ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

When both the fetus and mother have thyroid deficiency, it can be expected that neuropsychological development will be compromised, but it is not clear whether similar problems occur when only the mother is hypothyroid. This study reviewed thyrotropin (TSH) values in stored sera from >25,000 pregnant women. Forty-seven had serum TSH values at or above the 99.7th percentile for all pregnant women, and 15 others had levels between the 98th and 99.6th percentiles as well as a low thyroxine level (below 99.7 nmol/liter). The hypothyroid women were matched with 124 women whose TSH values were normal, and their children underwent 15 tests when they were 7 to 9 years of age. These tests evaluated intelligence, language function, attention, reading ability, visuomotor function, and performance at school.None of the infants in this study had congenital hypothyroidism. The hypothyroid and normothyroid women were comparable demographically and in their pregnancies. Case children performed less well than control children on all of the neuropsychological tests. Full-scale Wechsler IQ scores were an average of 4 points lower in the children of hypothyroid mothers than in the comparison group; 15 and 5 percent, respectively, had scores of 85 or below. IQ scores of the children of the 48 women not treated for hypothyroidism during pregnancy were an average of 7 points lower than those of control children, and 19 percent had scores of 85 or less. When examined 11 years after delivery, 64 percent of untreated women and 4 percent of control women had confirmed hypothyroidism.These findings suggest that it may be worthwhile to routinely screen for hypothyroidism in early pregnancy. Testing at the first prenatal visit and prompt follow-up of those with positive results would permit timely treatment and could prevent adverse neuropsychological effects during early child development.N Engl J Med 1999;341:549–555

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Autoimmune destruction of the pancreatic &bgr;-cells may well beginin uteroor at about the time of birth. Most but not all previous studies note a correlation between type 1 (insulin-dependent) diabetes in childhood and advanced maternal age. This population-based case-control study enrolled 196 children diagnosed as having type 1 diabetes and 325 control children matched for age and gender. The goal was to identify any environmental factors that might influence the onset of diabetes in childhood.Roughly 95 percent of both case and control subjects were white. Exclusive breast-feeding seemed to protect against diabetes. The risk of diabetes increased in the presence of certain postdelivery illnesses, chiefly infections and respiratory problems (including birth asphyxia). Hospitalization patterns were similar for case and control subjects. On univariate analysis, a maternal age older than 35 years correlated with childhood diabetes, as did type 1 diabetes in the mother and delivery by cesarean section. Cesarean delivery was no longer a significant factor after further analysis, and maternal age was of only borderline significance. No particular significance was attached to high or low birth weight, being the first born, or being a small-for-gestational-age infant.Neither the degree of maturation at birth nor birth size seem to strongly predict the development of childhood type 1 diabetes. It is not clear whether the apparent benefit from breast-feeding relates to the presence in cows’ milk of proteins that dispose to diabetes. Part of the reason why excessive illness correlates with diabetes may be that diabetic or preeclamptic mothers are more likely to have their newborn infants closely monitored. Older maternal age and maternal type 1 diabetes do seem to be important risk factors for childhood diabetes.Diabetes Care 1999;22:928–932

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Most women who develop toxoplasmosis while pregnant are detected by serological screening, and they should be counseled about the risk of congenital infection. With the goal of obtaining reliable risk estimates, data were obtained from women referred to a toxoplasmosis reference laboratory in Lyon, France, in the years 1987 to 1995. Obstetrical and pediatric information was available on 603 confirmed cases of maternal toxoplasmosis. At least 564 of these women received antiparasitic drugs. A total of 554 offspring were followed up for congenital infection, and those infected were observed for a median of 4.5 years.Only 36 infected women were symptomatic. The minimal rate of maternofetal transmission was 29 percent, excluding indeterminate cases. Infection was demonstrated in three of six fetal losses. All five planned terminations followed the diagnosis of fetal infection. The risk was relatively low when women were infected in early pregnancy but reached 40 percent at 26 weeks’ gestation and 72 percent by 36 weeks’ gestation. Of 153 congenitally infected live-born children, 27 percent had at least one specific sign of toxoplasmosis: chorioretinal lesions, intracranial calcification, or hydrocephaly. Chorioretinitis was the most common clinical sign of toxoplasmosis, followed by intracranial calcification. Most diagnoses were made in the first year of life, although chorioretinitis often was detected at a later time. The chance of clinical signs being detected declined as the duration of pregnancy before maternal IgM seroconversion occurred lengthened.Clinical signs of toxoplasmosis in the young infant do not necessarily mean functional impairment. Birth cohort studies and randomized treatment trials will be needed to assess the long-term risk of disability and to learn whether it can be prevented by early treatment.Lancet 1999;353:1829–1833

