妊娠合并肺动脉高压妊娠结局分析

目的分析妊娠合并肺动脉高压(PH)临床特点,探讨其围生期监护及妊娠终止时机、方式。方法收集福建医科大学附属第一医院2005年1月至2011年4月37例妊娠合并PH患者的临床资料,根据肺动脉压力情况分为轻度组19例[30～<50mmHg(1mmHg=0.133kPa)],中度组10例(50～<80mmHg),重度组8例(≥80mmHg)。分析心脏病情况及母婴结局。结果 (1)37例肺动脉高压患者中,风湿性心脏病18例,先天性心脏病11例,围生期心肌病5例,肥厚型心肌病1例,特发性肺动脉高压1例,未发现心脏器质性改变1例。(2)轻度组心功能Ⅰ～Ⅱ级占68.4%(13/19)。中度组心功能Ⅱ～Ⅲ级占70%(7/10)。重度组心功能Ⅲ～Ⅳ级占75%(6/8)。(3)32例患者(86.5%)行剖宫产术。1例轻度肺动脉高压孕妇经阴道分娩。1例产妇死亡(2.7%)。4例中期引产(12.1%)。7例早产,新生儿窒息3例,低出生体重儿4例,新生儿死亡1例。结论妊娠合并肺动脉高压属于高危妊娠,随着肺动脉压力升高心功能衰竭的发生率增加,围生儿疾病发生率和胎儿丢失率也明显增加,母儿预后取决于孕期是否伴有合并症。晚期妊娠患者以剖宫产终止妊娠为宜。     

Pregnancy and pulmonary arterial hypertension: A clinical conundrum

Pulmonary arterial hypertension (PAH) is a rare and devastating disease characterized by progressive increases in pulmonary arterial pressure and pulmonary vascular resistance which eventually leads to right ventricular failure and death. PAH inflicts most commonly women, majority of who are of childbearing age. Pregnancy in the setting of PAH is absolutely contraindicated due to high maternal fetal morbidity and guidelines do not exist for the management of such cases. A MEDLINE/PubMed search was performed identifying all relevant articles with “pulmonary arterial hypertension” and “pregnancy” in the title. Six case series were reviewed as well as our own center’s experience outlined. Though there exists generalized treatment measures that are followed in such cases, management varies among different national centers as well an on an international level. At our center patients are managed using a multidisciplinary approach at a high risk obstetric center with preference for intravenous prostacyclin therapy. Women of child bearing age with possible signs and symptoms of PAH must be promptly diagnosed and managed expectantly with an emphasis on maternal–fetal safety.     

Pregnancy outcome in women with labor-onset hypertension. Similar outcome between labor-onset hypertension and preeclampsia

Labor-onset hypertension is a poorly documented category, and there is scanty information concerning the outcome of pregnancy in this condition. A retrospective study was performed to compare the pregnancy outcome of 36 patients with labor-onset hypertension (group A) with 36 patients with classical preeclampsia diagnosed before labor (group B) who were matched for parity and age. There was no difference in age, past history of hypertensive pregnancies or family history of hypertension between the two groups. The need for intrapartum hypertensive and anticonvulsant treatment as well as the outcome of pregnancy were similar in both groups. The only significant difference was that group A patients had lower maximum and booking systolic and diastolic pressures. The results indicate that labor-onset hypertension represents a late manifestation of the preeclampsia process, because these patients had lower blood pressure in pregnancy and would not be identified until intrapartum elevation of blood pressure satisfied the diagnostic criteria of preeclampsia.     

Pregnancy outcome in women with psoriasis

OBJECTIVE: To determine pregnancy outcome in women with psoriasis. STUDY DESIGN: A case-control study of 145 deliveries in women with psoriasis during the years 1988-2004 was performed. For every birth, 6 births to nonpsoriatic women (n=860) were randomly selected and adjusted for ethnicity and year of delivery. RESULTS: Recurrent abortions (OR = 2.1, 95% CI 1.1-4.9, p = 0.04) and chronic hypertension (OR = 2.9, 95% CI 1.01-8.3, p= 0.048) were significantly associated with psoriasis in a multivariable analysis with backward elimination. Psoriasis was also found as an independent risk factor for cesarean delivery (CD) in another multivariable analysis with CD as the outcome variable (OR = 4.1, 95% CI 2.3-7.5, p < 0.001). CONCLUSION: A significant association exists between psoriasis and pregnancy complications. Moreover, psoriasis is an independent risk factor for CD. Thus, physicians should keep in mind that psoriasis might have nondermatologic implications that may adversely affect pregnancy.     

