社区管理的妊娠期糖尿病患者治疗中饮食控制联合运动干预的效果

目的:评价社区管理的妊娠期糖尿病患者治疗中,饮食控制+运动干预的重要价值。方法:取82例妊娠期糖尿病者(女性)加以观察,因治疗中干预法不同,将其分为1组、2组,行饮食控制的患者为1组,行饮食控制+运动干预的患者为2组,对比两组血糖水平、生活质量、妊娠结局等。结果:干预后,两组患者血糖水平均降低,较之1组,2组患者空腹血糖、餐后1h血糖水平降低幅度较大(P<0.05);干预后,较之1组,2组患者生活中躯体、心理、社会、物质评分均提升(P<0.05);干预后,1组患者妊娠不良结局发生率为26.83%,顺产发生率为56.10%;2组患者妊娠不良结局发生率为2.44%,顺产发生率为82.93%;较之1组,2组妊娠不良结局发生率明显降低,顺产率明显提高(P<0.05)。结论:社区妊娠糖尿病患者治疗中,饮食控制+运动干预有重要作用,可快速平稳患者血糖水平,提高患者生活质量,改善妊娠结局,值得广泛应用。

Acute fatty liver of pregnancy:An update on pathogenesis and clinical implications

Acute fatty liver of pregnancy (AFLP) is a serious maternal illness occurring in the third trimester of pregnancy with significant perinatal and maternal mortality. Till recently, it has been considered a mysterious illness. In this editorial, we review the recent advances in understanding the pathogenesis of AFLP and discuss the studies documenting a fetal-maternal interaction with a causative association between carrying a fetus with a defect in mitochondrial fatty acid oxidation and development of AFLP. Further, we discuss the impact of these recent advances on the offspring born to women who develop AFLP, such that screening for a genetic defect can be life saving to the newborn and would allow genetic counseling in subsequent pregnancies. The molecular basis and underlying mechanism for this unique fetal-maternal interaction causing maternal liver disease is discussed.

Intrahepatic cholestasis of pregnancy:When should you look further?

Pruritis with abnormal liver function tests is the classical presentation of intrahepatic cholestasis of pregnancy(ICP),a condition associated with significant fetal complications.Although the etiology of ICP is unclear in many cases,certain features of the clinical presentation should alert the practitioner to the possibility of an underlying metabolic defect, which may not only affect subsequent pregnancies, but may be an indicator of more serious subsequent liver disease.We report a kindred of Anglo-Celtic descent,among whom many members present with ICP,gallstones or cholestasis related to use of oral contraception.Genetic studies revealed a novel mutation in the ABCB4 gene,which codes for a phospholipid transport protein.The clinical significance of this mutation and the importance of identifying such patients are discussed.

Is infliximab safe to use while breastfeeding?

Inflammatory bowel disease (IBD) often affects women around the age of conception and pregnancy. Most drugs used to treat IBD are safe in pregnancy, but physicians must consider the clinical implications of certain treatment regimens in young, fertile females. We report an informative case of a pregnant patient with IBD who underwent treatment with infliximab during her pregnancy and while nursing her infant. Serum and breast milk infliximab levels were monitored throughout this time period. This case report suggests that targeted monoclonal antibodies and other biologic agents can be used with caution in pregnant and breastfeeding patients.

Choice of laxatives and colonoscopic preparation in pregnant patients from the viewpoint of obstetricians and gastroenterologists