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

The role of prenatal and early developmental influences in later antisocial behavior is of particular interest because such factors may be susceptible to intervention. This study sought to determine whether prenatal exposure to maternal nutritional deficiency predicts an increased risk of antisocial personality disorder (ASPD) at age 18 years. The study took advantage of the conditions created by the Dutch Hunger Winter of 1944 and 1945, when the German army kept food supplies from The Netherlands. Food became plentiful in mid-1945 after a period of increasingly meager nutrition. Food intake was based on the caloric content of weekly government wartime food rations. Dutch criteria for ASPD are quite similar to those in the fourth edition ofDiagnostic and Statistical Manual of Mental Disorders(DSM-IV).The risk of ASPD was increased for men exposed to severe (but not moderate) prenatal nutritional deficiency in the region of famine. Odds ratios for exposure in the first and second trimesters ranged from 2.1 to 3.0, but no increased risk was attached to third trimester deficiency. None of the offspring exposed to severe nutritional deficiency had other psychiatric diagnoses. Further analysis showed that the increased risk of ASPD was limited to men born in the famine region who had been exposed in the first and/or second trimester to severe maternal nutritional deficiency. A majority of cases occurring in the famine region (69 of 86) were classified as violent ASPD.These findings suggest that severe nutritional deprivation of the developing brainin uteromay raise the risk of antisocial behavior at the time of late adolescence. Numerous conditions, including war, forced migration, and natural disasters, may be responsible. In developed countries, specific micronutrient deficiencies, such as that of folate, probably are more important than severe prenatal protein-calorie deficiency.J Am Med Assoc 1999;282:455–462

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Screening, whether in the first or second trimester, is an effective means of selecting women for chorionic-villus sampling or amniocentesis when Down syndrome is a possibility. At present, however, at least 5 percent of screened women have to undergo amniocentesis for 60 to 80 percent of affected fetuses to be detected. The present study was an effort to integrate measurements made during both trimesters to yield a single risk estimate. Data were taken from published studies of first-trimester screening (for serum pregnancy-associated plasma protein A in 77 affected and 383 unaffected pregnancies; for nuchal translucency on ultrasound in 326 affected and 95,476 unaffected pregnancies). In the second trimester, varying combinations of serum &agr;-fetoprotein (AFP), unconjugated estriol, human chorionic gonadotropin (hCG), and inhibin A tests were available for 77 affected and 385 unaffected pregnancies. The test regimens compared included the following: 1) a double test, second-trimester measurements of serum AFP and hCG; 2) a triple test, second-trimester measurements of serum AFP, unconjugated estriol, and hCG; 3) a quadruple test, second-trimester measurements of the same parameters plus inhibin A; 4) a combined test, first-trimester measurements of pregnancy-associated plasma protein A, free &bgr; subunit of hCG, and nuchal translucency; and 5) an integrated test, first-trimester tests of pregnancy-associated plasma protein A and nuchal translucency and second-trimester measurements of serum AFP, unconjugated estriol, hCG, and inhibin A.At a false-positive rate of 5 percent, the integrated test detected 94 percent of cases, compared with 76 percent for the most effective second-trimester test (quadruple test) and 85 percent for the combined first-trimester tests. At a 1 percent false-positive rate, the integrated test detected 85 percent of cases, compared with 46 percent for the triple test. With the integrated test, only 1 percent of screened women would require an invasive procedure and karyotyping for 80 percent of affected pregnancies to be detected (Fig. 1). The corresponding figure for the double test was 22 percent. The reduced false-positive rate using the integrated test is especially evident for women aged 35 years and older.Fig. 1. Percentage of screened women who would need to undergo amniocentesis or chorionic-villus sampling in order for 80 percent of the pregnancies affected by Down syndrome to be detected, according to type of screening test. The double test includes measurements of serum &agr;-fetoprotein and human chorionic gonadotropin in the second trimester. The triple test includes measurements of serum &agr;-fetoprotein, unconjugated estriol, and human chorionic gonadotropin in the second trimester. The quadruple test includes measurements of serum &agr;-fetoprotein, unconjugated estriol, human chorionic gonadotropin, and inhibin A. The combined test includes measurements of serum pregnancy-associated plasma protein A, the free &bgr; subunit of human chorionic gonadotropin, and nuchal translucency in the first trimester. The integrated test includes measurements of serum pregnancy-associated plasma protein A and nuchal translucency in the first trimester and serum &agr;-fetoprotein, unconjugated estriol, human chorionic gonadotropin, and inhibin A in the second trimester. Used with permission from N Engl J Med 1999;341:461–467. © 1999 Massachusetts Medical Society.It is estimated that in the United States, using the integrated test rather than the triple test to detect Down syndrome prenatally would yield approximately 800 more affected pregnancies. It also would keep about 1400 unaffected fetuses from being lost as a result of amniocentesis or chorionic-villus sampling if all high-risk women were to have either of these procedures.N Engl J Med 1999;341:461–467