Retrospective analysis of outcome of pregnancy in women with congenital heart disease: Single-centre experience from North India

Objective: To study maternal and perinatal outcome in congenital heart disease (CHD) and to compare outcome between cyanotic and acyanotic CHD.
Method: A retrospective analysis of 196 cases of CHD was undertaken, and maternal and perinatal outcome of pregnancy was compared in cyanotic and acyanotic cases and between surgically corrected and uncorrected cases.
Results: Maternal and perinatal outcome was better in the acyanotic group. Maternal complications included higher incidence of cardiac complications in cyanotic group, (33.3% vs 3.4% in acyanotic group, P  = 0.001), abruption (12.5% vs nil) and pregnancy-induced hypertension (16.6% vs 5.2%). Rate of prematurity (25% vs 11.6%), intrauterine growth retardation (50% vs 15.1%, P  = 0.003) and abortion (4.1% vs 2.1%) was higher in cyanotic group. Mean gestational age at delivery was better in corrected group, 37.13 vs 34.93 weeks in uncorrected group. There was no case of infective endocarditis. There were four cases of maternal mortality in cyanotic group, two of which were in women with Eisenmenger syndrome. In acyanotic heart disease one case died undelivered and one died on first postoperative day.
Conclusion: Maternal and perinatal outcome is better in acyanotic CHD compared to cyanotic CHD. Surgical correction of cardiac lesions prior to conception improves outcome.     

Pregnancy outcome in 162 women with rheumatic diseases: experience of a university hospital in Turkey

Purpose

To evaluate the distribution and the obstetric outcomes of pregnancies with different types of rheumatic diseases managed in our unit.

Methods

Pregnancies of 162 women with rheumatic diseases, seen for their antenatal care at our department for the period between 2013 and 2017 were included in this retrospective clinical study. Obstetric and perinatal outcomes were main outcome measures.

Results

The most encountered rheumatic diseases were SLE (37.7%) followed by Behcet’s disease (20.4%) and rheumatoid arthritis (17.3%) in our series. The mean maternal age was 30.6 ± 5.3 and the rate of nulliparity was 38.3% in the overall group. Disease activation occurred in 14.1% of patients. Mean gestational age at delivery was 37.4 ± 3.1 and mean birth weight was 3004 ± 762 g. Stillbirth, neonatal death, fetal growth restriction, preeclampsia and preterm delivery rates were 1.2, 2.4, 17.3, 7.4 and 17.9%, respectively. Antiphospholipid syndrome had the highest incidences for fetal growth restriction (42.9%), preeclampsia (28.6%) and delivery ≤ 34 gestational weeks (42.9%). Pathologic uterine artery Doppler velocimetry was identified in 15 cases (15/162, 9.3%) in which 10 (66.7%) developed preeclampsia and/or fetal growth restriction during follow-up.

Conclusion

A majority of women with rheumatic diseases have successful pregnancies and deliver healthy babies, with the close and appropriate rheumatological, obstetric and neonatal monitoring.

     

Pregnancy outcome in women with autoimmune hepatitis

Introduction  

Autoimmune hepatitis (AIH) is a chronic disease of unknown cause, characterized by progressive hepatocellular inflammation and necrosis, frequently leading to cirrhosis. AIH usually affects young women and may influence fertility and pregnancy in them. Nearly 200 pregnancies have been reported so far in the world literature in women with AIH, and no definite guidelines have been established. We hereby report our experience of four pregnancies in women with definite diagnosis of AIH.     

Pregnancy outcome in women with pruritus gravidarum

OBJECTIVE: To investigate obstetric risk factors and pregnancy outcome in women with pruritus gravidarum who delivered during a 15-year period. METHODS: A population-based study comparing all pregnancies in women with and without pruritus gravidarum delivered between 1988 and 2002 was conducted. A multivariable logistic regression model was constructed in order to find independent risk factors associated with pruritus gravidarum. RESULTS: During the study period there were 159,197 deliveries, of which 376 (0.2%) occurred in patients with pruritus gravidarum. Using a multivariable analysis, the following conditions were found to be significantly associated with pruritus gravidarum: twin pregnancies, fertility treatments, diabetes mellitus and nulliparity. No significant differences were noted between the groups regarding perinatal outcomes, such as birth weight, low Apgar scores or perinatal mortality. Pruritus gravidarum was associated with higher rates of labor induction, and accordingly those fetuses were more likely to be delivered by cesarean delivery. CONCLUSION: Pruritus gravidarum, associated with multiple gestations, fertility treatments, diabetes mellitus and nulliparity, is not associated with adverse perinatal outcomes. However, there are higher rates of labor induction and cesarean delivery.     

