糖尿病史女性孕前管理

有糖尿病史的女性,如果孕前血糖没有得到良好的控制,妊娠后其母儿合并症和并发症发生率明显升高。重视糖尿病史女性的孕前咨询、孕前监测和评估并进行孕前干预是获得良好妊娠结局的关键。文章结合国内外指南,详细阐述糖尿病史女性的孕前管理方案,为临床工作提供参考。     

遗传性疾病史女性孕前咨询要点

随着人类对遗传性疾病认识的加深以及检测技术的快速发展,越来越多的有遗传病史的家庭可以通过产前诊断或者植入前诊断的方式获得健康后代。为了更加准确地提供相关咨询信息,遗传性疾病的诊断与遗传咨询已经成为产科医生必须掌握的技能之一。详细询问病史后利用遗传学基本知识与相应的检测技术,通过对患者及其家系成员实施遗传检测与咨询,寻找导致疾病表型的染色体或基因问题,从而为孕前咨询和获得健康后代提供确诊及预防的依据亦变得尤为重要。文章对有遗传性疾病史的女性如何进行孕前咨询进行阐述。     

高龄女性孕前管理

随着二孩政策的实行,近年来我国高龄孕妇人群明显增多。与非高龄孕妇人群相比,高龄孕妇在孕前及孕期面临更多问题,包括不孕、妊娠期合并症以及出生缺陷发生率高等,因此需要对该群体进行针对性的孕前管理。     

不良孕产史人群中血栓前状态易感基因分布调查

Objective?To explore the distribution of prethrombotic state susceptibility gene polymorphisms in the population with a history of poor pregnancy. Methods?From December 2018 to June 2021, 410 women with a history of poor pregnancy and childbirth (research group) and 111 normal women (control group) were collected as the research subjects. EDTA anticoagulated whole blood of the two groups were collected,its genomic DNA were extracted,fluorescence quantitative PCR technology was used to detect the distribution of prethrombotic state susceptibility gene polymorphisms. Results?① There was no significantly difference in MTHFR A1298 C, PAI-1 5G/4G, FⅤ A1691G, FⅡG20210A gene polymorphisms between the two group (P>0.05);② There were significantly difference in the distribution of genotypes in MTRR A66G sites AA,AG,GG between the two group (P<0.05).③ There were significantly difference in the AA,AG,GG genotypes and the G, A allele frequencies at the C677T site of MTHFR between the two group (P<0.05). Conclusion?The prethrombotic state susceptibility gene MTRR A66G locus and MTHFR C677T locus polymorphisms are related to the history of adverse pregnancy and childbirth.     

不良孕产史人群中血栓前状态易感基因分布调查CSCD

目的 探究血栓前状态易感基因多态性在不良孕产史人群中的分布。方法 收集2018年12月至2021年6月在山西省太原市妇幼就诊的410例有不良孕产史的女性(病例组)和111例无不良孕产史备孕女性(对照组)作为研究对象。采集两组人群EDTA抗凝全血,提取其基因组DNA,利用荧光定量PCR技术检测血栓前状态易感基因多态性在两组人群中的分布。结果 (1) MTHFR A1298 C、PAI-1 5G/4G、FⅤA1691G、FⅡG20210A基因多态性在对照组和病例组中分布差异无统计学意义(P> 0.05);(2) MTRR A66G位点AA、AG、GG基因型在对照组和病例组中分布差异有统计学意义(P <0.05);(3) MTHFR C677T位点AA、AG、GG基因型及G、A等位基因频率在对照组和病例组中的分布差异有统计学意义(P <0.05)。结论 血栓前状态易感基因MTRR A66G位点、MTHFRC677T位点多态性与不良孕产史密切相关。     

复发性流产孕前管理

        复发性流产在育龄期妇女中的发生率约为1%~5%,给育龄期女性造成身体和情感的双重打击。反复的清宫操作损伤子宫内膜,形成局部感染,导致宫腔粘连;多次的妊娠丢失给患者和家庭带来巨大的精神创伤,导致患者产生焦虑、紧张、沮丧等不良情绪。因此,复发性流产患者再次妊娠前急于向医师寻求帮助,然而复发性流产的病因复杂,约50%病因不明,临床诊治方面存在诸多争议,孕前管理非常棘手。因此,高度重视复发性流产女性的孕前管理,对促使再次成功妊娠并预防孕期并发症非常重要。本文主要针对复发性流产的孕前管理对象、病因筛查和孕前管理进行阐述。     

心脏病史女性孕前保健和管理

心脏病女性在妊娠期易发生心血管并发症,是孕产妇非产科因素死亡的重要原因,应加强孕前保健和管理。结合患者病史和检查进行孕前风险评估,能够手术矫正者建议其孕前手术治疗,不宜妊娠者应建议其避孕,允许继续妊娠者孕期应联合多学科管理,提高妊娠分娩安全性。     

