ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

In animal models there is considerable evidence that maternal stress and corticosteroids, its physiological signpost, are teratogenic, but little is known about whether the same is true for humans. This population-based case-control study sought to learn whether women describing specified life events during the periconceptual period were more likely than others to have an infant with a conotruncal cardiac defect, neural tube defect, orofacial cleft deformity, or limb anomaly. The respective numbers of mothers interviewed, from pregnancies ending in 1987–1989, were 207, 265, 662, and 165. Control subjects were randomly chosen from those having liveborn infants during the period under review. Women were interviewed by telephone to obtain information about whether anyone close to them had died and whether they or anyone close to them had experienced loss of their job or separation or divorce.During the 4-month periconceptional period, 14.5 percent of case mothers reported that someone close to them had died, 16 percent reported that they or someone close was separated or divorced, and 9 percent reported that they or someone close had lost their job. The corresponding rates for control subjects were 12, 14, and 8 percent. At least one event was reported by 33 percent of case women and 27 percent of control subjects. Odds ratios for an association with stressful life events were 1.4 for conotruncal heart defect, 1.9 for D-transposition of the great arteries, and 1.3 for tetralogy of Fallot. The prevalence odds ratio of a neural tube defect was 1.5. The prevalence rates of spina bifida and anencephaly were increased. Cleft deformity also correlated with stressful life events. The odds of having an infant with a limb anomaly was 1.3. These associations persisted after adjusting for race/ethnicity, mother’s educational level, smoking status, binge drinking, vitamin use, maternal age, and obesity. For only two types of anomaly, conotruncal heart defect and multiple cleft lip, did the risk increase with the number of stressful life events.These findings indicate that women who experience stressful life events, such as loss of a spouse or job or death of someone close, may be more likely than others to have an infant with certain congenital anomalies. In future studies it will be important to objectively evaluate stress retrospectively and to discern which aspects of stress or stress response relate to fetal development.Epidemiology 2000;11:30–35

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

The vascular form of Ehlers-Danlos syndrome (type IV) is a result of mutations in the type III procollagen gene (COL3A1). Those affected are at risk for rupture of arteries, the bowel, and the uterus. This review looked at the clinical histories of 220 index patients with type IV Ehlers-Danlos syndrome, biochemically confirmed in all cases, and their medical and surgical complications. TheCOL3A1mutation was identified in 135 patients. A comparison group consisted of 199 affected relatives. Twenty-six index patients and 105 relatives died, most often from arterial dissection or rupture. Thoracic and abdominal vessels were predominantly affected. More than two-thirds of all subjects had a single complication, and 21 percent had more than one complication. The chance of an index patient having a medical or surgical problem by age 20 was 25 percent and by age 40, more than 80 percent. Most bowel complications involved the colon, often its sigmoid portion.Eighty-one women had experienced 183 pregnancies, 167 of which ended in term delivery of a liveborn infant. There were 3 stillbirths and 13 abortions (3 of them voluntary). Twelve women died during the peripartum period or within 2 weeks after delivery. Five deaths resulted from rupture of the uterus during labor. Vessel rupture caused seven deaths, two at delivery and five in the postpartum period. Five of 81 women who had been pregnant once died. Both club-foot deformity and congenital hip dislocation were more frequent than expected. The rate of premature birth in the index group was 12.4 percent, compared with 11 percent among the US population. In addition to a 50 percent chance of having an affected child, women with type IV Ehlers-Danlos syndrome are at a much increased risk of pregnancy complications. For this reason they should be followed at specialized centers. Rupture of the uterus at term is a prominent cause of death, but it is not clear whether elective cesarean delivery would limit mortality.N Engl J Med 2000;342:673–680

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Women of childbearing age who have migraine frequently use sumatriptan to treat acute episodes. This open-label prospective study examined the tolerance of sumatriptan in 12,339 patients with migraine, 9861 of them women, who were typical in their demographic features and their pattern of drug injection. All were at least 18 years of age, and none were known to have heart disease. All patients had suffered three or more migraine attacks in the previous year. All but 5 of 173 pregnancies were well documented. Sumatriptan was not used during pregnancy in 92 instances, whereas 76 women used the drug during the first trimester. These groups exhibited no differences in pregnancy outcome. Normal perinatal outcomes were recorded in 79 percent of patients not exposed to sumatriptan and in 88 percent of patients who used sumatriptan after conception. The respective rates of spontaneous abortion were 12 percent and 10.5 percent. Preexisting factors that might influence perinatal outcome were similarly distributed in the two groups. No adverse effect of sumatriptan use on pregnancy or perinatal outcomes has yet emerged in an ongoing pregnancy registry.Arch Gynecol Obstet 1999;263:7–12

