糖尿病患者的孕前咨询与管理

糖尿病合并妊娠患者发生母胎相关疾病的风险明显增加,其后代发生代谢性疾病的风险上升.本文通过阐述糖尿病合并妊娠患者出现母胎并发症的风险,强调为糖尿病患者提供有效合理的孕前咨询与管理的必要性和重要性,对降低其孕期母胎相关疾病发病率、改善妊娠结局具有重要意义.     

Prenatal diagnosis of neural tube defects: VIII. The importance of serum alpha-fetoprotein screening in diabetic pregnant women

Maternal serum alpha-fetoprotein (AFP) screening of routine pregnancy is a valuable tool for the prenatal detection of neural tube defects (NTDs). Against our background experience with >24,000 screened pregnancies, we have studied 411 pregnant insulin-dependent diabetic women. More than a tenfold increase (19.5/1,000) in the frequency of NTDs was observed m the offspring of these diabetic patients (p < 0.000001). Serum AFP values were tower in diabetic than in nondlabetic women. Our data indicate that the normal standard of care for diabetic pregnancy should include serum AFP screening.     

Glycohemoglobin in diabetic pregnancy: a sequential study

Glycohemoglobin (Hb Alc) was assayed sequentially during pregnancy and post partum in 53 women. In a group of nondiabetic women (N = 13) Hb Alc fell significantly (p less than 0.001) from the first to the third trimester and then rose to first-trimester levels by 12 weeks' post partum. Glycohemoglobin levels of insulin-dependent diabetic patients (N = 28) followed a similar pattern but at significantly elevated levels compared to nondiabetic patients (p less than 0.001). In contrast, patients with chemical diabetes (N = 12) did not manifest any change of Hb Alc with time, although they did have glycohemoglobin levels above those of the normal subjects during the third trimester (p less than 0.001) and before 12 weeks' post partum (p less than 0.02). It is speculated that these fluctuations in Hb Alc are most likely due to changes in long-term blood glucose control. Additionally, because Hb Alc increased in vitro oxygen affinity, some of these women were followed for parameters of oxygen transport as well. No significant changes of parameters of oxygen transport were found, with the exceptions of P50 in vivo and P50pH7.40 during the third trimester and of P50 in vivo before 12 weeks' post partum     

The correlations of glycosylated serum protein and glycosylated hemoglobin concentrations with blood glucose in diabetic pregnancy

The usefulness of concentrations of glycosylated serum protein and glycosylated hemoglobin in monitoring glycemic control during pregnancy complicated by diabetes was evaluated by correlation of these parameters with fasting and 2-hour postprandial glucose concentrations of the previous 7 days. Glycosylated serum protein correlated with both fasting (r = 0.798, p less than 0.01, n = 71) and postprandial (r = 0.846, p less than 0.01, n = 69) blood glucose concentrations. Glycosylated hemoglobin also correlated with fasting (r = 0.571, p less than 0.01, n = 71) and postprandial (r = 0.510, p less than 0.01, n = 74) blood glucose concentrations. Monitoring glycosylated serum protein during pregnancy complicated by diabetes is clinically feasible and allows frequent reappraisal of diabetic control.     

Obstetric management when normoglycemia is maintained in diabetic pregnant women with vascular compromise

This study presents an obstetric protocol offering better management and prediction for normoglycemic insulin-dependent patients (White Class D4, F, R, or RF) who conceived after they were diagnosed as having vascular disease secondary to diabetes mellitus. Normoglycemia was accomplished during the pregestational phase, and conception occurred only after the glycosylated hemoglobin level was documented to be normal. Normoglycemia was maintained during pregnancy in the outpatient setting through the use of blood glucose monitoring performed by the patient. The obstetric protocol emphasized three additional areas of attention: (1) assessment of fetal growth by serial uterine fundal measurement and ultrasonography at gestational weeks 21 to 22; (2) assessment of fetal movement by patient-perceived fetal movements for 1 hour a week starting at week 35, increasing to 2 hr/day at week 37, and increasing to 3 hr/day from week 38 onward; and (3) cervical assessment at week 37 and preparation for vaginal delivery. Eight patients had a creatinine clearance of less than or equal to 80 ml/min prior to conception (mean = 66 +/- 6 ml/min). By 6 to 12 weeks' gestation all eight showed an increase in creatinine clearance (mean = 91 +/- 20, p less than 0.01). There was no change in the third trimester, and postpartum creatinine clearance was at antepartum levels. Proteinuria increased significantly by the end of the first trimester in all eight women and regressed post partum. Proteinuria (greater than 150 mg/24 hr) did not occur in the 14 women with normal antepartum creatinine clearance. Of 11 women with background retinopathy, six showed improvement in retinal status by fundus stereophotography whereas five showed no change. Of 11 women with proliferative retinopathy, five improved, five required laser therapy, and one remained in stable condition. Despite hemoglobin A1 levels in the normal gestational range (3% to 7.5%), there was a significant correlation of these levels with infant birth weights. None of the 22 infants died, and only one had any perinatal disease. Thus this protocol with its emphasis on fetal growth and size resulted in improvement in both maternal and infant outcome in pregnancies complicated by diabetes mellitus with vascular compromise.     

The oversuppression syndrome

Evidence that suggests an etiologic relation between the use of oral contraceptive steroids and the development of the oversuppression syndrome is reviewed. Investigation and management of factors probably responsible for the syndrome are presented. It is suggested that the problem is one of hypothalamopituitary dysfunction created by estrogen-progestin combinations. Condistions such as premature menopause, adrenal tumors, and Stein-Leventhal syndrome must be ruled out before a diagnosis of oversuppression is made. Clomiphene was found to be effective in restoring normal ovulatory function.     