AIM： To elucidate the preferences of gastroenterologists at our institution and compare them to those of obstetricians when making decisions in the pregnant patient, including which type of bowel preparations to use for flexible sigmoidoscopy or colonoscopy, as well as which laxatives can be used safely.METHODS： Surveys were mailed to all attending gastroenterologists （n = 53） and obstetricians （n = 99） at our institution. Each survey consisted of the 14 most common laxative or motility agents used in pregnancy and inquired about the physician＇s prescribing habits in the past as well as their willingness to prescribe each medication in the future. The survey also listed four common bowel preparations used prior to colonoscopy and sigmoidoscopy and asked the physician to rank the order of the preferred agent in each case.RESULTS： With regard to common laxatives, both gastroenterologists and obstetricians favor the use of Metamucil, Colace, and Citrucel. Both groups appear to refrain from using Fleets Phosphosoda and Castor oil. Of note, obstetricians are less inclined to use PEG solution and Miralax, which is not the case ,with gastroenterologists. In terms of comparing bowel preparations for colonoscopy, 50% of gastroenterologists prefer to use PEG solution and 50% avoid the use of Fleets Phosphosoda. Obstetricians seem to prefer Fleets Phosphosoda （20%） and tend to avoid the use of PEG solution （26%）. With regard to bowel preparation for sigmoidoscopy, both groups prefer Fleets enema the most （51%）, while magnesium citrate is used least often （38%）.CONCLUSION： It is clear that preferences in the use of bowel cleansing preparations between the two groups exist, but there have not been many case controlled human studies in the pregnant patient that give clear cut indications for using one versus another drug. In light of the challenge of performing controlled trials in pregnant women, more extensive surveys should be undertaken to gather a larger amount of data on physicians＇ experiences and individual preferences.

CERVICAL CYTOLOGICAL SCREENING AND MANAGEMENT IN PREGNANT AND POSTPARTUM WOMEN

Objeotive To examine and follow up cervical cytology of pregnant and postpartum women and study their cytopathologie characteristics, so as to determine screening and managing programs for abnormal cervical cytology. Mothods Totally 5296 patients in pregnancy and postpartum, in which 3729 by computer-assisted cytology test and 1567 by liquid-based monolayers cytology test, were examined and diagnosed by the Bethesda System made in 2001. Those proven epithelial abnormalities patients were followed up until the lesions regressed to normal. The remaining patients, who exhibited persistent abnormalities or progression, were given further examinations. Results The positive rate of cervical cytological test was 8.72% （462/5296）, including squamous carcinoma （SCA） 1 case （ 0.02% ）, high grade squamous intraepithelial lesion （HSIL） 34 cases （ 0.64% ）, low grade squamous intraepithelial lesion （LSIL） 145 cases （ 2.74% ）, atypical glandular cells （AGC） 5 cases （ 0.09% ）, atypical squamous cells cannot exclude HSIL （ASC-H） 14 cases （0.26%）, atypical squamous cells of undetermined significance （ASC-US） 263 cases （4.97%）. The 419 proven cytological abnormality cases were followed up successfully. The total transnegative rate in three months was 73.74% （309/419）, in which 303 cases （72.32%） persisted normal status for more than six months after regression. And the transnegative rate of ASC-US, ASC-H, AGC, LSIL, and HSIL were 79.56%, 64.29%, 100%, 72.14% and 44.12%, respectively. Forty-six cases received biopsy directed by colposcopy. The distribution of coincidence of cytopathologic and histopathologic diagnosis was： SCA 1 case （100%）, HSIL 10 cases （76.92%）, LSIL 13 cases （65%）, ASC-H 2 cases （50%）, ASC-US 3 cases （37.50%）, total 29 cases （63.04%）. Conclusions We should cast more attention to screening cervix lesions in pregnant and postpartum women. Their cytopathologic characteristics are liable to make the clinician give a false positive diagnosis. So we propose to follow up them closely and to lower the indication of biopsy.

Intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disorder characterized by maternal pruritus in the third trimester, raised serum bile acids and increased rates of adverse fetal outcomes. The etiology of ICP is complex and not fully understood, but it is likely to result from the cholestatic effects of reproductive hormones and their metabolites in genetically susceptible women. Equally unclear are the mechanisms by which the fetal complications occur. This article reviews the epidemiology, clinical features, diagnosis, etiology and management of ICP.