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Studies of fetal hemodynamics have shown no significant changes in pulsatility indices when prostaglandin E2(PGE2) was used to induce labor. Today PGE1is coming into favor because it is more often successful and is less costly, but its hemodynamic effects, if any, are unclear. This study sought changes in waveform indices of the umbilical artery (UA) and fetal middle cerebral artery (MCA) in spontaneous labor and after the intracervical administration of PGE1for elective induction of labor. Pulsed Doppler recordings were obtained at weekly intervals from 37 weeks until active labor in a prospective series of 49 healthy women free of evidence of fetal distress. Twenty-three of the women entered active labor spontaneously, and 26 were induced with PGE1. The systolic/diastolic (S/D) ratio, resistance index (RI), and pulsatility index were estimated.All waveform indices became significantly lower during spontaneous labor in both the UA and MCA, particularly the latter. In both vessels, the S/D ratio fell more than the RI. The waveform indices tended to increase in both vessels when labor was induced but did not change significantly during labor compared with prelabor values. The cerebral-umbilical ratio, which tended to decline after spontaneous labor, did not change significantly when labor was induced. During active labor, induced fetuses had significantly higher impedance in both vessels than those in spontaneous labor. Fetal heart rate tracings remained normal in both groups, and all infants had normal Apgar scores. Abnormal blood gas values were found more often in the UA after induced labor (23 vs. 4 percent). Nevertheless, all infants had an uneventful clinical course and were discharged within 5 days.Declining impedance in the UA and MCA during spontaneous labor helps prevent fetal cerebral hypoxia by maintaining adequate cerebral blood flow. No such adaptation is evident in PGE1-induced labor, and one result is a relatively high rate of abnormal UA blood gas values. This form of induction should be used cautiously in cases of severe preeclampsia or intrauterine growth retardation, where the fetus already is chronically hypoxic.Acta Obstet Gynecol Scand 1999;78:599–604

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

This 5-year follow-up study contrasted the effects on maternal and child health of two forms of assisted delivery: forceps and vacuum extraction. Of 313 women randomized into the study, 306 were sent follow-up questionnaires and 228 of them (nearly 75 percent) responded. The group included 115 women having forceps-assisted deliveries and 113 undergoing vacuum extraction.Either a third-degree perineal tear or an extended upper vaginal tear occurred in 5 percent of the ventouse group and 10 percent of the forceps group. Just over 40 percent of women in each group had had another child when followed up 5 years after the index delivery. Urinary incontinence was described by 47 percent of all women, and bowel urgency by 44 percent. One in five women reported losing bowel control sometimes or frequently. None of these symptoms correlated significantly with one or the other form of assisted delivery. Visual problems were reported for 12 to 13 percent of children in each group; all but one of 18 of these children had a family history of vision problems. Development did not differ significantly in the two groups of children; the overall incidence of developmental problems was low. This study, the first long-term follow-up of mothers and their children after assisted delivery, revealed no substantial differences in morbidity between the vacuum extraction and forceps techniques.Br J Obstet Gynaecol 1999;106:544–549

