palliative care specialists, and (3) long-term interaction that results in trustful relationships and experiences of intimacy and relief.

Conclusions

Teleconsultation fits the practice of home-based palliative care. Teleconsultation can, if well applied, facilitate computer-mediated but empathic patient-palliative care specialist relationships, which enable professional care attuned to the patient’s context as well as patient involvement. This article proposes a teleconsultation implementation guide for optimal use of teleconsultation in daily palliative care practice.     

单胎妊娠早产胎膜早破呼吸窘迫综合征的危险因素分析

目的:探讨单胎妊娠早产胎膜早破发生新生儿呼吸窘迫综合征(respiratory distress syndrome,RDS)的危险因素。方法:选择2017年5月至2019年5月在我院产科分娩的2810例产妇为研究对象,其中97例(3.45%)符合未足月胎膜早破(Preterm premature rupture of membranes,pPROM)标准,包括53例RDS。收集以下信息:PROM潜伏期、出生时胎龄、脐动脉搏动指数(Umbilical artery pulsatility index,UAPI)、大脑中动脉搏动指数(Middle cerebral artery pulsation index,MCAPI)、胎儿窘迫、产前使用类固醇、新生儿实验室参数、性别、体重、Apgar评分、分娩类型、妊娠高血压疾病、妊娠期糖耐量异常或糖尿病等信息,通过Logistic回归分析研究变量对RDS的影响。结果:Logistic回归分析结果显示,以下变量与RDS密切相关:新生儿性别女性(OR=0.517;95%CI:0.312-0.107;P=0.042),产前使用类固醇(OR=0.467;95%CI:0.355-0.698;P0.001),异常UAPI(OR=2.830;95%CI:1.783-6.234;P=0.002),异常MCA PI(OR=2.136;95%CI:1.120-4.017;P=0.032),胎儿窘迫(OR=2.420;95%CI:1.287-4.824;P=0.017),母体HGB(OR=0.689;95%CI:0.511-1.013;P=0.221),新生儿HGB(OR=0.752;95%CI:0.645-0.891;P0.001),新生儿RBC(OR=0.311;95%CI:0.201-0.565;P0.001)。结论:单胎妊娠早产胎膜早破发生RDS危险因素主要是性别、胎儿胎盘循环异常和胎儿窘迫。     

Specialized perinatal care: impact on perinatal mortality.

A neonatal intensive care unit was established at one hospital in 1972 when the neonatal mortality was 7.6 and the perinatal mortality 20.9 per 1000 deliveries. In 1973, with full operation of that unit and partial introduction of a high-risk pregnancy unit for fetal monitoring, the rates decreased to 6.4 and 14.9, respectively. With full operation of both units the rates decreased further, to 3.4 and 9.0 in 1974 and 3.8 and 8.9 in 1975. The frequency of cesarean section was 10.1% in 1972-73 and 11.6% in 1974-75. It is concluded that the centralization of obstetric and neonatal care, together with the development of qualified medical and nursing teams, had a major impact in reducing perinatal mortality, and that the frequency of cesarean section was not affected by the introduction of fetal monitoring, although the indications for this precedure became more specific.     

Contribution of preterm delivery to perinatal mortality.

A detailed retrospective analysis was made of the records of 486 preterm infants, who accounted for 5-1% of all births during 1973 and 1974. Whereas preterm delivery did not contribute to perinatal mortality in terms of stillbirth, it outweighed all other causes in terms of early neonatal deaths. Preterm birth was responsible for 85% of the early neonatal deaths not due to lethal congenital deformities. Early neonatal mortality rates were closely linked both to gestational age and birth weight and to the reason for preterm birth. Early neonatal mortality was high (97 per 1000) when preterm labour was spontaneous, whether or not associated with material or fetal disease or with multiple pregnancy, but low (27 per 1000) when preterm delivery was elective. Preventing spontaneous preterm labour would considerably reduce neonatal mortality in our community.     

Lethal malformations and perinatal mortality: a 10 year review with comparison of ethnic differences.

During 1976 to 1985 perinatal mortality in Leicestershire decreased from 21 to 9.5 per 1000 births. Throughout this period the incidence of lethal malformations, excluding neural tube defects, remained relatively constant at around 1.8 per 1000 births. Analysis of the malformations present in 201 lethally malformed babies showed that 147 (73%) had a disorder carrying a recurrence risk of 1% or greater. Only 7% of these malformations might have been predicted from the family history or advanced maternal age. The incidence of lethal malformations was significantly increased in the Asian population, largely because of an excess of autosomal recessive disorders. The contribution of lethal malformations to perinatal mortality has almost doubled over the past 10 years and is likely to increase despite prenatal diagnosis and improvements in obstetric and paediatric services.     

Prenatal,Perinatal and Neonatal Risk Factors for Intellectual Disability: A Systemic Review and Meta-Analysis

BackgroundThe etiology of non-genetic intellectual disability (ID) is not fully known, and we aimed to identify the prenatal, perinatal and neonatal risk factors for ID.MethodPubMed and Embase databases were searched for studies that examined the association between pre-, peri- and neonatal factors and ID risk (keywords “intellectual disability” or “mental retardation” or “ID” or “MR” in combination with “prenatal” or “pregnancy” or “obstetric” or “perinatal” or “neonatal”. The last search was updated on September 15, 2015. Summary effect estimates (pooled odds ratios) were calculated for each risk factor using random effects models, with tests for heterogeneity and publication bias.ResultsSeventeen studies with 55,344 patients and 5,723,749 control individuals were eligible for inclusion in our analysis, and 16 potential risk factors were analyzed. Ten prenatal factors (advanced maternal age, maternal black race, low maternal education, third or more parity, maternal alcohol use, maternal tobacco use, maternal diabetes, maternal hypertension, maternal epilepsy and maternal asthma), one perinatal factor (preterm birth) and two neonatal factors (male sex and low birth weight) were significantly associated with increased risk of ID.ConclusionThis systemic review and meta-analysis provides a comprehensive evidence-based assessment of the risk factors for ID. Future studies are encouraged to focus on perinatal and neonatal risk factors and the combined effects of multiple factors.     

The safety of obstetric services in small communities in northern Ontario.

The safety of the obstetric care system in the small hospitals of northern Ontario was assessed by analysing the outcomes of all obstetric cases over a 2-year period. Information was retrieved by place of residence rather than hospital of delivery so that the overall perinatal system, including the referral patterns, would be assessed. There was little difference in perinatal loss rate (stillbirths and neonatal deaths up to 28 days per 1000 births) for residents of areas served by different levels of obstetric care. Areas served by units where cesarean sections are done regularly but which do not have specialists in obstetrics or pediatrics had a perinatal loss rate of 10.43, whereas areas served by units staffed with two or more specialists in both obstetrics and pediatrics and handling more than 1000 deliveries per year had a perinatal loss rate of 12.13. Although many of the smaller hospitals did not have the minimum capabilities suggested for obstetric units relatively safe care was being provided. These results do not support the need for further centralization of obstetric services in northern Ontario.     

The outcome of twin pregnancies complicated by single fetal death after 20 weeks of gestation.

A retrospective study involving 972 twin births was conducted to evaluate the maternal and fetal outcomes of twin pregnancies complicated by single fetal death. The incidence of single fetal death in twin pregnancies after 20 weeks was 3.3%. Preterm birth rates for 37 and 32 gestational weeks were 81.3% and 41.6% respectively. The median interval between the diagnosis of fetal death and the delivery was 11 days (range 1-27 days). Eighteen (56%) infants were delivered by cesarean and 14 (43%) vaginally. Twin-twin transfusion syndrome (TTTS) was the cause of single fetal death in 8 of 32 twin pregnancies (25%). Ten of the surviving co-twins were lost in the neonatal period (31.3%) and half of those neonatal deaths were due to TTTS. TTTS is the major contributor for perinatal mortality in same-sex twins complicated by single fetal death. The death of one twin in utero should not be the only indication for preterm delivery, and in case of severe prematurity with a stable intrauterine environment; expectant management may be advisable until fetal lung maturation ensues.     

Osteocalcin is vitamin D-dependent during the perinatal period in the rat

The vitamin D-dependence of renal calbindin D-28K and osteocalcin during the perinatal period was studied in fetuses (days 18 and 21) and neonates (days 2, 12, 17 and 22) of rats fed either a standard diet (0.85% Ca-0.7% P; "high Ca-P diet" rats) or a mildly Ca-P restricted diet (0.2% Ca-0.2% P; "low Ca-P diet" rats). Body weight and plasma calcium levels were identical in both groups. Plasma 1,25(OH)2D concentrations were markedly higher in the low Ca-P diet rats at all stages of fetal and neonatal life (in 22-day-old neonates: 536 +/- 58 pg/ml versus 126 +/- 12 pg/ml). 1,25(OH)2D concentrations increased between day 18 and 21 of fetal life, remained constant between day 21 of fetal and day 12 of neonatal life, and increased sharply between day 12 and 17 in both groups; after day 17, 1,25(OH)2D concentrations increased further in pups fed the low Ca-P diet. Renal calbindin D-28K reached peak concentrations on day 12 of neonatal life; calbindin D-28K levels were similar in the high and low Ca-P diet rats at all stages of perinatal development. Plasma osteocalcin levels increased steadily during the perinatal period; at most stages of perinatal life, and already from the fetal period was osteocalcin higher in the low Ca-P diet rats than in the high Ca-P diet rats (in 22-day-old pups: 1106 +/- 47 ng/ml versus 429 +/- 14 ng/ml). Femoral osteocalcin concentrations were also increased in fetal and early neonatal (days 2 and 12) low Ca-P diet rats, while the femoral calcium content and concentration of these rats were decreased in the late neonatal period (days 12, 17 and 22). These studies indicate that osteocalcin is vitamin D-dependent in the fetal and neonatal rat.     

Perinatal mortality: a continuing collaborative regional survey.

A collaborative survey of perinatal mortality in each district of the Northern region set up in July 1980 was able to obtain information on 99% of all the registered perinatal deaths among babies born in 1981-2 to mothers resident in the region. There were 12.4 perinatal deaths/1000 births over this two year period, but 41% of the stillbirths and early neonatal deaths were of babies with a lethal malformation or weighing less than 1000 g at birth (or both). All causes of perinatal mortality had become less common than they had been at the time of the National Birthday Trust survey in 1958, though there had been a relatively small decrease in the number of deaths due to malformation (in the absence of any neural tube defect) and in the number of stillbirths of normally developed fetuses: 36% of the antepartum stillbirths among non-malformed singleton fetuses were associated with poor fetal growth (weight below the fifth centile at birth) and 21% were due to sudden unexplained placental abruption.     

Prenatal diagnosis of vascular anomalies: update and review of the literature

Optimal care for a subgroup of infants with complicated vascular anomalies requires prenatal diagnosis. Fetal vascular lesions are either vascular tumors or vascular malformations, both of which are often detected on routine ultrasound. Imaging, such as ultrasound and fetal MRI, can be used to examine lesions and provide the data for a differential diagnosis, which may impact the course of care both in utero and postnatally. Prenatal diagnosis provides the opportunity for antenatal intervention, parental counseling, and planning of the mode and location of delivery to optimize postnatal care. Prenatal diagnosis of vascular lesions also serves to alert the physician to the potential for associated syndromes and complications. Any indication of a vascular anomaly should be referred for further examination by an experienced multidisciplinary team of physicians to ensure the window in which evaluation, planning, and treatment can take place is not missed.     

Perinatal mortality and neonatal survival in Avon: 1976-9.

A study of perinatal and neonatal mortality figures for all 36 810 infants born to Avon residents during 1976-9 reported by year of birth and in relation to birth weight, gestational age, and th presence of lethal malformation showed the need for reporting mortality data for normally formed infants weighing 1000 g or more at birth and for assessing perinatal morbidity as well as mortality when attempting to evaluate the standard of perinatal care and the resources required to provide for it.     