染色体平衡易位伴不良孕史3例

目的报道3例染色体平衡易位伴不良孕史的病例。方法应用G显带技术对3例伴有不良孕史的女性患者进行染色体核型分析,检测到核型异常后用荧光原位杂交技术(FISH)进行验证。结果 3例患者均为平衡易位,核型分别为t(3;5)(p13;q13.3)、inv(4)(p16q13)和ins(4;7)(p15.2;q32q34),后用FISH验证结果与核型分析相符,经查询国内外权威数据库均未见3例异常核型相同报道。结论平衡易位是不明原因反复流产的重要因素之一,携带者再次妊娠应积极配合医生进行产前诊断。     

肾脏病史女性孕前保健

慢性肾脏病（CKD）妊娠不良结局包括流产、并发子痫前期、胎儿发育异常、胎儿生长受限、早产等。CKD女性妊娠需多学科共同管理,调整使用对胎儿影响较小的药物;帮助CKD患者选择合适的妊娠时机;指导患者调整生活状态,适应孕期的生理变化。     

血栓弹力图、血栓前状态与早期复发性流产的关系

目的:研究早期复发性流产(RSA)患者血栓弹力图(TEG)的改变,为早期RSA的诊断和治疗提供有效的检测指标。方法:对62例RSA患者和72例正常生育期妇女进行孕前及孕后的血栓弹力图(TEG)检测,统计各组TEG参数及妊娠丢失率。结果:(1)非孕状态时,RSA组与正常组相比,最大凝块振幅(MA)增高(P0.05)。(2)孕前MA≥64mm时,预测流产的敏感性和特异性分别为68%和82%。(3)RSA患者孕前异常MA纠正后,孕后TEG参数异常率及妊娠丢失率与孕前未纠正者比较,差异有统计学意义(P0.05)。结论:血栓弹力图可在非妊娠时鉴别部分RSA女性是否处在血栓前状态。在这样状态下未经治疗的RSA再次妊娠流产的风险增高。监测TEG有助于RSA的病因诊断,指导抗血小板药物的应用。     

The findings of the MBRRACE-UK confidential enquiry into Maternal Deaths and Morbidity

Reports from the UK Confidential Enquiries into Maternal Deaths and Morbidity are now published annually. In 2013–15, the maternal mortality rate was 8.8 per 100,000 maternities. Over two thirds of women died from medical and mental health causes and less than one third from obstetric causes. Cardiac disease remained the leading cause of maternal death in the UK. With the majority of women dying from pre-existing conditions, there remain multiple opportunities to reduce women's risk of complications in pregnancy through early and forward planning of the care of women with known pre-existing medical and mental health problems. Provision of appropriate advice and optimisation of medication prior to pregnancy, referral early in pregnancy for the appropriate specialist advice and planning of antenatal, intrapartum and postnatal care and effective postnatal provision of advice concerning risks and planning for future pregnancies are the key improvements needed to prevent women dying in the future.     

妊娠期高血压疾病血浆凝血酶生成活性检测的意义

目的探讨妊娠期高血压疾病(HDP)患者应用血浆凝血酶生成活性,判断HDP患者病情发展及预后。方法 2004年1月至2009年12月对上海市长宁区妇幼保健院、上海市宝山区罗店医院住院的妊娠妇女应用荧光发色底物分析方法,对妊娠期高血压疾病患者32例、轻度子痫前期35例、重度子痫前期38例(其中4例围产期发生急性D IC)和正常晚期孕妇50例血浆凝血酶生成活性进行检测,测定分析各组研究对象凝血酶生成的量和速度,并进行比较研究。结果正常孕妇凝血酶生成峰值为(362.0±29.6)nmol/L,妊娠期高血压疾病为(385.0±33.5)nmol/L,轻度子痫前期为(412.0±41.5)nmol/L,重度子痫前期为(624.0±67.6)nmol/L。轻、重度子痫前期患者较正常孕妇有显著增高(P<0.05),同时有纤维蛋白原及纤维蛋白降解产物D-二聚体(D-D)的明显改变,重度子痫前期凝血酶生成峰值与纤维蛋白原含量呈正相关关系(r=0.894,P<0.05)。结论轻、重度子痫前期患者存在不同程度的血栓前状态,重度子痫前期尤为明显。HDP患者血浆凝血酶生成活性检测可作为预测HDP患者血栓形成及D IC发生的实验室检查方法...     