The influence of gender roles on health seeking behaviour during pregnancy in Turkey

Objectives To explore the impact of gender roles in relation to health seeking behaviour during pregnancy and childbirth.

Methods The study was conducted in neighbourhoods with low antenatal care rates in three provinces of Turkey. The study population consisted of pregnant women who never got or discontinued antenatal care and their peers, families and community leaders. Sixteen focus group discussions and 125 in-depth interviews were conducted with a total of 239 participants.

Results Pregnancy and childbirth are interwoven strongly with gender roles. Since the patriarchal system acknowledges women through the means of childbirth, women are expected to have many children. Hence women experience pregnancy as a burden and are not motivated to seek antenatal care. During pregnancy, only ‘serious’ conditions are considered as legitimate reasons for accessing care. However, the decision regarding whether a pregnant woman is seriously sick or not belongs to the responsibilities of elder women, which delays service use.

Conclusions Providing information regarding the value of antenatal care also to elder women is essential in increasing the demand to the services. Incorporating gender perspectives into daily health practice and maintaining access to high quality reproductive care services are vital in reducing the gender based barriers to care.     

The early pregnancy assessment project: The effect of cooperative care in the emergency department for management of early pregnancy complications

Background: Early pregnancy assessment clinics (EPAC) have been introduced and accepted as the gold standard for management of early pregnancy problems (EPP). However, EPAC are not universally available and management of EPP within the emergency department (ED) can result in prolonged waiting times, inappropriate use of resources and no clear treatment or follow-up plan being implemented.
Aim: To assess the effect of an early pregnancy assessment protocol (EPAP) in the ED, designed to create a cultural change among doctors in relation to EPP in order to minimise use of resources, improve treatment times for patients and establish a clear management plan where dedicated EPAC services are not available.
Methods: An intervention, the EPAP was introduced to the ED and retrospective and prospective audits of the patients were carried out to assess the effect.
Results: Implementation of the EPAP decreased treatment time by 55%, representations by 48%, pathology blood tests by 56% and formal imaging services by 85%. Gynaecological consultation increased by 37% for each patient visit to the ED and by 9% for each EPP. Total direct cost saving was 63% per patient and no adverse outcomes were recorded.
Conclusion: Introduction of the EPAP was successful in creating cultural change and delivering clinical and financial benefits to the hospital, patients and staff. Early gynaecological consultation and bedside ultrasound scanning within the ED were key factors. Similar benefits could be reproduced in other institutions and for other clinical scenarios where a need has been identified.     

The tap test: A rapid indicator of fetal pulmonary maturity

We present here a new means to assess fetal pulmonary maturity called the tap test. It is rapid, inexpensive, and requires only 1 ml of amniotic fluid. The tap test was compared to the phospholipid profile in 88 fetuses, 70 of whom were delivered before term. All fetuses were born within 72 hours after the amniotic fluid specimen was obtained. The test results were correlated to the absence or presence of the neonatal respiratory distress syndrome. When the tap test was evaluated at 2, 5, and 10 minutes, the predictive values for a mature test result were 100%, 98%, and 98%; the predictive values for an immature test result were 43%, 52%, and 58%, respectively. For the phospholipid profile the predictive values for a mature and an immature test result were 98% and 37%. These findings indicate that the ability of the tap test to predict fetal pulmonary maturity is comparable, if not superior, to that of the phospholipid profile.     

The ultrasound estimation of sex-related variations of intrauterine growth

The fetal ultrasound parameters of biparietal diameter, head circumference, abdominal circumference, and the product of crown-rump length and trunk area were estimated from serial measurements at 16 weeks' gestation to term in a sample of 96 pregnant European women. The slower rate of growth in the female fetus compared to that in the male fetus was statistically significant by 28 weeks' gestation, and this discrepancy increased toward term. This sex-related difference was reflected in the birth weight, head circumference, and crown-heel length of the newborn infant. The variation of intrauterine growth affected both head and abdomen equally as the head/abdominal circumference ratio did not differ significantly between the sexes throughout pregnancy and the neonatal ponderal indices were similar.     

The effect of maternal demographic factors on infant mortality rates. Summary of the findings of the Louisiana Infant Mortality Study. Part I.

Birth and infant death certificates for Louisiana in 1972 were matched and reviewed to identify groups particularly in need of close medical support and counselling during the identify groups particularly in need of close medical support and counselling during the life phases of preparation for reproduction, gestation, and parenthood. From all recorded birth and infant death certificates for 1972 (69,556 birth and 1,541 death certificates) infant, neonatal, and postneonatal mortality rates were computed for maternal demographic (intrinsic patient physiocal and life-style characteristics) factors including age, race, parity by age cohort, education, and legitimacy. Excessive infant deaths were found among illegitimate offspring, except in mothers less than 15 years of age or nonwhites over 35 years of age; the less educated; those having too many children too soon; those of low birth weight; and whites relying on Charity Hospitals. An increased mortality rate was seen with nonwhites and with the younger and older mothers.     

The correlation between colposcopic grading, directed punch biopsy, and conization.

In a study group of 102 patients in whom colposcopy examinations were done, a series of 67 selected biopsies and 47 cold-knife conizations were performed. All patients had suspicious or positive Papanicolaou smears. There was a 96 to 98 per cent correlation between the colposcopic findings, biopsies, and cone specimens.