Metastatic low-grade endometrial stromal sarcoma of the sigmoid colon three years after hysterectomy

A 49-year-old woman, who had undergone hysterectomy for low-grade endometrial stromal sarcoma (ESS) 3 years ago, presented with a 2-wk history of lower abdominal pain. Barium enema and sigmoidoscopy disclosed a polypoid submucosal tumor. Histopathologic features of biopsy specimens from the lesion were similar to those of the resected uterine ESS. Under the diagnosis of metastatic ESS of the sigmoid colon, sigmoidectomy was performed. Microscopic examination demonstrated dense proliferation of spindle cells with little nuclear atypia, which were sometimes arranged in whorled pattern around abundant arterioles. Mitotic count is below 1 in 10 highpower fields. Immunohi-stochemically, the neoplastic cells were strongly positive for vimentin, estrogen receptor and progesterone receptor but negative for α-smooth muscle actin, S-100 protein and CD34. Thus, a final diagnosis of low-grade ESS metastasis to the sigmoid colon was made.Her postoperative course was uneventful and hormonal therapy with progestational agents is entertained.

THE ROLE OF HYSTERECTOMY IN THE THERAPY OF GESTATIONAL TROPHOBLASTIC TUMOR

To evaluate the role of hysterectomy for patients with gestational trophoblastic tumor. [WT5”BX]Methods.[WT5”BZ]We retrospectively analyzed 68 cases of gestational trophoblastic neoplasia treated by hysterectomy from 1985～1997 at PUMC hospital. Thirty eight cases were diagnosed of choriocarcinoma and 30 were invasive mole. [WT5”BX]Results.[WT5”BZ]Twenty three elder patients who didn’t desire to preserve fertility were selected for hysterectomy after shorter courses of chemotherapy, 22 of them had a complete remission(95 6%), the total aver age courses of chemotherapy was 4 2. Of twenty seven chemorefractory cases who were suspected of a refractory isolated lesion in the uterus, delayed hysterectomy as an adjunct to chemotherapy was performed, 20 of them got a complete remission(74 1%), the total average courses of chemotherapy were 9 4. Emergency hysterectomy is indicated in 18 patients with uterine perforation or life threatening hemorrhage, 17 cases had a complete remission(94 4%), the total average courses of chemotherapy were 7 6. [WT5”BX]Conclusion.[WT5”BZ]Although the development of effective chemotherapy has resulted in improved survival of patients with gestational trophoblastic tumor, hysterectomy remains an important adjuncts in the treatment of a selected subset of patients; in order to operate more completely and prevent recurrence, it’s better to perform extended hysterectomy for the indicated patients.

A COMPARATIVE STUDY OF TRANSVAGINAL ULTRASONOGRAPHY AND PELVIC ARTERIOGRAM IN ASSESSMENT OF PATIENTS WITH GESTATIONAL TROPHOBLASTIC TUMOUR

Objective:To compare the reliability of transvaginal ultrasonography with pelvic arteriography in the assessment of patients with gestational trophoblastic disease. Methods. Transvaginal ultrasonography was performed in 24 patients with gestational trophoblastic tumour. Within one week after ultrasound investigation, pelvic arteriography was carried out in each patient. Of 24 cases, 16 patients hadn’t been treated by chemical reagent, 5 had accepted 2 to 5 courses of chemotherapy, and 3 had achieved complete remission before both investigations performed. Results. In 3 patients with complete remission, 2 had no evidence of abnormal findings either on transvaginal ultrasonography or on pelvic arteriography, 1 showed intramyometrial lesions by both methods. In the remaining 21 patients, all demostrated a abnormal uterine image, and 5 of them accompanied with the finding of parametrium metastatic signs by transvaginal ultrasonography; these abnormal results were confirmed by pelvic arteriographic imaging. However, in two cases without clinical and ultrasonic signs of parametrium metastasis, pelvic arteriography indicated the early metastasis of parametrium ves- sels. Conclusions. Even though it is difficult to predict the early parametrium metastasis in patients with gestational trophoblastic disease by B-ultrasonic investigation, our data would support the introduction of transvaginal ultrasonography in the diagnosis and evaluation of gestational trophoblastic tumour.

