妊娠期重症肌无力对母儿的影响及诊治

重症肌无力(myasthenia gravis,MG)常发生在20～45岁的育龄女性,病情变化常难以预测。妊娠合并MG轻症者可考虑继续妊娠,重症者应终止妊娠。妊娠期间应加强监护,维持病情的稳定,确保母亲及胎儿的安全。妊娠期间用药是安全的,临床常用的药物有抗胆碱酯酶药、免疫抑制剂和免疫球蛋白等。MG不是剖宫产的指征,可经阴道自然分娩。新生儿可能会出现一过性的肌无力,但往往是暂时的。     

妊娠合并重症肌无力的临床研究进展

重症肌无力（myasthenia gravis,MG）是神经-肌肉接头传递障碍并以骨骼肌无力为特征的自身免疫性疾病。妊娠合并MG可使病情发生难以预测的变化。妊娠妇女MG病情、治疗方案对胎儿、新生儿、甚至子代的远期存在一定影响。MG与妊娠、分娩、麻醉等过程存在相互作用。妊娠期用药应采取个体化治疗方案;MG病情控制良好的妊娠妇女仅在有产科指征时方可考虑剖宫产术,阴道分娩则应尽可能缩短第二产程。 MG妊娠妇女的围生期治疗需要特殊关注。综述如上问题的研究进展。     

Myasthenia gravis and pregnancy

Myasthenia gravis (MG) is an autoimmune disorder of neuromuscular junction that has higher incidence in younger women than men, which could be related to differences in sex hormones physiology and immune system functioning between males and females. MG can first present during pregnancy and variably affect pregnancy, labor, and postpartum period. In this paper, we had an updated overview on our understanding about MG presentation and its effect on pregnancy and vice versa, therapeutic options for MG pregnant women, management of pregnancy or labor complications in MG patients, and finally fetal and neonatal considerations in MG pregnant women. A multidisciplinary approach, involving obstetricians/gynecologists, neurologists, and anes-thesiologists, plays a pivotal role in improving the clinical outcomes in both MG mothers and their infants during pregnancy, delivery and postpartum.     

Myasthenia gravis and pregnancy

We retrospectively analyzed the course and outcome of pregnancy in a group of 26 women with myasthenia gravis. Premature births were noted in 7.9% of pregnancies, the rate of cesarean section was 15.8%. Neonatal myasthenia was observed in 10 children born by 5 women (16% of the mothers). There were three neonatal deaths: two due to neonatal myasthenia, one in a child born with multiple congenital anomalies. Transient exacerbation of MG symptoms was observed during four pregnancies (10.5%). MG is not associated with increased risk for MG patient and the newborn. Giving birth to one child with transient MG increases the risk of transient MG in consecutive pregnancies.     

Myasthenia gravis in pregnancy: report on 69 cases

OBJECTIVE: To review our experience with pregnancies in women with myasthenia gravis (MG). STUDY DESIGN: Sixty nine pregnancies among 65 women with MG patients managed by our department over 28 years were included. The course of the disease in pregnancy, mode of delivery and postpartal period were evaluated. RESULTS: One pregnancy miscarried. In 15% of patients the MG deteriorated in pregnancy a further 16% in the puerperium. 17% of pregnancies were delivered by cesarean section, one due to myasthenia exacerbation. All women with puerperal infections developed exacerbations. One neonatal death, not attributable to myasthenia, was recorded. Transitory neonatal myasthenia gravis (TNMG) was diagnosed in 30% infants. Its incidence was inversely associated with maternal disease duration (P < 0.05). Newborns of thymectomized mothers showed lower rate of neonatal myasthenia compared to those of non-thymectomized women (P < 0.05). CONCLUSIONS: MG patients can have normal pregnancy and delivery but the course is unpredictable. Shorter disease history and infection predispose to puerperal exacerbation. Maternal thymectomy lessens the likelihood of neonatal myasthenia. An interdisciplinary approach is required for managing the pregnant women with MG.     

Myasthenia gravis and pregnancy.

Myasthenia gravis (MG) is a chronic autoimmune disorder of neuromuscular transmission characterized by varying degrees of weakness and easy fatigability of the skeletal muscles. Precipitants of myasthenic symptoms or crises include physical and emotional stress, systemic illness, infections, hypo or hyperthyroidism, pregnancy, any type of surgery with general anaesthesia as well as corticosteroids. The authors report two cases of MG in pregnancy and discuss briefly the various aspects of the disease course and management in pregnancy. As MG occurs predominantly in women of reproductive years, it is important that obstetricians are aware of this condition and its management in pregnancy.     

Migraine treatment in pregnancy

Migraine disorders are a common entity in women, especially during childbearing years. Fortunately, because of sustained elevated levels of estradiol in pregnancy, the incidence of migraine in pregnancy diminishes. Treatment options for pregnant women with migraines should begin with nonpharmacological remedies that promote a healthier lifestyle and address factors that provoke migraines. Triggers include alcohol, oral contraceptives, fasting, caffeine, and fatigue. Some women, however, will continue to have severe intractable headaches associated with symptoms such as nausea, vomiting, and possible dehydration. These symptoms not only disrupt the patient but also may become a risk to the developing fetus. The choice of which pharmacological method to use should not only be based on the severity of the migraine but should account for embryotoxicity, teratogenicity, fetal growth abnormalities, and perinatal effects. Pharmacological treatment includes acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, antiemetics, and 5-HT₁ receptor agonists. Mild attacks may be managed with analgesics, whereas disabling ones usually respond to more specific drug therapy. Prophylactic treatment is rarely indicated in pregnancy and should be reserved for women with migraines that are long lasting, frequent, and unaffected by analgesics. Possible drugs that can be used in pregnancy include β-blockers, calcium channel blockers, amitriptyline, and NSAIDs.     

MIGRAINE AND PREGNANCY

Migraine is an episodic headache disorder that occurs in four percent of children, six percent of men, and 18 percent of women. Most women with migraine improve during pregnancy. Some women have their first attack during pregnancy. Migraine can recur postpartum; it can also begin at that time. Despite their drug use, migraineurs do not differ from nonmigraineurs in their incidence of miscarriages, toxemia, congenital anomalies or stillbirths. Drugs are commonly used during pregnancy and, although medication use should be limited, it is not absolutely contraindicated. Most drugs are not teratogenic. Adverse effects such as spontaneous abortion, developmental defects, and various postnatal effects depend on the dose and route of administration and the timing of the exposure relative to the period of fetal development. In migraine, the risk of status migrainosus to the fetus may be greater than the potential risk of the medication used to treat the mother. Nonpharmacologic treatment is the ideal solution; however, analgesics such as acetaminophen and opioids can be used on a limited basis. Preventive therapy is a last resort.     

Obstetric and perinatal management of myasthenia gravis

Three new cases of patients with myasthenia gravis during pregnancy are presented. The unpredictable course of myasthenia gravis (MG) in pregnancy is discussed. The course of labor in patients with MG is normal. The effects of certain drugs on the course of diseases are assessed. In our group of patients only one patient had an exacerbation of her MG after using an aminoglycoside. There were 7 live births. None of the newborns developed neonatal myasthenia.     

Dyspepsia in pregnancy.

Dyspepsia with or without nausea is common during pregnancy. Known ulcer disease, gastritis, and GERD may improve during pregnancy. Many women have a stoic and long-suffering posture during pregnancy owing to an unrealistic expectation concerning the teratogenicity of commonly used drugs. It is appropriate in medicine to alleviate pain and suffering when possible, and many drugs can be used safely and effectively to control upper gastrointestinal tract symptoms. When symptoms are persistent into the late second trimester, refractory to pharmacologic treatment, or severe, H. pylori infection, complications of ulcer disease, and underlying cancer should be suspected and sequentially ruled out. More timely treatment and work-up of nonobstetric disease during pregnancy is expected to lower perinatal complications.     

Gastric cancer in pregnancy -- a case report

Nausea and vomiting are common sufferings of pregnant woman. No gynaecologist would consider carcinoma of the stomach as a probable differential diagnosis according the extremely rare probability of this disease during pregnancy. Consequently, a late diagnosis in pregnancy can result in spreading throughout the whole abdomen. In this advanced stage, it is only possible to recommend palliative care to the patient followed by short survival. Fetal metastasis is a rare entity, therefore caesarean section and chemotherapy should not be performed until fetal maturity. If vomiting and nausea are prolonged after the sixteenth week of pregnancy a malignant disease of the stomach should be excluded. Only in case of short delay between symptoms and diagnosis, the stomach cancer can be resected totally followed by a better overall survival of the patient.     

The diagnosis of infections in pregnancy

The frequent questions in which symptoms which infections should be excluded cannot be answered in a simple manner. In daily practise only such infections are possible to be excluded meaning a certain risk for the fetus. Of course other infections may be taken into consideration for differential diagnosis additionally. Especially Coxsackie-echoviruses, mycoplasmas and mononucleosis have been discussed as fetal damaging factors. Coxsackie-echovirus infections in late pregnancy may be responsible for severe neonatal diseases. Occasionally each banal infectious disease of a pregnant woman the gynaecologist is confronted with the question for the fetal risk. According to the symptoms the most important infections listed in tabl. XIV should be excluded. The remaining ones belong to the complex of the so called normal risk of 3.5 per cent in each pregnancy. This fact should be mentioned towards the pregnant women because of legal reasons.     

The incidence of maternal dental treatment during pregnancy.

A questionnaire was given to women who had delivered a live baby to assess their knowledge and uptake of dental treatment during their recent pregnancy of the 496 women surveyed, 95% knew that dental treatment was free on the National Health Service for 1 year after that pregnancy. Despite a high level of knowledge in this area, 64% underwent a dental check-up during pregnancy and of those women who had a check-up 27% had dental restorations placed in their teeth during that pregnancy. Only 26% of women were advised to see a dentist by a health professional. The exact incidence of dental treatment during pregnancy is not known, however, if our area is typical of the United Kingdom, large numbers of women are undergoing dental treatment during pregnancy and the contribution that this makes to maternal and fetal health should be studied.     

Audit standards in ectopic pregnancy.

Due to a combination of increasing public awareness and improved diagnostic techniques, women now present to the clinician early in pregnancy. The majority of women with an ectopic pregnancy are haemodynamically stable. This enables the gynaecologist to consider several management options, such as expectant, medical or laparoscopic surgical treatment rather than just the conventional open surgical approach. This review article examines current literature on the management of ectopic pregnancy and proposes audit standards to be used in the diagnosis and optimal treatment of ectopic pregnancy. It is hoped that this would then enable meaningful audit and review of current clinical practice, leading to improved patient outcome.     

Neurological disease in pregnancy

Neurological disease encompasses a broad spectrum of conditions which may be affected by pregnancy, present de novo in pregnancy, or are caused by the pregnancy itself. In the Confidential Enquiry into Maternal Deaths Report 2006–08, 36 women died from diseases of the central nervous system, and 11 of these women were deemed to have had major substandard care. The overall number of deaths is similar to that of previous years, and the proportion with epilepsy was unchanged. Pre-pregnancy counselling should be offered to patients in order to optimise their condition, as well as to make appropriate changes to medication. A thorough history and physical examination should be performed, and specialist advice sought early when looking after these women in their pregnancies. Women should be managed by a multidisciplinary team, ideally including a neurologist, specialist nurse or midwife, obstetrician with an interest in maternal medicine, obstetric physician and an obstetric anaesthetist.     

晚期妊娠合并重型肝炎的产科处理

妊娠合并重型肝炎病死率高,其救治仍是产科一大难题。对于晚期妊娠合并重型肝炎,现阶段应强调早期识别和集中救治,在产前、病情较轻尚未发展到重型肝炎前及时转运到有条件的医院诊治其预后较好;应积极治疗,待重型肝炎病情有所控制后选择适当时机及时终止妊娠;在分娩方式方面,剖宫产同时行子宫次全切除预后较好。     

Myasthenia gravis and pregnancy

Three pregnancies in two women with myasthenia gravis (MG), are presented. The first woman expressed no antenatal complications and delivered a full-term 3350 g baby by caesarean section, because of a previous caesarean. The second woman had two preterm births in subsequent pregnancies, which were complicated by hydramnios. Her first pregnancy ended in neonatal death of a 860 g female with multiple congenital anomalies. In her second pregnancy there was an exacerbation of MG and the baby, an 880 g male died soon after birth, due to respiratory failure.     

妊娠期需氧菌性阴道炎的诊断与治疗

需氧菌性阴道炎（aerobic vaginitis,AV）是由于阴道内乳杆菌水平下降,需氧菌过度繁殖导致的阴道炎症。妊娠期AV常见致病菌为B族链球菌、大肠埃希菌、粪肠球菌和金黄色葡萄球菌,可引起早产、胎膜早破、绒毛膜羊膜炎、新生儿感染等不良母儿结局。有症状及无症状但既往有感染相关流产或者早产病史的高风险妊娠女性需进行AV筛查。妊娠期AV可依据临床特征结合湿片镜下AV评分法或革兰染色涂片结合临床特征的联合诊断标准进行诊断。妊娠期AV应在权衡治疗获益与潜在风险的情况下进行治疗,可采用妊娠期安全的抗菌药物,也可选用乳杆菌制剂和中成药等辅助治疗。     

Breast cancer during pregnancy

Breast cancer in pregnancy is an uncommon situation but poses dilemmas for patients and their physicians. There is a paucity of prospective studies regarding diagnosis and treatment of breast cancer during pregnancy. Women diagnosed with breast cancer during pregnancy have similar disease characteristics to age-matched controls. Current evidence suggests that diagnosis may be carried out with limitations regarding staging. Surgical treatment may be performed as for non-pregnant women. Radiotherapy and endocrine or antibody treatment should be postponed until after delivery. Chemotherapy is allowed after the first trimester. Physicians should be aggressive in the workup of breast symptoms in the pregnant population to expedite diagnosis and allow multidisciplinary treatment without delay.     

Takayasu's syndrome in pregnancy.

Two cases of Takayasu's syndrome in pregnancy are presented. The obstetric courses of these women are compared with those of 7 others described in the literature. Symptoms of this rare condition may respond variably during pregnancy. Of the 9 women, 5 had worsening of their symptoms during gestation while 4 had milder symptoms than they had had prior to pregnancy. The best therapy is rest. Vaginal delivery is recommended and cesarean section should be reserved for obstetric indications.