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Congenital cytomegalovirus (CMV) infection is the major infectious cause of sensorineural hearing loss (SNHL) in children and is found in about 1 percent of infants born in the United States. Hearing loss may be apparent at birth or may be delayed and is of varying severity. Universal screening of newborn infants is an attempt to lower the age at detection so that intervention can begin by 6 months of age. This study, in a predominantly black and urban population, evaluated 388 children born at one hospital in the years 1980 through 1996 who were diagnosed in the newborn period as having congenital CMV infection. Routine audiological assessment began at age 3 to 8 weeks at the first clinic visit and was repeated at ages 6 and 12 months and then annually. Hearing loss was defined as thresholds of ≥21 dB and sensorineural loss as an air-bone gap of <10 dB.Only 17 percent of infants were screened before being discharged from the nursery. Suspected congenital CMV infection was by far the most common indication. The prevalence of SNHL at birth was 5.2 percent, and late-onset hearing losses continued to occur through the first 6 years of life. By age 6, the cumulative incidence of SNHL was 15.4 percent. The risk was greatest in children who had symptomatic disease at birth. Hearing loss became worse in nearly half of the children with SNHL recognized either at birth or later. Approximately one third of affected children had a fluctuating hearing loss. Just over 8 percent of children had hearing loss with thresholds of 30 dB or higher by age 6 years. At this time, 36 percent of children with symptomatic CMV infection and 11 percent of those who were asymptomatic had SNHL.Universal screening of newborn infants for SNHL secondary to congenital CMV infection may lower the age at detection in some cases but will not solve the problem of children who develop late-onset hearing loss that still may impair the development of speech and language.J Pediatr 1999;135:60–64

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Because increased urinary lactate excretion can be detected by magnetic resonance spectroscopy in hypoxic newborn infants, a study was planned to learn whether the urinary lactate and creatinine levels, measured within hours after birth, are a specific and sensitive means of predicting hypoxic-ischemic encephalopathy (HIE). Forty consecutive neonates with perinatal asphyxia, all born at 36 weeks’ gestation or later, were studied. Urinary proton magnetic resonance spectroscopy was done to determine the lactate:creatinine ratio within 6 hours of birth and again at age 2 to 3 days. Fifty-eight normal infants served as a control group. Real-time ultrasonography was done at intervals up to 10 days after birth to detect increased echogenicity or encephalomalacia. Surviving infants were assessed neurodevelopmentally at age 12 months.HIE developed in 16 of the 40 asphyctic infants but none of the control group. These groups did not differ in birth weight or gestational age. Hyperechogenicity in the basal ganglia and thalamus, as well as diffuse brain edema, were frequent findings in infants who developed HIE. The mean urinary lactate:creatinine ratio within 6 hours of birth was 16.75 in those infants who later developed HIE, 88-fold higher than in asphyctic infants who did not follow this course, and 186 times higher than in normal infants. A ratio of 0.64 or higher was 94 percent sensitive and 100 percent specific in predicting HIE. The ratio tended to increase with the severity of encephalopathy, although not to a significant degree. When they were 2 to 3 days old, infants who developed HIE still had ratios 10 times higher than normal infants and nearly 5-fold higher than asphyctic infants who did not develop HIE. Ten of 16 children who developed HIE neonatally had an adverse outcome; 5 of them had severe neurodevelopmental impairment, and 5 died before age 4 months. Only one of these infants had a postdelivery lactate:creatinine ratio of <1.00, and all but one had a ratio of 3.12 or higher. These ratios were significantly higher than in infants who had a favorable outcome. Estimating the urinary lactate:creatinine ratio by magnetic resonance spectroscopy shortly after birth can help predict which asphyctic infants will develop HIE, and thereby help guide intervention.N Engl J Med 1999;341:328–335

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID