妊娠合并风湿性心脏病患者心功能状态对妊娠结局的影响

目的探讨妊娠合并风湿性心脏病患者心功能状态对妊娠结局的影响。方法对1993年1月至2006年7月在我院产科分娩的、资料齐全的65例妊娠合并风湿性心脏病患者的临床资料进行回顾性分析。根据患者的二尖瓣狭窄程度分为二尖瓣正常组20例（瓣口面积〉4．0cm^2）、轻度狭窄组11例（瓣口面积2．5—4．0cm^2）、中度狭窄组14例（瓣121面积1．5—2．5cm^2）以及重度狭窄组20例（瓣口面积〈1．5cm^2）;根据是否伴有肺动脉高压分为正常压力组33例[肺动脉压〈30mmHg（1mmHg=0．133kPa）]、轻度升高组18例（肺动脉压31—49mmHg）、中度升高组7例（肺动脉压50～79mmHg）和重度升高组7例（肺动脉压≥80mmHg）;根据孕前是否进行心脏手术分为心脏手术组14例和非心脏手术组51例;根据患者的不同心功能状态分为Ⅰ级组24例、Ⅱ级组13例、Ⅲ级组13例、Ⅳ级组15例,观察各组的围产儿结局。分析以上各种因素对妊娠合并风湿性心脏病患者妊娠结局的影响。结果（1）二尖瓣正常组患者心功能Ⅰ～Ⅱ级者为80％（16／20）,Ⅳ级组患者中,80％（12／15）在中度狭窄组（6例）及重度狭窄组（6例）,与二尖瓣正常组和轻度狭窄组的心功能Ⅳ级发生率（20％,3／15）比较,差异有统计学意义（P〈0．05）。（2）正常压力组患者心功能Ⅰ～Ⅱ级者为73％（24／33）,重度升高组患者心功能Ⅳ级的发生率（6／7）明显高于心功能Ⅰ级的发生率（1／7）,两者比较,差异有统计学意义（P〈0．05）。（3）心脏手术组患者心功能Ⅰ～Ⅱ级发生率为71％（10／14）,Ⅲ级和Ⅳ级的发生率均为14％（2／14）,前后两者比较,差异有统计学意义（P〈0．05）;非心脏手术组患者Ⅰ～Ⅳ级心功能发生率之间分别比较,差异均无统计学意义（P〉0．05）。（4）心功能Ⅰ～Ⅲ级组患者的平均孕周及新生儿平均出生体重分别比较,差异无统计学意义（P〉0．05）;而心功能Ⅳ级组平均孕周为（34．6±3．1）周,新生儿平均出生体重为（2176±186）g,明显低于心功能Ⅰ级组,两组比较,差异有统计学意义（P〈0．05）。心功能Ⅲ～Ⅳ级组患者中,共发生医源性流产和引产9例（14％,9／65）,医源性早产18例（28％,18／65）,胎儿生长受限4例（6％,4／65）,围产儿死亡3例（5％,3／65）;而心功能Ⅰ～Ⅱ级组患者以上指标均为0。（5）65例妊娠合并风湿性心脏病患者中合并心房纤颤者7例,其心功能Ⅲ～Ⅳ级（心功能衰竭）的发生率为6／7。结论妊娠合并风湿性心脏病患者伴中、重度二尖瓣狭窄、重度肺动脉压升高及心房纤颤,容易发生心功能衰竭危及生命,不宜妊娠。已妊娠者应尽早终止妊娠;心功能Ⅲ～Ⅳ级的妊娠合并风湿性心脏病患者的医源性流产、早产和围产儿病率均增加,围产儿结局不良。     

Recurrent risk of adverse pregnancy outcome

It is an unfortunate fact that all pregnancies do not end with healthy babies and healthy mothers. Families who have experienced an adverse pregnancy outcome require accurate information about the risk of recurrence to plan future childbearing. This article examines the recurrence risk of four complications of pregnancy: gestational diabetes, preterm delivery, stillbirth, and preeclampsia. Combined, these four complications are responsible for approximately 24% of maternal and neonatal morbidity and mortality.     

Periodontal disease and bacterial vaginosis increase the risk for adverse pregnancy outcome

OBJECTIVES: To determine whether periodontal disease or bacterial vaginosis (BV) diagnosed before pregnancy increase the risk for adverse pregnancy outcome. METHODS: We enrolled a total of 252 women who had discontinued contraception in order to become pregnant. The first 130 pregnant women were included in the analyses. RESULTS: Multivariate analysis showed a strong association between periodontal disease and adverse pregnancy outcome (OR 5.5, 95% confidence interval 1.4-21.2; p = 0.014), and a borderline association between BV and adverse pregnancy outcome (OR 3.2, 95% confidence interval 0.9-10.7; p = 0.061). CONCLUSION: Our study suggests that pre-pregnancy counseling should include both oral and vaginal examinations to rule out periodontal disease and BV. This may ultimately have an impact on antenatal healthcare, and decrease the risk for adverse pregnancy outcome.     

Epstein-Barr virus infection during pregnancy and the risk of adverse pregnancy outcome

OBJECTIVES: To study the association between Epstein-Barr virus (EBV) antibody status in early pregnancy and pregnancy outcomes including fetal death, length of gestation and fetal weight and length at birth. DESIGN: Nested control study. SETTING: Population based health registers. POPULATION: The source population comprised 35,940 pregnant women. Cases were all (280) women with fetal death and a random sample of 940 women with a live born child. METHOD: Information on pregnancy outcome was obtained from the Norwegian Medical Birth Registry. Serum samples from the first trimester were tested for EBV antibodies. In women seronegative for EBV, further serum from late pregnancy was analysed to detect seroconversion. Main outcome measures Vital status, length of gestation, weight and length at birth. RESULTS: There was no association between EBV antibody status and fetal death. Women with significant EBV reactivation had a significantly shorter duration of pregnancy, and associated lighter babies, compared with women without significant reactivation (stillborn: 176 vs 197 days, P=0.16, and live born: 271 vs 279 days, P=0.03, respectively). CONCLUSION: Significant reactivation of EBV infection during pregnancy may influence pregnancy duration.     

Idiopathic bleeding during the second half of pregnancy as a risk factor for adverse perinatal outcome.

OBJECTIVE: To investigate pregnancy outcome in women suffering from idiopathic vaginal bleeding (IVB) during the second half of pregnancy. METHODS: A comparison between patients admitted to the hospital due to bleeding during the second half of pregnancy and patients without bleeding was performed. Patients lacking prenatal care as well as multiple gestations were excluded from the analysis. Stratified analyses using the Mantel-Haenszel technique and a multiple logistic regression model were performed to control for confounders. RESULTS: During the study period, 173,621 singleton deliveries occurred at our institute. Of these, 2077 (1.19%) were complicated with bleeding upon admission during the second half of pregnancy. After excluding cases with bleeding due to placental abruption, placenta previa, cervical problems, etc., 67 patients were classified as having IVB (0.038%). Independent risk factors associated with IVB, using a backward, stepwise multivariable analysis were oligohydramnios (OR=6.2; 95% CI 3.1-12.7; p < 0.001), premature rupture of membranes (OR=3.4; 95% CI 1.8-6.2; p < 0.001), intrauterine growth restriction (IUGR, OR 5.6; 95% CI 2.5-12.2; p < 0.001), and Jewish ethnicity (OR=1.9; 95% CI 1.0-3.5; p=0.036). These patients subsequently were more likely to deliver preterm (<37 weeks, 56.7% vs. 7.3%; mean gestational age of 33.6+/-5.7 weeks vs. 39.2+/-2.1 weeks; p < 0.001) and by cesarean delivery (CD, 35.8% vs. 12.1%, OR=4.0; 95% CI 2.4-6.6; p < 0.001). Higher rates of low Apgar scores (<7) at 1 and 5 minutes were noted in these patients (OR=10.3; 95% CI 5.9-17.8; p < 0.001 and OR=17.8; 95% CI 7.1-44.5; p < 0.001, respectively). Moreover, perinatal mortality rate among patients admitted due to idiopathic bleeding was significantly higher as compared to patients without bleeding (9.6% vs. 1.2%, OR=8.4; 95% CI 3.3-21.2; p < 0.001). However, when controlling for preterm delivery, using the Mantel-Haenszel technique, the association lost its significance. CONCLUSION: Idiopathic vaginal bleeding during the second half of pregnancy is a risk factor for adverse perinatal outcome, mostly due to its significant association with preterm delivery. Careful surveillance, including fetal monitoring, is suggested in these cases in order to reduce the adverse perinatal outcome.     

Maternal morbid obesity and the risk of adverse pregnancy outcome

OBJECTIVE: To evaluate whether morbidly obese women have an increased risk of pregnancy complications and adverse perinatal outcomes. METHODS: In a prospective population-based cohort study, 3,480 women with morbid obesity, defined as a body mass index (BMI) more than 40, and 12,698 women with a BMI between 35.1 and 40 were compared with normal-weight women (BMI 19.8-26). The perinatal outcome of singletons born to women without insulin-dependent diabetes mellitus was evaluated after suitable adjustments. RESULTS: In the group of morbidly obese mothers (BMI greater than 40) as compared with the normal-weight mothers, there was an increased risk of the following outcomes (adjusted odds ratio; 95% confidence interval): preeclampsia (4.82; 4.04, 5.74), antepartum stillbirth (2.79; 1.94, 4.02), cesarean delivery (2.69; 2.49, 2.90), instrumental delivery (1.34; 1.16, 1.56), shoulder dystocia (3.14; 1.86, 5.31), meconium aspiration (2.85; 1.60, 5.07), fetal distress (2.52; 2.12, 2.99), early neonatal death (3.41; 2.07, 5.63), and large-for-gestational age (3.82; 3.50, 4.16). The associations were similar for women with BMIs between 35.1 and 40 but to a lesser degree. CONCLUSION: Maternal morbid obesity in early pregnancy is strongly associated with a number of pregnancy complications and perinatal conditions. LEVEL OF EVIDENCE: II-2     

妊娠期糖耐量减低的处理与新生儿结局的关系

目的 探讨妊娠期耐量减低的合理处理与胎儿及新生儿预后的关系。方法 收集１９９６年７月～１９９８年６月妊娠期糖耐量减低的孕妇９８例,其中６１例在孕期接受饮食控制或胰岛素治疗（治疗组）;３７例未进行治疗（未治疗组）,对两组围产儿妊娠结局进行比较。结果 治疗组巨大儿发生率为６．６５％明显低于未治疗组的３５．１４％（Ｐ〈０．０１）,胎儿窘迫发生率治疗组为１９．６７％,未治疗组为３７．８４％,两组比较,差异     

Second-trimester maternal serum alpha-fetoprotein and risk of adverse pregnancy outcome(1)

OBJECTIVE: To determine the risk of adverse pregnancy outcome by maternal serum alpha-fetoprotein (MSAFP) level. METHODS: We followed 77,149 pregnant women and their infants from MSAFP screening in the 15th to 20th week of gestation until 1 year after birth. Information on pregnancy outcome was obtained from national registries. The relative risks (RRs) and 95% confidence intervals (CIs) for adverse pregnancy outcome were estimated according to the level of MSAFP, with adjustment for confounders. RESULTS: A total of 638 pregnancies resulted in spontaneous abortion, 289 in stillbirth, and 437 in infant death. Compared with women with MSAFP levels at 0.75-1.24 multiples of the median (MoM), those with MSAFP levels greater than or equal to 2.5 MoM had an increased risk of spontaneous abortion (RR 12.5; 95% CI 9.7, 16.1), preterm birth (RR 4.8; 95% CI 4.1, 5.5), small for gestational age (RR 2.8; 95% CI 2.4, 3.2), low birth weight (RR 5.8; 95% CI 5.0, 6.6), and infant death (RR 1.9; 95% CI 1.2, 2.8). Women with MSAFP levels below 0.25 MoM had an increased risk of spontaneous abortion (RR 15.1; 95% CI 9.3, 24.8), preterm birth (RR 2.2; 95% CI 1.3, 3.8), and stillbirth (RR 4.0; 95% CI 1.0, 16.0); those with levels less than 0.5 MoM had an increased risk of infant death (RR 1.9; 95% CI 1.2, 3.0). The increased risk of infant death remained after the subtraction of recognized conditions associated with extreme MSAFP values. CONCLUSION: Pregnant women with extreme MSAFP values in the second trimester have an increased risk of fetal and infant deaths. Obstet Gynecol 2001;97:277-82.     

Effect of aspirin in prevention of adverse pregnancy outcome in women with elevated alpha-fetoprotein

Abstract

Background: To evaluate the effect of low-dose aspirin in prevention of adverse pregnancy outcomes (APO) in women with second trimester alpha-fetoprotein (AFP) >2.5 multiple of median (MOM) and to compare aspirin effect on women with normal and abnormal uterine artery (UtA) Doppler. The primary outcome was the adverse pregnancy outcome.

Methods: This randomized controlled trial was conducted in singleton pregnant women, who had unexplained AFP >2.5 MOM and gestational age between 15 and 18 weeks of gestation. They were assigned randomly to receive either aspirin (N?=?65) or control (N?=?68). UtA Doppler velocimetry studies were performed at the time of targeted ultrasonographic exam.

