Osteoporosis transitoria de cadera y gestación

Transient osteoporosis of the hip (TOH) is a rare disorder of unknown etiology, characterized by acute, progressive disabling pain in the hip without prior trauma. This disease is more common among middle-aged men and during the third trimester of pregnancy.     

Hodgkin's disease during pregnancy: diagnostic and therapeutic management

OBJECTIVES: To evaluate the possibility that women affected by Hodgkin's disease (HD) during their second or third trimester of pregnancy can safely carry their pregnancy to term. METHODS: From 1986 to 1997, 6 women came to our Center during the second trimester of pregnancy and were diagnosed as having HD. Three of these 6 patients were treated with chemotherapy before delivery and 3 of them were kept under observation and started treatment after delivery. RESULTS: All 6 women gave birth to a healthy female. CONCLUSIONS: The pregnancy does not worsen the course of the illness and does not compromise long-term clinical remission and recovery.     

The influence of normotensive pregnancy and pre-eclampsia on angiotensin-converting enzyme

Serum angiotensin-converting enzyme (SACE) levels were determined in normotensive pregnant subjects and patients with pre-eclampsia in the third trimester of pregnancy and 5 days, 3 and 6 months after parturition, and also in the first and second trimester in the normotensive group. SACE levels were reduced during pregnancy and 5 days after delivery in the normotensive subjects compared with the levels 3 and 6 months after delivery and to the non-pregnant control subjects. After correction for plasma volume expansion, SACE was reduced in first and second trimester only. In pre-eclampsia both SACE and corrected SACE were significantly lower in third trimester and 5 days after parturition than 3 and 6 months after delivery and in non-pregnant control subjects. The reason for the reduced level of SACE in first and second trimester during normal pregnancy is not known. The low SACE levels in pre-eclampsia may be a secondary phenomenon due to a decreased placental synthesis without primary importance for the blood pressure regulation.     

New treatment approach for osteopenia

Nearly 44 million persons in the United States have osteoporosis or osteopenia, most of whom are osteopenic. Because of sheer numbers, an increased number of fractures occur in the osteopenic group. Bone mineral density alone, based on dual energy X-ray absorptiometry scan results, is not enough to identify persons at increased risk for fracture. The World Health Organization (WHO) Working Group On Osteoporosis has developed an online tool, known as FRAX, to calculate future hip fracture probability based on individual clinical risk factors. Determining the risk of hip fracture is critical because it is the most devastating osteoporosis complication. The FRAX model was developed from population-based cohort studies in Europe, North America, Asia, and Australia. In 2008, the National Osteoporosis Foundation (NOF) adopted the WHO approach in the treatment of osteopenia. This article presents a clinical scenario to demonstrate the application of the WHO FRAX tool and the new NOF guidelines.     

Effect of iron supplementation on serum ferritin levels during and after pregnancy

Summary. Serum ferritin, total plasma ferritin and haematological indices were determined during and for 6 months after normal pregnancy in 45 healthy women, 21 of whom took oral iron supplements. The physiological effect of pregnancy was to markedly depress serum ferritin concentration. During unsupplemented pregnancy median serum ferritin concentration decreased to approx. 6.0 μg/l by 28 weeks gestation, this concentration was maintained until term and was associated with the appearance of erythrocyte microcytosis during the third trimester. At 6 months postpartum, individual and average serum and total plasma ferritin values showed a deficit compared with the values recorded at the beginning of pregnancy. Oral iron supplementation during pregnancy modified the fall in serum ferritin, median serum ferritin concentrations remained about 14.0μg/I after 28 weeks gestation; normocytic erythropoiesis was maintained throughout the third trimester and no deficit in serum and total plasma ferritin occurred as a result of pregnancy. It is concluded that routine oral iron administration should be recommended during pregnancy, certainly after 28 weeks gestation.     

Pregnancy, low-back pain and pelvic girdle pain

Prevalence and factors influencing pelvic joint and low-back pain during pregnancy are hereby reported. They can be associated with considerable disabilities as far as daily activities are concerned. They may be reduced by appropriate measures. Disc herniation rarely occurs during pregnancy and can be treated by oral or epidural steroid administration. Surgical intervention is scarcely indicated. In these cases MRI may be used, but only after the first trimester. Though uncommon, osteoporosis leading to vertebral or hip pain and fracture can occur during pregnancy and breastfeeding. Women concerned may have a pre-existing bone disease revealed by the physiological bone loss that occurs during pregnancy and breastfeeding. Other factors may influence bone mineral density variation such as osteomalacia, steroid or heparin administration. The relationship between transient osteoporosis of the hip and osteoporosis is discussed. Bone investigations and bone mineral density measurement after delivery are required.     

Knochenerkrankungen in Schwangerschaft und Stillzeit

At the German reference center for pregnancy-associated osteoporosis patients with osteological disorders during pregnancy and lactation are recorded. Approximately 75% suffered from pregnancy-associated osteoporosis with a leading symptom of back pain due to vertebral fractures and 25 % suffered from hip pain caused by bone marrow edema. Affected were mainly primigravida. Diagnostic imaging is essential, especially magnetic resonance imaging (MRI), as it is safe in pregnancy. Bone density measurements show a T-score ≤?2.5 according to the WHO criteria for patients with pregnancy-associated osteoporosis. Women with bone marrow edema often suffer from systemic osteopenia. Treatment should involve weaning, substitution of calcium and vitamin D is recommended. Analgesics therapy is essential. Pregnancy-associated osteoporosis usually requires a specific treatment, such as parathyroid hormone. Due to its self-limiting course in many cases bone marrow edema is sufficiently treated by weight load relief via crutches.     

Bone remodeling and bone mineral density during pregnancy

INTRODUCTION. The effect of pregnancy upon the maternal skeleton is not fully understood. The information that has been gathered by recent studies is conflicting with regard to overall loss or gain of bone during pregnancy. The aim of the present longitudinal, controlled study, therefore, was to investigate the effect of pregnancy on lumbar spine, wrist, and hip bone mineral density, and to describe bone remodeling during pregnancy as indicated by biochemical markers of both bone resorption and formation. MATERIALS AND METHODS. Thirty healthy women (15 subjects seeking pregnancy and 15 non-pregnant controls) were studied. Bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry before conception and within 2 weeks after parturition. Markers of bone resorption (urinary cross-linked type I collagen N-telopeptides, serum type I collagen C-telopeptides) and bone formation (total and bone specific alkaline phosphatase, osteocalcin), and total serum calcium were analyzed before, during (once in each trimester), and after pregnancy. RESULTS. During pregnancy, BMD decreased significantly by 3.4+/-4.1% at the lumbar spine and 4.3+/-3.9% at the trochanter, while there was a slight but significant increase in BMD at the proximal 1/3 of the forearm (1.3+/-1.9%). Total hip and femoral neck BMD did not change significantly, nor did total and ultradistal forearm BMD. Bone resorption increased during pregnancy with peak levels in the third trimester (N-telopeptides) or post partum (C-telopeptides), respectively. The increase in bone resorption was accompanied by a significant decrease in serum calcium in the third trimester. Markers of bone formation showed a biphasic pattern with decreases from baseline to the first (total and bone specific alkaline phosphatase) or second trimester (osteocalcin), respectively, followed by a significant increase in the third trimester and post partum. There was no change in any parameter in the control group throughout the study. CONCLUSION. In conclusion, pregnancy is characterized by high bone turnover with resorption preceding formation. During the first and second trimester bone remodeling is uncoupled. Serum calcium decreases as bone resorption peaks in late pregnancy. There are significant decreases in bone mineral density at sites rich in trabecular bone, such as the lumbar spine and the trochanter.     