Bochdaleck's hernia complicating pregnancy: Case report

Diaphragmatic hernia complicating pregnancy is rare and results in a high mortality rate, particularly if early surgical intervention is not undertaken. We report a case in which a woman presenting at 23 wk＇s gestation was admitted with symptoms of respiratory failure and bowel obstruction due to incarceration of viscera through a left posterolateral defect of the diaphragm （Bochdalek＇s hernia）. Surgery （left thoracoabdominal incision） demonstrated compression atelectasis, mediastinal shift, strangulation and gangrene of the herniated viscera which led to segmental resection of the involved portion of large intestine with re-establishment of bowel continuity by end to end anastomosis. The greater omentum was partly necrotic necessitating resection. The diaphragmatic defect was closed with interrupted sutures. Postoperative period was uncomplicated. Pregnancy was allowed to continue until 39 wk＇s gestation at which time elective cesarean delivery was performed. It is concluded that symptomatic maternal diaphragmatic hernia during pregnancy is a surgical emergency and requires a high index of suspicion.

Trans-acting factors from the human fetal liver bindingto the human ε-globin gene silencer

The developmental stage-specific silencing of the human ε-globin gene during embryonic life is controlled, inpart, by the silencer (-392bp～-177bp) upstream of thisgene. In order to elucidate its role, the nuclear extractfrom the human fetal liver has been prepared and the interactions between trans-acting factors and this silencerelement have been examined. By using DNasel footprinting assay, a major protected region from -278bp to -235bpwithin this silencer element was identified. Furthermore,we found in gel mobility shift assay and Southwestern blotting assay that there were at least four trans-acting factors (MW ≈ 32, 28, 26 and 22kD) in the nuclear extractisolated from the human fetal liver, which could specifically bind to this region. Our results suggested that thesetrans-acting factors might play an important role in silencing the human embryonic ε-globin gene expression at thefetal stage through the interactions with this silencer.

PULMONARY EMBOLISM DURING PREGNANCY AND THE POSTPARTUM PERIOD: REPORT OF 2 CASES

Objective. To investigate the high risk factors, clinical features, diagnosis and treatment of pulmonary embolism (PE) during pregnancy and the postpartum period.Methods. Two cases of PE during pregnancy and postpartum period were reported retrospectively.Results. The first case was a pregnant woman with congenital heart disease at 39-week gestation. She underwent a successful cesarean section (CS) because of heart disease, but she manifested tachycardia, tachypnea, cyanosis, and dyspnea suddenly on the 10th day after CS and died soon after the onset of these symptoms. The diagnosis of PE was highly suspected clinically. The second case was a twin-pregnancy woman at 35-week gestation. Because of severe perinatal myocardiopathy, cesarean section was performed. Unfortunately, the patient died abruptly on the operation table. The diagnosis of PE was confirmed by autopsy.Conclusions. The maternal mortality of PE during pregnancy and postpartum period is quite high. Whenever there is any doubt, objective examinations for PE should be started early in order to strive for the chances of the anticoagulant therapy.

Preeclampsia-What is to blame?The placenta,maternal cardiovascular system or both?

Preeclampsia(PE)is a pregnancy-specific syndrome,complicating 2%-8% of pregnancies.PE is a major cause of maternal mortality throughout the world with 60000 maternal deaths attributed to hypertensive disorders of pregnancy.PE also results in fetal morbidity due to prematurity and fetal growth restriction.The precise aetiology of PE remains an enigma with multiple theories including a combination of environmental,immunological and genetic factors.The conventional and leading hypotheses for the initial insult in PE is inadequate trophoblast invasion which is thought to result in incomplete remodelling of uterine spiral arteries leading to placental ischaemia,hypoxia and thus oxidative stress.The significant heterogeneity observed in pre-eclampsia cannot be solely explained by the placental model alone.Herein we critically evaluate the clinical(risk factors,placental blood flow and biomarkers)and pathological(genetic,molecular,histological)correlates for PE.Furthermore,we discuss the role played by the(dysfunctional)maternal cardiovascular system in the aetiology of PE.We review the evidence that demonstrates a role for both the placenta and the cardiovascular system in early-and late-onset PE and highlight some of the key differences between these two distinct disease entities.

