摘要:

A new case of congenital hypofibrinogenemia in pregnancy is reported and the literature is reviewed from an obstetric perspective. An association with spontaneous abortion, abruption, and postpartum hemorrhage is documented and management options are presented.

ISSN:0029-7828    

出版商:OVID    

年代:1989

数据来源: OVID

ISSN:0029-7828    

出版商:OVID    

年代:1989

数据来源: OVID

ISSN:0029-7828    

出版商:OVID    

年代:1989

数据来源: OVID

ISSN:0029-7828    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

In diabetic pregnancy, the fetus is at risk for congenital malformation, stillbirth, and perinatal death. Although the incidence of stillbirth and perinatal death has decreased as control of diabetes in pregnancy has improved, the incidence of malformation has not decreased and may even have increased. The present authors review some of the experimental work that has been undertaken to determine the cause of this impasse.At or near term, the mammalian placenta is impermeable to insulin, which cannot, therefore, be the cause of congenital malformations. The authors favor an alternative explanation, based on the hypothesis that an “insulin-like” substance is present in the fetoplacental unit at an appropriate stage in embryogenesis. By “like” substance, they mean, not an analogue, but an insulin homologue, specifically designated relaxin.Relaxin is related to insulin through a common ancestral polypeptide resembling proinsulin. Its usual source is the corpus luteum, but it is found also in the decidua and the term placenta. Among other functions, relaxin enhances secretion of collagenase and plasminogen. This property may lead to collagen degradation in fetal membranes and to eventual rupture at parturition.Relaxin influences the distensibility of the nonpregnant uterus in animals without ovaries maintained on estrogen, but has little effect alone. For maximum effect and greatest increase in the collagen framework, relaxin must be combined with estrogen and progesterone in accurate dosage.In pregnant women, one stimulus to relaxin production is hCG. The serum profiles of relaxin and hCG are similar. Moreover, in nonpregnant women, injection of hCG during the late follicular phase causes relaxin secretion. In women having cesarean sections, a linear relation was found between progesterone and relaxin concentrations in the serum of blood from the ovarian vein on the side of the corpus luteum.The authors studied the known functions of relaxin in relation to the development of the embryonic palate. During fetal development, the palatal shelves undergo reorientation from their initial vertical position lateral to the tongue to a horizontal alignment cephalad to it and fuse to form the secondary palate. Swelling of the shelves is generally attributed to production of sulphated proteoglycans in the matrix, and shelf remoulding and direction of movement are physically controlled by concomitantly developed collagen, arranged in a specific way. Cleft palate may be produced experimentally by drugs that inhibit proteoglycan synthesis (such as cortisone, chlorcyclizine, and diazonorleucine) and by those that cause abnormalities of fetal collagen. This effect is not limited to the palate but involves the whole embryo.When acting with specific amounts of estrogen and progesterone, relaxin has effects on collagen that resemble those of substances causing cleft palate in laboratory animals. If, in normal circumstances, a high relaxin secretion is avoided during the stage of organogenesis, disharmony among the three hormones could give rise to numerous malformations other than cleft palate.Among diabetic women studied before the 10th week of pregnancy, investigators found that those in whom diabetes was not well controlled had estradiol, prolactin, and hCG levels below the range associated with normal pregnancy, and that these rose to normal after careful control of the diabetes with insulin. It is possible, therefore, that administered insulin, while correcting maternal plasma glucose, may, by raising circulating hCG and estrogen concentrations (and thus increasing relaxin levels), trigger a teratogenic response in certain predisposed embryos.

ISSN:0029-7828    

出版商:OVID    

年代:1989

数据来源: OVID

ISSN:0029-7828    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The risk to the fetus after maternal rubella during the first 12 weeks of pregnancy has been established: 81 to 90 per cent of the fetuses are infected, and about 85 per cent of congenitally infected infants are damaged. Little is known about the risk to the fetus when maternal rubella occurs just before conception. Developmental abnormalities have been reported after such infection, but no systematic study of the outcome of the pregnancies has been made. The present authors report a prospective study of 61 pregnancies in which confirmed maternal rubella occurred shortly before or shortly after conception.From 1978 to 1987, 44 cases of maternal rubella, in which the rash appeared from 5 weeks before to 6 weeks after the last menstrual period, were reported to the Institut in Stuttgart. From 1975 to 1987, 17 cases were reported to the Surveillance Centre in England. Mixed products of conception or individual fetal organs from 39 aborted pregnancies were tested for rubella virus. Cord sera from 22 pregnancies that continued to term were tested for rubella IgM antibody.No evidence of intrauterine infection was found in 38 pregnancies in which the maternal rash appeared before, or within 11 days after, the onset of the last menstrual period (Table 1). The shortest interval between the appearance of the rash and fetal infection occurred when the rash appeared 12 days after the last menstrual period. All 10 cases in which the rash appeared 3 to 6 weeks after the last menstrual period resulted in fetal infection.Of the four IgM-positive infants, two had clinical evidence of congenital rubella at birth. One had a heart defect and failed to thrive; the other had a heart defect, microphthalmia, and hepatosplenomegaly; both later showed bilateral deafness. The other two IgM-positive infants appeared normal at birth but were reported to have bilateral deafness with no other abnormality at 14 months and at 2 years of age. All 18 IgM-negative infants appeared to be normal at birth. Information on subsequent progress has been obtained for 17, in all of whom development has been normal up to a mean age of 2 years (range, 1/2–5 years).