Results: Two groups were comparable regarding the maternal characteristics. The frequency of APO in aspirin and control groups were 26.1% versus 44.1% (p?=?0.045), the frequency of preterm delivery before 34 weeks were 3.2% versus 22.0% in aspirin and control group, p?=?0.001. Other outcomes were similar in both groups. The frequency of adverse outcomes in women with abnormal UtA Doppler was 39.1% in aspirin and 60.0% in control group, p?=?0.556.

Conclusion: Low-dose aspirin reduces APO and delivery before 34 weeks of gestation in pregnant women with unexplained elevated AFP.     

风湿免疫性疾病母婴不良结局监测和防范

风湿免疫性疾病好发于育龄女性,妊娠合并风湿免疫性疾病是产科最常见的高危妊娠。大多数的风湿免疫性疾病在孕期均可发生病情变化,甚至危及母婴生命。充分认识妊娠与风湿免疫性疾病的相互影响,建立多学科管理团队,开展有效的孕期监测手段,防范母婴不良结局是一项重要任务。     

Perinatal outcome in women with severe chronic hypertension during the second half of pregnancy.

OBJECTIVES: To determine the perinatal outcome associated with severe chronic hypertension (SCH) in pregnancies of > or =20 weeks' gestation. METHODS: A retrospective analysis of data obtained prospectively of patients with SCH (> or =160/110 mmHg) who were hospitalized and delivered during a 5-year period. Each patient received intensive monitoring of the clinical status throughout the hospitalization (mother, fetus and neonates). Antihypertensive drugs were used for blood pressure > or =160/110 mmHg, glucocorticoids for pregnancies of 24-34 weeks and magnesium sulfate for women with superimposed pre-eclampsia (SPE). The main outcome measures were fetal and neonatal deaths, fetal growth restriction (FGR), major neonatal complications and length of stay in the neonatal intensive care unit (NICU). RESULTS: Of 154 women studied, 78% developed SPE and the mean week's gestation at delivery was 34.5+/-4.6. The average birth weight was 2329+/-1011 g. and the FGR was 18.5%. Four patients had a dead fetus at the time of admission, eight during the hospitalization and there were six neonatal deaths resulting in perinatal mortality of 11.4%. Thirty-eight babies were admitted to the NICU, average stay was 14.8 days. The most common contributors to neonatal mortality and morbidity were pulmonary complications and sepsis. CONCLUSIONS: This study found that the neonatal outcomes in pregnancy with SCH are better than the historical experience, but preterm deliveries, cesarean section, SPE, abruptions and total perinatal mortality remains very high.     

Risk for recurrence of preeclampsia and outcome of subsequent pregnancy in women with preeclampsia in their first pregnancy

Objective: To assess subsequent pregnancy outcome and to identify risk factors for recurrence of preeclampsia (PET) in women with PET in their first pregnancy. Methods: A retrospective cohort study of all nulliparous women diagnosed with PET during the years 1996–2008 (PET group, N = 600). Outcome of subsequent pregnancy was compared with a control group of nulliparous women without PET matched by maternal age in a 3:1 ratio (N = 1800). Results: Subsequent pregnancies in the PET group were characterized by a higher rate of preterm delivery at less than 37 and 34 weeks (15.2% vs. 5.7%, p < 0.001 and 3.8% vs. 0.8%, p < 0.001, respectively), placental abruption (1.7% vs. 0.2%, p = 0.004), IUGR (2.8% vs. 0.9%, p = 0.016), and PET (5.9% vs. 0.8%, p < 0.001). Risk factors for PET and adverse outcome in the subsequent pregnancy included: PET complicated by placental abruption in the index pregnancy (OR = 10.8, 95%-CI = 1.8–34.6), PET requiring delivery prior to 34 weeks in the index pregnancy (OR = 6.5, 95%-CI = 1.6–22.5), chronic hypertension (OR = 5.3, 95%-CI = 1.9–12.7), and maternal age > 35 (OR = 4.3, 95%-CI = 1.2–20.5). Conclusion: PET in the first pregnancy is independently associated with an increased risk for adverse pregnancy outcome and recurrence of PET in the subsequent pregnancy in a manner that is related to the severity of PET in the first pregnancy.     

Teenage pregnancy: risk factors for adverse perinatal outcome.

OBJECTIVES: To assess the perinatal outcome of teenage pregnancy in a large cohort and to determine risk factors for low birth weight (LBW) in teenage pregnancy. STUDY DESIGN: All singleton first deliveries to mothers of age 16-24 years between 1990 and 1997 were included. The deliveries were subdivided into three maternal age groups (16-17 and 18-19 compared to 20-24 years) and parameters of perinatal outcomes were compared. To adjust for potential confounding effects on the association between young maternal age and birth weight, logistic regression analysis was performed for LBW with maternal ethnicity, pregnancy-induced hypertension, lack of prenatal care and malformations of the newborn. RESULTS: Among a total of 11 496 patients, 600 (5.2%) were 16-17 years old, 2097 (18.2%) were 18-19 years old and the remaining 8799 (76.6%) were 20-24 years old. Bedouin ethnicity and lack of prenatal care were common in the youngest mothers. Rates of preterm delivery were 14.2%, 9.8% and 8.8% in the three age groups, respectively (p < 0.05). Rates of malformations, small for gestational age, LBW and very LBW were also significantly higher in the youngest mothers. Rates of pregnancy-induced hypertension, operative delivery and Cesarean delivery were not significantly different among the three age groups. A multivariate analysis on LBW was performed to assess the unique contribution of young maternal age, adjusted for potential confounders. Adjusted ORs for LBW were 1.25 (95% CI 1.00-1.56) for maternal age < 18 years, 1.80 (95% CI 1.54-2.03) for Bedouin ethnicity, 2.57 (95% CI 2.14-3.07) for pregnancy-induced hypertension, 1.55 (95% CI 1.30-1.84) for lack of prenatal care and 4.09 (95% CI 3.2-5.2) for malformations. CONCLUSIONS: Teenage pregnancy was found to be associated with adverse outcome such as LBW, preterm delivery, small for gestational age and malformations. The risk for LBW was affected mainly by demographic factors (maternal ethnicity, lack of prenatal care) and medical factors (pregnancy-induced hypertension, malformations).     

Inflammatory bowel disease: risk factors for adverse pregnancy outcome and the impact of maternal weight gain

Objective: To identify risk factors for adverse pregnancy outcome in women with inflammatory bowel disease (IBD) and to assess the effect of maternal pre-pregnancy weight and weight gain during pregnancy on pregnancy outcome. Methods: A retrospective, matched control study of all gravid women with IBD treated in a single tertiary center. Data were compared with healthy controls matched to by age, parity and pre-pregnancy BMI in a 3:1 ratio. Results: Overall, 300 women were enrolled, 75 women in the study group (28 with ulcerative colitis and 47 with Crohn’s disease) and 225 in the control group. The rates of preterm delivery and small for gestational age were higher in the study group (13.3 vs. 5.3% p = 0.02 and 6.7 vs. 0.9%, p = 0.004). The rate of cesarean section (36 vs. 19.1%; p = 0.002), NICU admission (10.7 vs. 4.0%, p = 0.03) and low 5-Min Apgar (4.0 vs. 0.4%, p = 0.02) were increased in the study group. Disease activity within 3 months of conception [OR 8.4 (1.3–16.3)] and maternal weight gain of less than 12 kg. [OR 3.6 (1.1–12.2)] were associated with adverse pregnancy outcome. Conclusion: Active disease at conception and inappropriate weight gain during pregnancy are associated with increased adverse pregnancy outcome in patients with IBD.     

Evidence of endothelial dysfunction in preeclampsia and risk of adverse pregnancy outcome

The purpose of this study is to investigate whether endothelial dysfunction, as assessed by elevated cellular fibronectin (cFN), in women with preeclampsia is associated with an increased risk of preterm and/or small-for-gestational-age (SGA) births. Maternal plasma cFN was measured by enzyme-linked immunosorbent assay in samples collected at admission to delivery in 605 normotensive women, 171 women with transient hypertension, and 187 women with preeclampsia. Logistic regression was used to estimate the risk for preterm delivery, SGA, or both. Elevated cFN in women with preeclampsia was associated with an increased risk of both preterm and SGA births (odds ratio, 3.0; confidence interval [CI], 1.0-8.7) compared with women with preeclampsia without elevated cFN. The risk of preterm birth was 14.7-fold higher (CI, 8.1-26.7) and the risk of SGA was 6.8-fold higher (CI, 3.5-13.1) in women with preeclampsia, hyperuricemia, and elevated cFN compared with normotensive women. Elevated cFN is prevalent among women with preeclampsia and identifies women at increased risk of preterm delivery and SGA.