DIAGNOSIS AND TREATMENT OF THE MALIGNANT GESTATIONAL TROPHOBLASTIC TUMOR WITH PULMONARY METASTASIS COMPLICATED WITH PULMONARY TUBERCULOSIS

Objective. To evaluate the diagnosis and treatment for malignant gestational trophoblastic tumor(MGTT) with pulmonary metastasis complicated with pulmonary tuberculosis. Methods. To analyze ten cases of MGTT with pulmonary metastasis complicated with pulmonary tuberculosis in our hospital from 1980 to 1997 retrospectively. Results.From the x ray film, there are great resemblances between MGTT with pulmonary metastasis and pulmonary tuberculosis. Of 10 patients, 7 of them were examined out pulmonary tuberculosis during the chemotherapy of MGTT. Pulmonary tuberculosis appeared six months before chemotherapy in three cases. All of the patients were treated with multiagent chemotherapy. Seven patients achiceved a complete remission, 2 patients developed drug resistance and died of cerebral haemorrhage and cerebral herniation, 1 woman who had achieved a complete remission from MGTT for 14 months died of miliary tuberculosis. Conclusion. It is very important to make differential diagnosis of the MGTT with pulmonary metastasis complicated with pulmonary tuberculosis. Trying to avoid excessive anti tumor treatment owing to mistake pulmonary tuberculosis for pulmonary metastasis, and avoiding missing an opportunity of anti tuberculosis treatment because of missed diagnosis should be emphasized.

Association between gamete source, exposure and preeclampsia: A review of literature

Preeclampsia complicates 3%-5% of pregnancies and is one of the major causes of maternal morbidity and mortality. The pathologic mechanisms are well described but despite decades of research, the exact etiology of preeclampsia remains poorly understood. For years it was believed that the etiology of preeclampsia was the result of maternal factors, but recent evidence suggests that preeclampsia may be a couple specific disease where the interplay between both female and male factors plays an important role. Recent studies have suggested a complex etiologic mechanism that includes genetic imprinting, immune maladaptation, placental ischemia and generalized endothelial dysfunction. The immunological hypothesis suggests exaggerated maternal response against fetal antigens. While the role of maternal exposure to new paternal antigens in the development of preeclampsia was the initial focus of research in this area, studies examining pregnancy outcomes in pregnancies from donor oocytes provide intriguingly similar findings. The pregnancies that resulted from male or female donor gametes or donor embryos bring new insight into the role of immune response to new antigens in pathogenesis ofpreeclampsia. The primary goal of the current review is the role of exposure to new gametes on the development of preeclampsia. The objective was therefore to provide a review of current literature on the role of cohabitation length, semen exposure and gamete source in development of preeclampsia.

Physical activity during pregnancy and the role of theory in promoting positive behavior change:A systematic review

Background: Physical activity(PA) during pregnancy provides physical and psychological benefits for mother and child. U.S. guidelines recommend ≥30 min of moderate exercise for healthy pregnant women most days of the week; however, most women do not meet these recommendations. Theory assists in identifying salient determinants of health behavior to guide health promotion interventions; however, the application of theory to examine PA among pregnant women has not been examined cohesively among multiple levels of influence(e.g.,intrapersonal, interpersonal, neighborhood/environmental, and organizational/political). Subsequently, this systematic review aims to identify and evaluate the use of health behavior theory in studies that examine PA during pregnancy.Methods: Articles published before July 2014 were obtained from Pub Med and Web of Science. Inclusion criteria applied were:(1) empiricallybased;(2) peer-reviewed;(3) measured factors related to PA;(4) comprised a pregnant sample; and(5) applied theory. Fourteen studies were included. Each study's application of theory and theoretical constructs were evaluated.Results: Various theories were utilized to explain and predict PA during pregnancy; yet, the majority of these studies only focused on intrapersonal level determinants. Five theoretical frameworks were applied across the studies—all but one at the intrapersonal level. Few determinants identified were from the interpersonal, neighborhood/environmental, or organizational/political levels.Conclusion: This systematic review synthesized the literature on theoretical constructs related to PA during pregnancy. Interpersonal, community,and societal levels remain understudied. Future research should employ theory-driven multi-level determinants of PA to reflect the interacting factors influencing PA during this critical period in the life course.