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Not only do about 24 million African women living in malaria-endemic regions become pregnant each year, but they are more likely than nonpregnant women to have a high level of parasitemia and anemia and consequently are at increased risk of abortion and stillbirth, premature delivery, and intrauterine growth restriction. The spread of chloroquine resistance has discouraged attempts to deal with this problem. Specialists participating in a symposium in 1997 noted that maternal anemia and low-birthweight infants are consistently observed despite very different malaria transmission pressures in different areas. Malarial parasitemia has been documented more often in women testing positive for human immunodeficiency virus. Maternal deaths are a useful initial marker of exposure to malaria but are best replaced by more sensitive clinical indicators, such as maternal anemia and low birthweight. Both low birthweight and intrauterine growth restriction are recognized as contributing to infant deaths.Effective prophylaxis has been impeded by drug resistance as well as complex obstetrical logistics, cost, and poor compliance. Biweekly administration of 25 mg of pyrimethamine and 100 mg of dapsone demonstrably increases birthweight and reduces anemia. Two or more intermittent doses of a sulfadoxine-pyrimethamine (SP) combination have proved effective in lowering the risk of subsequent parasitemia, placental infection, and maternal anemia. Even a single SP treatment may confer benefit. A useful alternative, at least in children, is a combination of 1.2 mg/kg chlorproguanil and 2.4 mg/kg dapsone. Amodiaquine has been used to treat children and nonpregnant women, but little is known of its efficacy in pregnancy. There is a lack of information about the value of iron supplementation in pregnant women. Treated bed nets have been shown to protect women in some studies but not in others; their effectiveness may decline with increased transmission of malaria. Quinine is still the preferred treatment for severe malaria in pregnant women. Pregnant women should not be given repeated doses of SP, which may cause hypersensitivity reactions.Efforts are needed to find antimalarial drugs that will be the best alternatives to SP if drug resistance is increasing. Adolescent girls should be targeted before their first pregnancy. Standardizedin vivotests are needed determine the efficacy of antimalarial agents, both for treating acute infection and for intermittent use in pregnant women. Furthermore, work is warranted to evaluate treated bed nets for controlling maternal malaria in different settings.Ann Trop Med Parasitol 1999;93(Suppl 1):S11–S17

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Despite suggestions that fetal malformations are more frequent in women with type I diabetes only when glycemic control is seriously deficient, it remains possible that even slightly impaired control is teratogenic. This possibility was examined by relating pregnancy outcomes to glycated hemoglobin A1c(HbA1c) concentrations before 14 weeks’ gestation. Data were obtained prospectively from 488 women living in a defined area of southern Finland. A total of 691 pregnancies in the years 1988–1997 yielded 709 offspring. The control population included 729 nonselected pregnancies in nondiabetic women. Malformations were diagnosed by intrauterine or neonatal ultrasonography. Diabetic women were more often nulliparous than control women, had shorter gestations, and had more multiple pregnancies.The frequency of major fetal malformation was 4.2 percent in the diabetic group and 1.4 percent in the control group for a relative risk (RR) of 3.1. Five of the diabetic pregnancies were terminated after malformations were diagnosed. Combining major and minor malformations, rates were 10.3 percent for diabetic women and 4.4 percent for control subjects. The only factors associated with an increased risk of malformation on logistic regression analysis were an elevated HbA1cvalue and nulliparity. The RR for major malformations was 3.0 in diabetic women whose HbA1cvalue was only slightly increased (2–5.9 SD units) and increased to 4.8 for values exceeding 9.4 percent. Only diabetic subjects with normal HbA1cvalues had a malformation risk similar to that in the control population. Central nervous system malformations were limited to infants born to diabetic women; the RR compared with the national population was 8.8. These findings suggest that the risk of fetal malformation is increased when a pregnant woman with type I diabetes has even a slightly elevated HbA1clevel. The goal should be normoglycemia during early pregnancy.Diabetologia 2000;43:79–82

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

As many as one-third of women suffer damage to the anterior part of the anal sphincter at the time of their first vaginal delivery, and perhaps a third of these have new bowel symptoms. This is one of the most common causes of fecal incontinence. This study examined the long-term outcome in 55 consecutive women who were followed for at least 5 years and for a median of 6.5 years after anterior overlapping anal sphincter repair. Thirty-two of them underwent repair shortly after delivery, and the other 23 underwent repair in middle age. Seven of the 46 evaluable patients (15 percent) had required additional surgery for fecal incontinence, and there was one outright failure. Of the remaining 38 patients, 27 (71 percent) reported improved bowel control, 23 of them by at least 50 percent when rating their symptoms on a scale of 0 to 10. Five others had not improved, and six reported that their condition had deteriorated. None of the patients were fully continent when last evaluated, but six had no fecal urgency, and eight were free of soiling. Twenty-five of the 38 patients found that their symptoms restricted their lifestyle to some extent. Patient self-ratings of improvement a median of 15 months after surgery predicted long-term outcome.These findings suggest that the results of overlapping anal sphincter repair performed in women with obstetric damage deteriorate over time. Patients should know preoperatively that although they are likely to improve to some degree, perfect continence is rare and new evacuation problems are a possibility. Many of these patients will be satisfied by even slight improvement in their symptoms.Lancet 2000;355:260–265