Bone mineral density in grand multiparous women with extended lactation

OBJECTIVE: We sought to assess whether the accumulation of multiple, frequent pregnancies and the accompanying repeated extended lactation events was a risk factor for low bone mineral density and osteoporosis. STUDY DESIGN: The study population consisted of 30 grand multiparous women who had borne at least 6 children and lactated for at least 6 months with each child, as well as 6 nulliparous, premenopausal women from a population of Finnish American women associated with the Laestadian Church in Washington State. The Church membership has not embraced contraception or extensive bottle-feeding, resulting in a group of women who are either pregnant or lactating during most of their adult reproductive lives. The medical history included the delivery date, birth outcome, infant birth weight, and number of months lactated for each pregnancy, as well as other health information. Bone mineral density of the lumbar spine, femoral neck, and radius was measured with the Hologic QDR 4500-C dual-energy x-ray absorptiometry scanner. Proc Genmod, SAS version 6.14 (Statistical Analysis Systems, Inc, Cary, NC), was used to perform a Wilcoxon test for a nonparametric analysis of covariance and significance adjusted for age and body size. RESULTS: The 2 study groups did not differ in terms of body mass index, history of smoking, or family history of osteoporosis and fracture, although the parous group was, on average, 8 years older than the nulliparous group (P <.05). The accumulation of repeated pregnancy and lactation events without a recovery interval was not associated with lowered bone mineral density or the presence of osteoporosis or osteopenia. CONCLUSIONS: This study suggests that bone mineral density levels can be sustained in the presence of the rapidly changing hormone environment associated with multiple pregnancies accompanying lactation events without a "recovery" interval.     

Osteopenia in pregnancy during long-term heparin treatment: a radiological study post partum

Osteopenia, sometimes with compression fractures of the spine, is a side-effect of long-term heparin treatment. The frequency is unknown. In this study, 70 women were given subcutaneous heparin as therapy for, or prophylaxis against, thromboembolism during pregnancy. All, except two, were examined by X-ray of the spine and hip first week post partum. The duration of treatment and the dosage of heparin varied. There were 12 (17%) with obvious osteopenia, including two women with multiple fractures of the spine (3%). Re-examination 6-12 months post partum showed that the changes were reversible in most cases. Another 18 women were examined about three years after heparin treatment during pregnancy. No obvious osteopenia was found among them or in a control group of 30 women examined in the first week post partum. The degree of osteopenia was not correlated with either the heparin dose or the duration of treatment. Women treated with heparin in consecutive pregnancies do not seem to have an increased risk of osteopenia.     

Osteopenia in pregnancy during long-term heparin treatment: A radiological study post partum

Summary. Osteopenia, sometimes with compression fractures of the spine, is a side-effect of long-term heparin treatment. The frequency is unknown. In this study, 70 women were given subcutaneous heparin as therapy for, or prophylaxis against, thromboembolism during pregnancy. All, except two, were examined by X-ray of the spine and hip first week post partum. The duration of treatment and the dosage of heparin varied. There were 12 (17%) with obvious Osteopenia, including two women with multiple fractures of the spine (3%). Re-examination 6–12 months post partum showed that the changes were reversible in most cases. Another 18 women were examined about three years after heparin treatment during pregnancy. No obvious osteopenia was found among them or in a control group of 30 women examined in the first week post partum. The degree of osteopenia was not correlated with either the heparin dose or the duration of treatment. Women treated with heparin in consecutive pregnancies do not seem to have an increased risk of osteopenia.     

妊娠合并肺栓塞15例临床分析

目的分析妊娠合并肺栓塞临床特点及妊娠结局。 方法收集广州医科大学附属第三医院妇产科2010年3月至2014年1月收治的15例妊娠合并肺栓塞患者的临床资料,对其一般情况、临床症状、辅助检查、治疗措施及妊娠结局进行回顾性分析。 结果(1)发病时间：妊娠早期1例,妊娠中期6例,妊娠晚期2例,剖宫产术后产褥期6例。(2)终止妊娠方式：剖宫产8例,剖宫取胎术5例,利凡诺引产1例,自然流产1例。(3)结局：孕妇死亡4例,存活11例;健康足月儿6例,早产儿3例,死胎6例。 结论提高对妊娠合并肺栓塞疾病的认识,尽早确诊和治疗,改善其妊娠结局。     