Glycaemic control throughout pregnancy and risk of pre-eclampsia in women with type I diabetes

The aim of this study was to examine the influence of pre-pregnancy care and its effect on early glycaemic control and also the effect of glycaemic control in later pregnancy on risk of pre-eclampsia in women with type I diabetes. A prospective cohort study of 290 consecutive nonselected pregnancies in women with type I diabetes was performed from 1991 to 2002. We examined the relationship of monthly glycosylated haemoglobin (HbA1c) level, pre-pregnancy care, parity, diabetes duration, microvascular complications, maternal age, weight and smoking with risk of pre-eclampsia. Pre-eclampsia developed in 31/243 singleton births (12.8%). HbA1c level at 24 weeks was significantly increased in women with pre-eclampsia compared with women without pre-eclampsia (6.0 versus 5.6%, P= 0.017) and was, after nulliparity, the strongest independent predictor of increased risk (OR 1.65 for each 1% increase in HbA1c; P= 0.01). In contrast, there was no relationship between pre-pregnancy care or HbA1c level at booking and risk of pre-eclampsia.     

低分子肝素在复发性流产中的应用及监测

复发性流产患者需全面筛查病因,对因治疗能取得良好的妊娠结局。低分子肝素主要应用于血栓前状态、抗磷脂综合征和自身免疫性疾病等引起的复发性流产的防治。文章重点讨论低分子肝素在复发性流产患者中的应用与监测相关问题。     

低分子肝素在复发性流产中的应用及监测

复发性流产患者需全面筛查病因,对因治疗能取得良好的妊娠结局.低分子肝素主要应用于血栓前状态、抗磷脂综合征和自身免疫性疾病等引起的复发性流产的防治.文章重点讨论低分子肝素在复发性流产患者中的应用与监测相关问题.     

“on PINK ELEPHANTS” Coping with Gender Identity Disorder

This study considers various factors, such as personality, psychological distress, emotional problems, emotional support, clinical and sociodemographic characteristics, of women who asked for an abortion and compares them with psychological distress 3 months after the abortion. Using factorial analysis of a personality test (Eysenk Personality Inventory) and a clustering method that utilized the factorial scores, it was possible to identify three groups which had different personality characteristics, namely: neurotic, extravert and extravert—neurotic. The three groups proved to be significantly different in certain sociodemographic and social support characteristics and also in the degree of psychological distress (symptom checklist; SCL 90) before and after abortion. Following the abortion, estimation of psychological distress showed that the extravert group, with low distress initially, exhibited an improvement in global severity index (GSI), anxiety, somatization and depression. The neurotic group, who had a higher degree of distress initially, tended to get worse, while the extravert—neurotic group obtained better scores for somatization but worse scores for hostility and paranoia. Estimation of the prevalence of women with a higher degree of distress (a GSI score ≥ 1) before and after the abortion, on the contrary, did not show significant variations. Certain social and emotional support variables correlate with postabortion emotional variations, but these variations seem to be closely related to personality. The data thus support the hypothesis that the emotional state of a woman after an abortion is closely related to her emotional state before the abortion and with her personality characteristics. These data may suggest the need of specific forms of psychological support for women with high neuroticism and lack of support and/or with previous psychological disturbances, in order to improve their emotional state before and after an abortion.

Zusammenfassung

In dieser Studie werden verschiedene Faktoren untersucht, so zum Beispiel: Persönlichkeit, psychologische Beschwerden, emotionale Probleme, emotionale Unterstützung, klinische und soziodemographische Merkmale von Frauen, die einen Schwangerschaftsabbruch vornehmen lassen wollten. Diese Faktoren werden mit den psychologischen Beschwerden drei Monate nach dem Abbruch verglichen. Mit Hilfe der Faktoranalyse eines Persönlichkeitstests (EPI) und eines die Faktorenwerte nutzenden Clusterverfahrens konnten drei Gruppen mit unterschiedlichen Persönlichkeitsmerkmalen defmiert werden, und zwar: neurotisch, extrovertiert und extrovertiert—neurotisch. Für die drei Gruppen ergaben sich signifikante Unterschiede im Hinblick auf bestimmte soziodemographische Merkmale und Merkmale der sozialen Unterstützung sowie bezüglich des Grades der psychologischen Beschwerden (SCL 90) vor und nach dem Schwangerschaftsabbruch. Nach dem Abbruch ergab eine Bewertung psychologischer Beschwerden bei der extrovertierten Gruppe mit geringen Anfangsbeschwerden eine Besserung im Hinblick auf GSI, Angst, Somatisierung und Depression. Bei der neurotischen Gruppe, bei der ein höheres Anfangsniveau in bezug auf Beschwerden vorhanden war, trat im allgemeinen eine Verschlechterung ein, wohingegen sich für die extrovertiert—neurotische Gruppe bessere Werte in bezug auf die Somatisierung und schlechtere Werte im Hinblick auf Feindseligkeit und Paranoia ergaben. Für die Schätzwerte bezüglich der Häufigkeit von Frauen mit einem höheren Grad an Beschwerden (GSI-Wert ≥ 1) vor und nach einem Abbruch wurden dagegen keine signifikanten Abweichungen beobachtet. Bestimmte Parameter der sozialen und emotionalen Unterstützung weisen eine Korrelation zu emotionalen Abweichungen nach dem Abbruch auf, die jedoch in engem Zusammenhang mit der Persönlichkeit zu stehen scheinen. Die Daten stützen also die Hypothese, daβ ein enger Zusammenhang zwischen emotionaler Verfassung von Frauen nach einem Schwangerschaftsabbruch und ihrem/ihrer emotionalen (Rest fehlt – Anm. d. Ü.). Die praktischen Auswirkungen dieser Feststellungen betreffen die Möglichkeit, aus der Gesamtheit aller Frauen, die einen Abbruch vornehmen lassen wollen, eine Untergruppe von hochgradig neurotischen Frauen, die keine Unterstützung erfahren und/oder bereits früher unter seelischen Störungen litten, zu ermitteln, für die eine Art spezieller psychologischer Betreuung aufgebaut werden könnte, deren Ziel eine Besserung ihrer emotionalen Verfassung vor und nach einem Abbruch ist.

Résumé

Cette étude examine différents facteurs: la personnalité, la souffrance psychologique, les problèmes èmotionnels, le soutien émotionnel, les caractéristiques cliniques et sociodémographiques des femmes désireuses d'avorter et les compare avec la souffrance psychologique trois mois après l'avortement. L'analyse factorielle d'un test de personnalité (EPI) et une méthode typologique utilisant les scores factoriels a permis d'identifier trois groupes dont la personnalité était différente, à savoir: une personnalité névrosée, extravertie et extravertie—névrosée. Les trios groupes se sont avérés nettement différents en ce qui concerne certaines caractéristiques sociodémographiques et de support social ainsi que le degré de souffrance psychologique (SCL 90) avant et après l'avortement. Après l'avortement, l'évaluation de la souffrance psychologique indiquait que le groupe extraverti dont le taux de souffrance était initialement faible, manifestait une amélioration du GSI, une baisse de l'anxiété, de la somatisation et de la dépression. L'état du groupe, névrosé dont le taux de souffrance initiale était plus élevé, avait tendance à s'aggraver tandis que le groupe extraverti—névrosé obtenait des meilleures scores en matière de somatisation mais des scores inférieurs en matière d'hostilité et de paranoïa. Par contre, l'estimation du nombre de femmes dont le degré de souffrance (un score GSI ≥ 1) était plus élevé avant et après l'avortement, n'indiquait pas des variations appréciables. Il existait une corrélation entre certaines variables relatives au support social et émotionnel et les changements d'émotivité après l'avortement mais ceux-ci semblent dépendre surtout de la personnalité. Done, les données corroborent l'hypothèse que l'état émotionnel d'une femme après un avortement est fortement influencé par son état émotif avant l'avortement et dépend de sa personnalité. Ces données pourraient indiquer la nécessité d'un support psychologique spécifique pour les femmes fortement névrosées et sans soutien et/ou souffrant précédemment de troubles psychologiques afin d'améliorer leurs état émotionnel avant et après l'avortement.     

Double versus single thrombophilias during pregnancy

Objective: The primary objective of this study was to evaluate whether women with double thrombophilias have a greater risk for obstetric complications as compared with women who have single thrombophilias.

Study design: This is a retrospective cohort study of all patients in a single practice with a clinically significant inherited thrombophilia and treated with anticoagulation between 2005 and 2013. Thrombophilias evaluated include: factor V Leiden, prothrombin G20210A gene mutation, protein S deficiency, protein C deficiency, and antithrombin III deficiency. Double thrombophilia was defined as the presence of two thrombophilias or homozygosity for factor V Leiden or prothrombin Gene Mutation. Demographic and obstetrical outcome data were collected. Data on all patients with double thrombophilias who met inclusion criteria was reported. Data was then compared between the patients with double thrombophilias and single thrombophilias with singleton gestations. The data was analyzed with Pearson’s chi-squared or Student’s t-test as appropriate with p value <.05 used for significance.

Results: Eighteen patients with clinically significant double thrombophilias who met inclusion criteria were identified. Most patients delivered full term (88.9%) and appropriate for gestational age (77.8%) infants. One hundred thirty-two patients with single thrombophilias and 14 patients with double thrombophilias with singleton gestations were then compared. Demographic characteristics were not significantly different between the two groups. There were no significant differences in obstetrical outcomes between patients.

Conclusions: There were no significant differences in obstetrical outcomes for patients with clinically significant double thrombophilias versus single thrombophilias when treated with anticoagulation.