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

In view of the late sequelae of obstetrical brachial plexus injury (OBPI), which range from minor functional impairment to total paralysis of the upper extremity, the ability to predict recovery was studied in a series of liveborn infants born in the years 1988–1996 whose gestational age was at least 30 weeks and who had no lethal congenital abnormalities. OBPI was diagnosed in 62 of 13,366 infants (0.46 percent of those evaluated). Twenty-two infants recovered completely within 1 month of birth, and 23 others had delayed but complete recovery. Of the 17 infants with residual paresis (27 percent of those with OBPI), 11 underwent surgery but 3 have severe paresis.OBPI was more prevalent in infants whose birth weight exceeded 3500 gm than in those who weighed less (1.16 percent vs. 0.14 percent). One in three of the heavier infants failed to recover fully. The chance of recovering fully did not seem to depend on whether the infant was delivered in cephalic or breech presentation. Infants who did not recover fully had risk factors similar to those of the overall group. Significant risk factors for nonrecovery included nonwhite origin, multiparity, diabetes, a second stage lasting longer than 1 hour, operative vaginal delivery (in multiparas), and higher birthweight. In a predictive model of nonrecovered OBPI in infants who were born vaginally in cephalic presentation, the most prominent variable was birthweight. An odds ratio of 51 was associated with a birthweight of 4000 gm or higher. This experience affirms the difficulty of predicting OBPI. Multivariate factor analysis may, however, permit individualized risk assessment and appropriate counseling.Eur J Obstet Gynecol Reprod Biol 2000;88:133–138

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

The risk of transmitting human immunodeficiency virus type I (HIV-1) in breast milk is an established one, but its magnitude remains uncertain, and it is not clear whether this risk exceeds that of dying from formula-related diarrhea in developing countries. A randomized trial was started in Nairobi, Kenya, in 1992 to compare mortality and the risk of HIV infection in breast-fed and formula-fed infants. Initially 425 HIV-1–seropositive pregnant women who had received no antiretroviral study were enrolled in the trial. The infant was breast-fed in 212 instances and formula fed in 213. Randomization took place at about 32 weeks. End points were assessed after a median follow-up of 2 years in 401 mother-infant pairs. The study population was primarily of lower socioeconomic status. The median maternal age was 23 years.The cumulative risk of HIV-1 infection was significantly higher for breast-fed infants. At 24 months it was 36.7 percent, compared with 20.5 percent for formula-fed infants. In the breast-feeding group, this practice accounted for 44 percent of all transmissions. A risk difference was apparent by age 6 weeks, and 87 percent of the overall difference in risk was manifest by age 12 months. Mortality curves did not differ significantly overall, but significantly more infants assigned to breast-feeding were infected or dead at 24 months (42 percent vs. 30 percent). The rate of HIV-1–free survival was 58 percent in the breast-fed group and 70 percent in the formula-fed group.In Kenya, formula feeding substantially reduces the risk of transmitting HIV-1 to newborn infants, but formula remains too expensive for most infected women in sub-Saharan Africa. In addition to the direct cost of formula, antenatal viral testing is necessary and women require education in formula feeding.JAMA 2000;283:1167–1174

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Preimplantation genetic diagnosis (PGD) has been available for nearly 10 years, and this approach presently is practiced in 17 countries for an increasing number of indications. The few studies done suggest that PGD is most accepted by women who have previously had an affected pregnancy terminated. Because substantial investment is needed to set up a PGD program, for both equipment and highly trained personnel, an attempt was made to determine the level of demand for the procedure in the United Kingdom in a survey of patient interest groups, regional genetics centers, assisted conception units, and health authorities. Couples were sent a questionnaire to learn how aware they are of PGD technology. The conditions targeted for the survey included cystic fibrosis, thalassemia, retinitis pigmentosa, Duchenne muscular dystrophy, hemophilia, leukodystrophy, Huntington disease, and sickle cell anemia.More than 70 percent of the institutions surveyed and all patient interest groups responded to the questionnaire.In vitrofertilization units reported referring up to 156 cases annually, and genetics centers reported referring 52. Patient interest groups knew of another 48 referrals. Two-thirds of regional genetics centers were aware of PGD methods of diagnosing cystic fibrosis, but fewer knew of methods for diagnosing X chromosome–linked disorders or chromosomal translocations. About one-fourth of the centers still believe that accuracy and reliability are controversial issues. About one-fourth ofin vitrofertilization units had referred couples for PGD, chiefly to detect cystic fibrosis. Eight of nine patient groups were aware of PGD, but only two knew which hospitals offer the procedure. A large majority of patient groups and one-third of genetic centers reported believing that inadequate information is available on PGD. Only 18 percent of the health authorities surveyed have a policy for PGD, and nearly two-thirds were unaware of the procedure. About three in four authorities did not know how the cost of a cycle of PGD compares with that of caring for an affected child. This survey in itself seems to have raised awareness of PGD. Contact with patient interest groups has been especially fruitful. It would seem that a lack of information about this practice has limited patient choices.Prenat Diagn 1999;19:1205–1208

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID