Diabetes in pregnancy: health risks and management

Diabetes in pregnancy is increasing and therefore it is important to raise awareness of the associated health risks to the mother, the growing fetus, and the future child. Perinatal mortality and morbidity is increased in diabetic pregnancies through increased stillbirths and congenital malformation rates. These are mainly the result of early fetal exposure to maternal hyperglycaemia. In the mother, pregnancy may lead to worsening or development of diabetic complications such as retinopathy, nephropathy, and hypoglycaemia. This review defines pregestational and gestational diabetes and the associated health risks to the growing fetus and mother. Management is discussed, focusing on clinical evidence based guidelines published by the American Diabetic Association and the UK National Institute for Health and Clinical Excellence on the management of pregnant women with pre-existing diabetes.     

Current concepts in the management of obesity. An evidence based review

The increasing prevalence of overweight and obesity is an important public health problem contributing to significant excess in morbidity and mortality. A cross-sectional national epidemiological household survey showed that the prevalence of obesity in female Saudi subjects was among the highest reported. Obesity is a complex multifactorial chronic disease that develops from an interaction of genotype and the environment. Our understanding of how and why obesity develops is incomplete, but involves the integration of social behavioral, cultural physiological, metabolic and genetic factors. While there is agreement about health risks of over weight and obesity, there is less agreement about their management. Primary health care services should play the dominant role for obesity management. Family physicians need to assess the patient's readiness to enter weight loss therapy and take appropriate steps for motivation. Weight loss and weight maintenance therapy should employ the combination of low caloric diet, increased physical activity, and behavioral therapy. Weight loss drugs may be used as part of comprehensive weight loss program. Weight loss surgery is an option for carefully selected patients with severe obesity Body Mass Index greater than 40. After successful weight loss, a program consisting of dietary therapy, physical activity, and behavioural therapy, which should be continued indefinitely, enhances the likelihood of weight loss maintenance.     

Pregnancy weight gain and postpartum loss: avoiding obesity while optimizing the growth and development of the fetus

Weight gain during pregnancy may contribute to obesity development. Concerns about possible adverse effects of pregnancy weight gain on later maternal weight and on labor and delivery must be rigorously evaluated in light of possible benefits for fetal growth and development. Birth-weight rises with increased pregnancy weight gain, and perinatal and neonatal mortality fall as birthweight increases in both preterm and term infants. The lowest mortality is observed at 3500 to 4500 g in infants of white women. Although often thought to be at high risk, infants termed "macrosomic" include infants of the lowest mortality rate. Thus, restricting weight gain may be detrimental to the baby. Weight gain that is optimal for the mother and the baby differs according to the mother's prepregnancy weight. Pregnancy weight gain exceeding current recommendations is associated with increases in maternal fat gain, pregnancy complications, and delivery problems and should be discouraged. Postpartum weight loss is essential to prevent permanent weight increase. Smoking cessation during pregnancy, reduced postpartum physical activity, and other lifestyle changes can contribute to increased postpartum weight. Health care providers can help to reduce obesity risk by regularly monitoring women's weight; promoting appropriate prepregnancy weight, pregnancy weight gain, and postpartum weight less; and explicitly encouraging maintenance of an active postpartum lifestyle.     

Acute pancreatitis in pregnancy: a 6-year single center clinical experience

Background  The acute abdomen remains a challenge for all obstetricians and physicians who take part in the care of women in pregnancy. To add substantially to our understanding of acute pancreatitis (AP) in pregnancy, in particular affirming the increased risks for mother and fetus associated with AP, we explored features of clinical manifestation and the strategy of management of this disease during pregnancy, and its effects on maternal and fetal outcomes.

Methods  A retrospective review of medical records of all pregnant patients diagnosed with AP admitted to the Department of Obstetrics and Gynecology, Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University between 2005 and 2010 was performed. Information was collected from presentation, management, and outcome from medical records.

Results  There were 11 cases in 2010, accounting for 44% of 25 cases. Among these cases, mild AP (MAP) occurred in 15 cases (60%), while the rest cases were severe AP (SAP) (40%). The major etiology of AP in pregnancy was due to gallstone and cholecystitis. Clinical features together with elevation of the plasma concentrations of pancreatic enzymes were the cornerstones of diagnosis. Positive conservative treatment was taken in most of the cases (21 cases, 84%) with a favorable outcome. Seven cases of critically ill patients were monitored in intensive care unit, and 4 patients underwent surgical interventions. As a result, all of 25 patients had better prognosis, no maternal death was observed. There were 8 preterm labors and 2 fetal losses, accounting for the perinatal mortality of 8%. Fetal malformation was not observed.

Conclusions  While a pregnant woman suffers acute abdominal pain, early diagnosis and severity assessment of AP are very important. Conservative comprehensive treatment with intensive care is recommended. Surgical intervention should be performed as late as possible.

     

边远山区孕产妇系统管理的探索与研究

目的探索边远山区孕产妇系统管理模式,制定有效的管理措施,减少孕产期并发症,降低孕产妇、围生儿死亡率,提高住院分娩率,降低难产发生率,提高出生人口素质,切实保护母婴安全。方法建立以系统管理和优化服务为基础,以信息网络为依托,高危产妇筛查为重心的边远山区孕产妇系统管理模式,采取多种形式的健康教育、宣传、孕期指导、减免费用及危重救治等干预措施。结果通过实施边远山区孕产妇系统管理,边远山区孕产妇登记造册率、产前检查率、住院分娩人数等得到明显提高,孕产妇死亡率、围生儿死亡率、孕产期并发症及难产的发生率均得到有效控制。结论边远山区孕产妇管理系统的成功实施,可以有效提高出生人口素质,切实保护母婴安全。     

Did we do it right?--an evaluation of the colour coding system for antenatal care in Malaysia

Identification of pregnancies that are at greater than average risk is a fundamental component of antenatal care. The objective of this study was to assess the level of appropriate management and outcomes among mothers with hypertensive disorders of pregnancy, postdates and anemia in pregnancy, and to determine whether the colour coding system had any effect on the maternal mortality ratios. A retrospective follow-through study confined to users of government health services in Peninsular Malaysia was carried out in 1997. The study areas were stratified according to their high or low maternal mortality ratios. The study randomly sampled 1112 mothers out of 8388 mothers with the three common obstetric problems in the selected study districts. The study showed that the prevalence of anemia, hypertensive disorders in pregnancy and postmaturity among mothers with these conditions were according to known international standards. There was no significant difference in the colour coding practices between the high and low maternal mortality areas. Inappropriate referrals were surprisingly lower in the areas with high maternal mortality. Inappropriate care by diagnosis and by assigned colour code were significantly higher in the areas with high maternal mortality. The assigned colour code was accurate in only 56.1% of cases in the low maternal mortality areas and in 55.8% of the cases in the high maternal mortality areas and these two areas did not differ significantly in their accurate assignment of the colour codes. The colour coding system, as it exists now should be reviewed. Instead, a substantially revised system that takes cognisance of evidence in the scientific literature should be used to devise a more effective system that can be used by health care personnel involved in antenatal care to ensure appropriate level of care and referrals.     

2007～2008年南宁市妇幼卫生统计年报主要指标分析

目的通过分析南宁市妇幼卫生工作现状,为今后制定干预措施提供依据。方法对20072008年南宁市妇幼卫生统计年报中的主要指标进行统计分析研究。结果与2007年相比,2008年南宁市孕产妇死亡率有所上升;婴儿死亡率和5岁以下儿童死亡率有所下降。南宁市孕产妇死亡率、婴儿死亡率和5岁以下儿童死亡率存在明显城乡差异。结论南宁市孕产妇保健和儿童保健管理工作有待进一步加强。孕产妇保健和儿童保健的重点应放在农村和城市流动人口,应联合有关部门,加强对城市非户籍常住人口中孕产妇的追踪管理,提高产前检查率和住院分娩率;加大对农村孕产妇健康教育宣传和干预。要重视儿童急性呼吸系统疾病的防治,要积极开展儿童伤害监测,应加强安全教育和积极防范儿童意外     

孕妇超重和肥胖对子代神经和精神发育异常的影响及管理建议

流行病学研究发现孕期营养过剩、孕妇超重和肥胖可能影响子代神经系统及精神心理发育,本文通过总结和分析孕妇超重和肥胖对子代神经、精神发育异常的影响及机制进展,发现孕妇超重和肥胖可能增加子代罹患智力发育障碍、孤独症谱系障碍、注意缺陷多动障碍、焦虑与抑郁、精神分裂症、进食障碍和食物成瘾的风险,但是宫内环境影响子代神经精神系统发育的机制尚不明确,可能涉及氧化应激和炎性反应、大脑发育过程中胰岛素及葡萄糖和瘦素信号系统失调、多巴胺和5-羟色胺系统失调及反馈环路受损、以及脑源性神经营养因子介导的突触可塑性受损等。孕期体质量的合理管理可能会改善孕妇超重和肥胖对子代神经系统的不良影响,加强育龄女性社区保健工作是协助管理超重和肥胖孕妇的重要环节。     

Pregnancy in renal transplant recipients: report of two successful pregnancies in a patient with impaired renal function.

Pregnancy in renal transplant recipients is common and, in spite of several potential problems, overall maternal and fetal outcome has been good in patients with transplants that are functioning well. The presence of renal impairment or hypertension, or both, usually leads to complications, especially in the mother. A patient is described who had a baseline creatinine clearance of about 35 mL/min-1.73 m2 and two successful pregnancies. Renal function deteriorated in the 3rd trimester of the first pregnancy but was reversible; permanent loss of function occurred in the 3rd trimester of the second pregnancy. The potential fetal and maternal risks and details of management of pregnant transplant recipients are reviewed.     

Management of epilepsy in women

There are many aspects to the management of epilepsy in women related to their role in reproduction. Some of these need to be considered in adolescents, some are related to pregnancy, concerning both the mother and her infant, and others with the menstrual cycle and the menopause. This review considers contraception, fertility, teratogenicity, and the use of folic acid. It also discusses the special investigations in pregnancy, hyperemesis, the effect of pregnancy on the control of epilepsy, the effect of seizures on the fetus, a first fit in pregnancy, pseudoseizures, seizures during delivery, vitamin K, breast feeding, postpartum maternal epilepsy, hereditary risks, counselling, catamenial epilepsy, the menopause, and bone density.     

早发型重度子痫前期妊娠116例结局分析

目的探讨早发型重度子痫前期的临床转归。方法收集天津市中心妇产科医院2008年1～12月住院分娩116例重度子痫前期孕妇的临床资料,按发病孕周将患者分为两组：55例孕周≤32周为早发型重度子痫前期（earlyonset severe pre-eclampsia,EOSP）组,61例孕周〉32周为晚发型重度子痫前期（late onset severe pre-eclampsia,LOSP）组。主要分析指标：发病孕周、终止妊娠孕周、保守治疗时间、孕妇严重并发症、围产儿死亡、新生儿窒息。结果两组孕妇并发症发生率、新生儿窒息、围产儿死亡情况比较,差异有显著性（P〈0.05）;早发型组保守治疗时间为（4.56±3.01）d,晚发型组为（3.08±2.14）d,两组保守治疗时间比较,差异有显著性（P〈0.05）。结论早发型重度子痫前期发病早、病情重,对母婴危害极大。恰当的围产期管理并适时终止妊娠可改善母婴妊娠结局,剖宫产是早发型重度子痫前期的主要分娩方式。     

学龄期儿童肥胖现况及影响因素分析

目的通过调查学龄期儿童肥胖现况及影响因素,为后期肥胖干预提供一定的理论依据。方法采用自制的《儿童家庭饮食行为调查问卷》对咸阳市随机抽样的1 000名儿童及其家长从基本信息及儿童期生活方式、饮食行为习惯进行调查。结果1 000名调查对象中,共检出肥胖儿童82例,男女童肥胖率差异具有统计学意义（P < 0.05）;各年龄段男女童肥胖率差异无统计学意义（P > 0.05）;随着年龄的增加,男女童肥胖率均呈升高趋势。家族肥胖史、家庭收入、母亲口味偏好与儿童肥胖呈正相关关系（P < 0.05~P < 0.01）;而母亲学历与锻炼时间与儿童肥胖呈负相关关系（P < 0.01和P < 0.05）。结论学龄期儿童肥胖现况较严重,应当从饮食行为、生活方式方面进行有效干预。     

Diabetes and pregnancy

Diabetes in pregnant women is associated with an increased risk for maternal and neonatal morbidities and remains a significant medical challenge. Fortunately, the prognosis has changed dramatically, related to an increased clinical awareness of the potential risks for the mother and the infant, better health care and intensive treatment strategies to maintain the closest to normal metabolic milieu. Diabetes and pregnancy may be divided into pregestational diabetes (women previously diagnosed with type 1 or type 2 diabetes) and gestational diabetes defined as any glucose intolerance detected during pregnancy that has evolved from a diagnosis associated with the metabolic risk of type 2 diabetes to a clinical condition associated with higher risks for maternal and perinatal morbidity. Early diagnosis of gestational diabetes is an important step to improve outcomes and systematic or selective screening with the OGTT should be established. Associated with the global epidemic in diabetes, pregnancy associated with diabetes is saturating high-risk obstetric clinics and neonatal intensive care units, becoming a heavy burden to the health care systems around the world.     

Advanced abdominal pregnancy: a case report of good maternal and perinatal outcome

Advanced abdominal pregnancy is understood to mean any extra-uterine pregnancy found within the peritoneal cavity that is greater than 20 weeks gestation. Its management is one of laparotomy with varying complications including poor perinatal outcome and increased maternal morbidity and mortality. There is no accepted consensus for the complete removal of the placenta at laparotomy. This paper reports the management of a unique case of advanced abdominal pregnancy that was diagnosed by ultrasound at 20 weeks gestation and treated conservatively until delivery of a viable female neonate at 33 weeks and 4 days by elective laparotomy. At the time of laparotomy, the placenta was removed completely with good maternal outcome. This, to the best of our knowledge, is the first case in the West Indian literature documenting complete removal of the placenta at the time of laparotomy with good maternal outcome.     

Malaria in pregnancy

Malaria during pregnancy is a recognised risk factor for maternal and foetal complications and it is endemic in certain areas of our country. Pregnancy also enhances the severity of malaria particularly with P falciparum infestation. The outcome of effects of malaria in pregnancy on the mother and foetus is studied here. This is a prospective observational study conducted in the department of obstetrics and gynaecology of RG Kar Medical College during the period from 1st January 2001 to 31st December 2006. Forty pregnant women with malaria in pregnancy were studied. Another 40 non- pregnant women during the same period were served as control. The maternal complications were compared with the controls and the outcome of pregnancy was studied. There was statistically significant (p < 0.05) increase in the incidence of anaemia, cerebral malaria, renal failure, hepatic failure, hypoglycaemia, hypotension and death in the pregnant women in comparison to non-pregnant women. P falciparum infection was also more during pregnancy. There was also increased incidence of abqrtion, preterm labour, intra-uterine growth restriction and intra-uterine foetal death. Treatment with antimalarial drugs particularly in cerebral malaria does not give good results as there were 12 maternal deaths in this series. Every attempt should be made to prevent malaria during pregnancy by various measures as it is associated with high maternal morbidity and mortality and adversely affects the neonatal outcome.     

Understanding maternal mental illness: psychiatric autopsy of a maternal death

Maternal mental illness is a significant public health concern, with established adverse outcomes on both mother and infant, such as impaired mother-infant bonding and infant cognitive and emotional development. In severe cases, maternal mortality and infanticide can tragically occur. This is a report on the suicide of a mother who jumped to her death at three months postpartum. She suffered from puerperal psychosis with bipolar features, with onset at six weeks postpartum. The case highlights the burden of maternal mental illness in our community as well as the need for resources and services to care well for mothers. With a better understanding of its presentation and risk factors, early identification and intervention can reduce morbidity and mortality.     

Placenta previa and it's relation with maternal age, gravidity and cesarean section

The placenta provides the essential connection between the mother and the developing fetus. Placental position were routinely mentioned in an ultrasound report starting from early second trimester to the end of third trimester when asked for pregnancy evaluation. The aim of this study was to see the prevalence of lower segment placenta (placenta previa) and its relations with previous cesarean section delivery, parity and maternal age. The study conducted in Centre for Nuclear Medicine and Ultrasound (CNMU) Mymensingh in a period from January 2001 to December 2002. About 2536 pregnant women (those included in this study) underwent ultrasound examination during pregnancy at third trimester. The prevalence of lower segment placenta was 1.34%. The highest prevalence of placenta previa (2.58%) was seen in 3rd and higher gravida group. Also the highest prevalence were seen 30 yr. and above age group in compare to below 30 yr. age group. No increased prevalence of placenta previa were seen in previous cesarean section (C / S) delivery group (0.65%) in compare to normal delivery group (1.97%). From our study it was seen that development of lower segment placenta has relation with increased number of gravidity and maternal age but no increased prevalence were seen in subjects with previously done cesarean section     

Management of diabetes mellitus in pregnancy

Diabetes is a common problem in pregnancy and the incidence depends on the racial predisposition and geographical distribution where the reports originate. Despite improvement in perinatal care, many serious clinical problems are still associated with diabetes during pregnancy. The overall strategy of management includes early identification of diabetes during pregnancy, combined management to achieve optimal glucose control with dietary manipulation and insulin, maternal and fetal monitoring during the antenatal period and determination of the delivery time. Intensive intrapartum monitoring and neonatal care at delivery and thereafter are also essential. The outlook for the newborn of the diabetic mother has changed dramatically in recent years and both perinatal mortality and morbidity rate have declined as a result of pre-pregnancy preparation and meticulous control of maternal blood glucose throughout pregnancy. Successful pregnancy outcome depends on the cooperation of the patient, the obstetrician, the physician, the neonatologist and the health educator.     

Management of diabetes during pregnancy

Evidence now exists that maintaining normal maternal plasma glucose in the diabetic mother results in an infant mortality risk equal to that in the general population and may reduce the late fetal complications of maternal diabetes: macrosomia and perinatal hypoglycemia. Careful attention to diet, home glucose monitoring, multiple insulin injections, and frequent dose adjustments are often required to achieve this goal. Since organ development occurs within the first few weeks after conception, pregnancy planning and optimization of diabetes management prior to pregnancy is critical to good outcome in diabetic women eager to begin a family.     

贵州省农村婴儿死亡危险因素的病例对照研究

目的：探讨贵州省农村婴儿死亡的危险因素,为降低农村婴儿死亡提供科学依据.方法：以2002年死亡的婴儿作为病例组,同期存活婴儿作为对照组,进行成组的病例对照研究.结果：通过Logistic回归分析结果表明,农村妇幼卫生服务利用（产前检查、住院分娩、产后访视等3项同时利用）校正OR为0.255（95%CI 0.076～0.665）,定期体检校正OR为0.501（95%CI 0.449～0.886）,体重低于2.5 kg的校正为OR10.231（95%CI 3.854～27.155）,出生缺陷的校正OR为9.971（95%CI 2.380～41.78）,孕期负性事件的校正OR为2.146（95%CI 1.249～4.855）,母亲年龄＞35岁的校正OR为3.11（95%CI 1.180～6.134）,怀孕前3月感冒与发烧2.345（95%CI 1.184～4.642）,父亲的文化程度为小学、初中、高中及以上（与文盲比）的校正OR值均小于1.结论：低体重儿、出生缺陷、孕期负性事件、怀孕前3月感冒与发烧、高龄孕产妇是贵州省农村地区婴儿死亡的高危因素;而母亲同时接受产前检查、住院分娩、产后访视3项卫生服务及父亲文化程度高、婴儿定期体检是婴儿的保护因素.