ISSN:0029-7828    

出版商:OVID    

年代:1989

数据来源: OVID

ISSN:0029-7828    

出版商:OVID    

年代:1989

数据来源: OVID

ISSN:0029-7828    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

There are pregnancy-related conditions which may or may not be hypertensive in origin but which can cause serious illness and diagnostic problems. One such condition is characterized by hemolysis, elevated liver enzyme activity, and low platelet count, and is known as the HELLP syndrome. There is disagreement as to whether the syndrome represents a separate disease entity or whether it is a part of the preeclamptic process. In either case, it is important to identify the variations correctly because they indicate a “sick” pregnancy in which both mother and baby are at grave risk.The present authors report the case of a woman who had some degree of pregnancy-induced hypertension, but in whom the presence of jaundice, abdominal pain, and a single gallstone was thought to represent a co-existent obstructive cholecystitis. Actually, she was suffering from a well-developed HELLP syndrome, and the gallstone was not related to her condition.The 26-year-old woman was admitted to a country hospital with pregnancy-induced hypertension and upper abdominal pain. Her blood pressure was 130/90 mm Hg, and she had ankle edema but no proteinuria. Her conjugated and total bilirubin levels, aspartate aminotransferase activity, and alkaline phosphatase activity were distinctly elevated. Because of her chemical state of jaundice and the repeated episodes of upper abdominal pain, a gall bladder ultrasound examination was performed on the 4th day after admission. This showed a solitary, large, mobile calculus within the gall bladder. Gall bladder, bile ducts, liver, and pancreas were normal in appearance. By the 5th day in hospital, the patient was jaundiced clinically and showed bile and urobilinogen in her urine.On the 8th hospital day, the patient's blood pressure was 140/100 mm Hg, and her urinary output was recorded as 300 ml in 24 hours. She had edema of the legs and sacrum, and she complained of pain in the right upper abdomen. She was transferred to the authors' hospital, where an investigation for HELLP syndrome was begun. A complete blood picture showed a hemoglobin level of 104 gm/liter (normal, 110–135 gm/liter), a platelet count of 49 × 109/liter (normal, 150–400 × 109/liter), and a reticulocyte count of 4.2 per cent (normal, 0.2–2.0 per cent). The numerous spherocytes and fragmented cells that were found were consistent with microangiopathic hemolysis. This was confirmed later by a reduced serum haptoglobin level of 0.2 gm/liter (normal, 0.45–2.35 gm/ liter). The multiple blood analysis showed mixed hyperbili-rubinemia, elevation of all liver enzyme activities, a distinctly raised uric acid level that was consistent with pre-eclampsia, and a reduced serum albumin level, which probably contributed to the patient's peripheral edema.Preparations were made to expedite delivery of the infant and within 3 hours of induction, the patient spontaneously delivered (vaginally), a live male infant weighing 2.34 kg, with Apgar scores of 7 and 10 at 1 and 5 minutes, respectively. The recorded blood loss at delivery was 250 ml.The next day the patient's blood pressure was settling, her hemoglobin level was 101 gm/liter, and her platelet count was 127 × 109/liter. By the 3rd postpartum day, however, her hemoglobin level had dropped to 82 gm/liter, and her platelet count had decreased to 63 × 109/liter. The blood film confirmed the continuing presence of microangiopathic hemolysis. The blood chemistry was improving, but the patient was still jaundiced. In view of the continuing nature of the HELLP process, four units of packed red blood cells were given to the patient.Subsequently, slow but steady improvement was made. On the 6th postpartum day, the patient's hemoglobin level was 114 gm/liter, and her platelet count was 164 × 109/ liter. She was discharged on the 20th day after delivery. The need for a cholecystectomy was to be decided by her general practitioner.

ISSN:0029-7828    

出版商:OVID    

年代:1989

数据来源: OVID