Measure of hemodynamic patterns by thoracic electrical bioimpedance in normal pregnancy and in preeclampsia

OBJECTIVE: To compare the differences in the hemodynamics between normal pregnancy and preeclampsia, using thoracic electrical bioimpedance. STUDY DESIGN: We compared heart rate, end-diastolic volume, systolic volume, cardiac output, ejection fraction and peripheral vascular resistances in 18 healthy pregnant women with 15 with preeclamptic women at the following intervals: third trimester, 48 h post-partum, 2 and 6 months post-partum. We took the measurements by thoracic electrical bioimpedance. Statistical analysis was performed by means of Wilcoxon rank-sum test and p < 0.05 was considered statistically significant. RESULTS: The heart rate was lower in the preeclampsia group during the third trimester and the systolic volume was also lower at 48 h post-partum; this implies a lower cardiac output in women with preeclampsia during pregnancy and in the immediate puerperium. The systemic vascular resistances were higher in preeclampsia in the third trimester and at 48 h post-partum. At 2 and 6 months post-partum, the hemodynamic situation had equalized in both groups. CONCLUSIONS: Preeclampsia is a situation of low cardiac output and high peripheral resistances compared with a normal pregnancy.     

The reasons for termination of pregnancy in the third trimester

Objective To analyse the process in making decisions leading to termination of pregnancy in the third trimester and to evaluate the maternal morbidity associated with this procedure.
Design Retrospective study.
Setting The Maternité Port Royal University Hospital, Paris, France.
Population A consecutive series of 956 terminations of pregnancy performed for fetal anomalies in singleton pregnancies, 305 of which were in the third trimester and 651 in the second.
Main outcome measures Indications for termination of pregnancy; process leading to late termination of pregnancy; maternal morbidity.
Results One hundred and thirteen (37%) third trimester terminations of pregnancy were associated with false negative resulted from the results of earlier screening tests. In 15 terminations (15%), the decision was postponed, although the poor fetal prognosis was established earlier. In 55 (18%) the diagnosis was not possible earlier than the third trimester, and in 122 (40%) the diagnosis was possible earlier but the poor prognosis for the fetus was not established until the third trimester. Maternal morbidity due to termination of pregnancy was similar in the second and third trimester.
Conclusion One-third of late terminations of pregnancy could have been avoided by more efficient screening in the second trimester. However, because fetal prognosis is not always clear when a malformation is diagnosed, postponing the decision until fetal development allows more thorough evaluation and may avoid unnecessary termination of pregnancy in the second trimester. This could be the main beneficial aspect of not setting a limit to the gestational age for performing termination of pregnancy. To analyse the process in making decisions leading to termination of pregnancy in the third trimester and to evaluate the maternal morbidity associated with this procedure. The Maternit6 Port Royal University Hospital, Paris, France.     

Amoebic liver abscess in pregnancy

We describe the case of an amoebic liver abscess (ALA) presenting in the third trimester of pregnancy which raised both diagnostic and treatment dilemmas as well as being associated with preterm labour. Amoebic liver abscess is caused by the protozoan organism Entamoeba histolytica which is endemic in many parts of the developing world. Invasion of the colonic mucosa results in the clinical syndrome of amoebic dysentery and in some cases dissemination to the liver or other organs occurs resulting in abscess formation. Amoebic liver abscess is a rare complication of pregnancy and there are few reports in the world literature, these being mostly from endemic areas. We present here the case of a caucasian female who presented with an amoebic liver abscess in the third trimester of pregnancy, thirteen months after returning to Australia from a short holiday in Bali.     

Reflex sympathetic dystrophy involving the ankle in pregnancy: characteristics and therapeutic management

We report the case of a multigravida presenting in the first trimester of pregnancy with reflex sympathetic dystrophy involving both ankles. Preferential location of reflex sympathetic dystrophy in pregnancy is classically the hip (9 times out of 10). Symptoms develop mostly with primipara in the third trimester of pregnancy or in post-partum. Fracture is the major risk of reflex sympathetic dystrophy. Peculiarities of reflex sympathetic dystrophy's treatment in the course of pregnancy are evoked. The end of the pregnancy can be shortened with the aim of stabilizing disease even to activate its healing. Pathophysiologic mechanisms of reflex sympathetic dystrophy in pregnancy seem multiple and complex. Our observation, by its atypical characteristics, recalls it.     

Cardiovascular function in pregnancy: effects of posture

Objective To evaluate the cardiovascular response to active postural changes in pregnancy.
Design Prospective study.
Setting Outpatient Clinic, Fetal Maternity Unit.
Participants Sixteen healthy women referred prior to pregnancy.
Methods Heart rate, arterial pressure, echocardiographic end–diastolic and end–systolic left ventricular volumes (Teichholz's formula) were measured in the three months before pregnancy, at the end of the first and second trimester, at mid third trimester, and six months after delivery in the supine and standing position, in thirteen women (mean age 33, range 25–38 years).
Results Cardiac output (supine position) significantly increased (28%): it reached its maximum at the second trimester, remained steadily elevated in the mid third trimester, and returned to baseline after delivery. Cardiac output increased during pregnancy also in the active orthostatic position, the percentage increase being greater (70%) since the standing pre–conception value was lower. The postural stress induced similar changes in heart rate, arterial pressure and left ventricular ejection fraction before, during and after pregnancy. However, the reduction in cardiac output associated with early standing attenuated significantly at the second trimester and it was absent at mid third trimester (  F = 3.13, P = 0.021  ). This was due to the interplay between the significantly lesser increase in systemic vascular resistance, occurring since the first trimester, and the significantly lesser decrease in left ventricular end–diastolic volume which was observed in the mid third trimester.
Conclusion These data indicate that the elevated cardiac output is adequately maintained in pregnancy during the postural challenge, due to optimisation of the responses of preload and afterload.     

Case report of laparoscopic cholecystectomy in the third trimester of pregnancy.

Laparoscopic cholecystectomy has not been reported during pregnancy. This is the first reported case of a cholecystectomy by laparoscopic technique in the third trimester of pregnancy. The patient (and her baby) had a rapid, uneventful recovery identical to that of a nonpregnant patient.     

Induced abortion and duration of third stage labour in a subsequent pregnancy.

We set out to evaluate the impact of first trimester induced abortion on the duration of third stage labour and related complications in a subsequent pregnancy. The study was conducted in Shanghai city at 15 general hospitals (or maternity and infant health institutes) from November 1993 to March 1998. We identified all nulliparae who came for antenatal care within the first 63 days of pregnancy (2953); the women were divided into two cohorts according to their previous history of first trimester induced abortion. After enrollment, the women were interviewed five times from recruitment until 42 days after delivery. We included in the study all 1363 women who had a singleton vaginal live birth. Of these women, 703 were primigravida (non-exposed), 534 had had one previous first trimester induced abortion, and 126 women had had two or more first trimester induced abortions. The duration of third stage labour in minutes was longer in women with one or more previous induced abortions (mean=7.32 minutes) compared with primigravid women (mean=6.79 minutes). Prolonged third stage labour (>30 minutes) following one or more induced abortions was seen for 3.4% versus 1.0% in primigravid women. After adjusting for a number of potential confounders, women with one or more previous first trimester induced abortions had an odds ratio of prolonged third stage labour of 2.59 (95%C.I.=1.06-6.37) compared with primigravida, especially after an interpregnancy interval of more than 6 months (OR=3.24, 95%C.I.=1.29-8.13). The odds ratio of prolonged third stage labour was 3.14 (95%C.I.=1.22-8.09) if gestational age at the time of the induced abortion exceeded 49 days. Women with a first trimester induced abortion had no significantly increased risk of postpartum haemorrhage or retained placenta. It was concluded that a history of one or more first trimester induced abortions was related to an increased risk of prolonged third stage labour in the following pregnancy, particularly if the induced abortion was performed after 49 days of gestation.