Prevalence of congenital anomalies at birth among offspring of women at risk for a genetic disorder and with a normal second-trimester ultrasound.

The goal of this study was to determine the prevalence and the nature of congenital anomalies found at birth in offspring of women who had a normal second-trimester ultrasound and/or amniocentesis. Two groups of women were studied in our prenatal diagnosis clinic between 1991-1997. Group 1 consisted of pregnant women who had an amniocentesis for advanced maternal age (AMA), or for familial chromosomal or monogenic disorders. Group 2 consisted of pregnant women attending the prenatal diagnosis clinic and who had no indication for amniocentesis. Those with an abnormal ultrasound and/or amniocentesis were excluded. At the time of delivery, a questionnaire was sent pertaining to perinatal complications and the anomalies detected during the neonatal period. From a total of 15, 370 questionnaires sent from 1991-1997, 10,823 (group 1, n = 8,877; group 2, n = 1,946) were returned (overall response rate, 70.4%). Mean maternal age was 36 years in group 1 and 29 years in group 2. The prevalence of perinatal complications was similar in the two groups. In each group, the prevalence of all unforeseen anomalies was 2.9%. In group 1, the distribution of those anomalies was: major anomalies, 67.7%; minor anomalies, 23.9%; and multiple congenital anomalies (MCA), 8.3%. In group 2, the distribution was: major anomalies, 70.7%; minor anomalies, 24.1%; and MCA, 5.2%. In patients at risk for a genetic disease and consulting in a prenatal diagnosis clinic, the prevalence of all anomalies diagnosed at birth was 2.9%, even if the second-trimester ultrasound and amniocentesis results were normal. Therefore, it is important to inform those couples of this remaining risk.     

National census of availability of neonatal intensive care. British Association for Perinatal Medicine

ObjectiveTo determine whether availability of neonatal intensive care cots is a problem in any or all parts of the United Kingdom.DesignThree month census from 1 April to 30 June 1999 comprising simple data sheets on transfers out of tertiary units.SettingThe 37 largest high risk perinatal centres in the United Kingdom.ParticipantsOne obstetric specialist and one neonatal specialist in each centre.ResultsAll units provided data. The number of intensive care cots in each unit was between five and 16. During the three months 309 transfers occurred (equivalent to 1236 per year), of which 264 were in utero and 45 postnatal. Sixty five in utero transfers involved multiple births, hence the census related to 382 babies (1528 per year). There was considerable regional variation. The reason for transfer in most cases was “lack of neonatal beds”.ConclusionsCurrently most major perinatal centres in the United Kingdom are regularly unable to meet in-house demand; this has implications for the service as a whole. The NHS has set no standards to help health authorities and primary care groups develop services relating to this specialty; such a step may well be an appropriate lever for change.     

Fetal Genotyping in Maternal Blood by Digital PCR: Towards NIPD of Monogenic Disorders Independently of Parental Origin

PurposeTo date, non-invasive prenatal diagnosis (NIPD) of monogenic disorders has been limited to cases with a paternal origin. This work shows a validation study of the Droplet Digital PCR (ddPCR) technology for analysis of both paternally and maternally inherited fetal alleles. For the purpose, single nucleotide polymorphisms (SNPs) were studied with the only intention to mimic monogenic disorders.MethodsNIPD SNP genotyping was performed by ddPCR in 55 maternal plasma samples. In 19 out of 55 cases, inheritance of the paternal allele was determined by presence/absence criteria. In the remaining 36, determination of the maternally inherited fetal allele was performed by relative mutation dosage (RMD) analysis.ResultsddPCR exhibited 100% accuracy for detection of paternal alleles. For diagnosis of fetal alleles with maternal origin by RMD analysis, the technology showed an accuracy of 96%. Twenty-nine out of 36 were correctly diagnosed. There was one FP and six maternal plasma samples that could not be diagnosed.DiscussionIn this study, ddPCR has shown to be capable to detect both paternal and maternal fetal alleles in maternal plasma. This represents a step forward towards the introduction of NIPD for all pregnancies independently of the parental origin of the disease.