Changes of Nerve Growth Factor in Amniotic Fluid and Correlation with Ventriculomegaly

Objective To detect the change of nerve growth factor (NGF) level in human amniotic fluid during gestation, and to explore the relationship between this change and fetal ventriculo-megaly (VM). Methods The studied subjects (collected from 2004 to 2007) were divided into four groups, including the second-trimester pregnancy group (n=113), third-trimester pregnancy group (n=110), fetal cerebral VM group (n=12), and healthy control group (n=12) which matched with the VM group in gestational weeks. The amniotic fluid specimens were obtained during amniocentesis or cesarean section. The NGF levels in amniotic fluid were detected with en-zyme-linked immunosorbent assay. Results A significantly negative correlation was found between gestational age and the NGF level in amniotic fluid (r= 0.6149, P<0.0001). The NGF level in patients with fetal VM was significantly lower than that in healthy controls (33.95±29.24 pg/mL vs. 64.73±16.21 pg/mL, P=0.024). Conclusion NGF levels in amniotic fluid may be a sensitive marker for fetal VM.

Placental expressions of estrogen receptor α,estrogen receptor β in intrahepatic cholestasis of pregnancy

To investigate the association of the expression of estrogen receptor ct, estrogen receptor 13 in placenta with intrahepatic cholestasis of pregnancy （ICP） susceptibility. Methods： In 14 cases of mild ICP, 14 cases of severe ICP and 14 cases of normal cases （control group） with corresponding age and gestation weeks, the expressions of ERa and ERD were detected by means of immunohistochemical method S-P. Results： The mean grey numbers of ERa in each group mentioned above were 151.684±3.76, 149.854±3.69, 153.184±3.18, without significant difference （P〉0.05） The mean grey numbers of ERβ in each group mentioned above were 146.51±3.81, 139.434±9.97, 149.87±4.17, with significant difference （P〉0.05）; the expression of ERI3 of severe ICP group was significantly higher than that of the mild ICP group and the control group （P〈0.05）. The expression of ERβ in every group was higher than that of ERa （P〈0.05）. Conclusion： ERβ maybe play an important part in the etiology and development of ICP

Liver disease in pregnancy

Liver diseases in pregnancy may be categorized into liver disorders that occur only in the setting of pregnancy and liver diseases that occur coincidentally with pregnancy. Hyperemesis gravidarum, preeclampsia/eclampsia, syndrome of hemolysis, elevated liver tests and low platelets (HELLP), acute fatty liver of pregnancy, and intrahepatic cholestasis of pregnancy are pregnancy-specific disorders that may cause elevations in liver tests and hepatic dysfunction. Chronic liver diseases, including cholestatic liver disease, autoimmune hepatitis, Wilson disease, and viral hepatitis may also be seen in pregnancy. Management of liver disease in pregnancy requires collaboration between obstetricians and gastroenterologists/hepatologists. Treatment of pregnancy-specific liver disorders usually involves delivery of the fetus and supportive care, whereas management of chronic liver disease in pregnancy is directed toward optimizing control of the liver disorder. Cirrhosis in the setting of pregnancy is less commonly observed but offers unique challenges for patients and practitioners. This article reviews the epidemiology, pathophysiology, diagnosis, and management of liver diseases seen in pregnancy.