Pregnancy in chronic renal insufficiency: single centre experience from North India

Background  Renal disease during pregnancy is relatively uncommon. The diagnosis of renal disease before or during pregnancy was only 0.03% in a population-based study of pregnant women with kidney disease. However, there is a paucity of scientific data regarding the general topic of renal disease in pregnancy on which to base clinical management and counselling recommendations. Materials and methods  A retrospective analysis of 14 year period was carried out in a referral hospital in northern India. Pregnant women were analyzed with respect to degree of renal impairment for the effect of renal disease on course of pregnancy, complications during pregnancy and perinatal outcome. Results  Outcome of 30 pregnancies (29 women) was available during the study period of 14 years. Pregnancy outcome was comparable in all types of glomerulonephritis. Progression of the disease during pregnancy was observed in total six patients. Proteinuria was in the range of 800 mg/day to 6.2 g/day (2.802 ± 1.519 g/day). Anemia was identified in 12(46.1%) and 3(7.7%) required multiple blood transfusions. Twenty-four (90%) women developed hypertension during pregnancy. Mild hypertension was seen in 40% patients and, 43.3% had severe hypertension requiring drug therapy. Obstetrical complications included a high frequency of preterm delivery (85%) and caesarean section (30%). Overall fetal survival rate was 77%. Conclusions  Most women with chronic renal disease will have a successful outcome if they receive proper prenatal care. Pregnant women with moderate or severe renal insufficiency have increased rates of complications due to worsening renal function, hypertension, and other obstetrical complications, but fetal survival is high.     

妊娠合并风湿性心脏病患者心功能状态对妊娠结局的影响

目的探讨妊娠合并风湿性心脏病患者心功能状态对妊娠结局的影响。方法对1993年1月至2006年7月在我院产科分娩的、资料齐全的65例妊娠合并风湿性心脏病患者的临床资料进行回顾性分析。根据患者的二尖瓣狭窄程度分为二尖瓣正常组20例（瓣口面积〉4．0cm^2）、轻度狭窄组11例（瓣口面积2．5—4．0cm^2）、中度狭窄组14例（瓣121面积1．5—2．5cm^2）以及重度狭窄组20例（瓣口面积〈1．5cm^2）;根据是否伴有肺动脉高压分为正常压力组33例[肺动脉压〈30mmHg（1mmHg=0．133kPa）]、轻度升高组18例（肺动脉压31—49mmHg）、中度升高组7例（肺动脉压50～79mmHg）和重度升高组7例（肺动脉压≥80mmHg）;根据孕前是否进行心脏手术分为心脏手术组14例和非心脏手术组51例;根据患者的不同心功能状态分为Ⅰ级组24例、Ⅱ级组13例、Ⅲ级组13例、Ⅳ级组15例,观察各组的围产儿结局。分析以上各种因素对妊娠合并风湿性心脏病患者妊娠结局的影响。结果（1）二尖瓣正常组患者心功能Ⅰ～Ⅱ级者为80％（16／20）,Ⅳ级组患者中,80％（12／15）在中度狭窄组（6例）及重度狭窄组（6例）,与二尖瓣正常组和轻度狭窄组的心功能Ⅳ级发生率（20％,3／15）比较,差异有统计学意义（P〈0．05）。（2）正常压力组患者心功能Ⅰ～Ⅱ级者为73％（24／33）,重度升高组患者心功能Ⅳ级的发生率（6／7）明显高于心功能Ⅰ级的发生率（1／7）,两者比较,差异有统计学意义（P〈0．05）。（3）心脏手术组患者心功能Ⅰ～Ⅱ级发生率为71％（10／14）,Ⅲ级和Ⅳ级的发生率均为14％（2／14）,前后两者比较,差异有统计学意义（P〈0．05）;非心脏手术组患者Ⅰ～Ⅳ级心功能发生率之间分别比较,差异均无统计学意义（P〉0．05）。（4）心功能Ⅰ～Ⅲ级组患者的平均孕周及新生儿平均出生体重分别比较,差异无统计学意义（P〉0．05）;而心功能Ⅳ级组平均孕周为（34．6±3．1）周,新生儿平均出生体重为（2176±186）g,明显低于心功能Ⅰ级组,两组比较,差异有统计学意义（P〈0．05）。心功能Ⅲ～Ⅳ级组患者中,共发生医源性流产和引产9例（14％,9／65）,医源性早产18例（28％,18／65）,胎儿生长受限4例（6％,4／65）,围产儿死亡3例（5％,3／65）;而心功能Ⅰ～Ⅱ级组患者以上指标均为0。（5）65例妊娠合并风湿性心脏病患者中合并心房纤颤者7例,其心功能Ⅲ～Ⅳ级（心功能衰竭）的发生率为6／7。结论妊娠合并风湿性心脏病患者伴中、重度二尖瓣狭窄、重度肺动脉压升高及心房纤颤,容易发生心功能衰竭危及生命,不宜妊娠。已妊娠者应尽早终止妊娠;心功能Ⅲ～Ⅳ级的妊娠合并风湿性心脏病患者的医源性流产、早产和围产儿病率均增加,围产儿结局不良。     

Pregnancy outcome in women with prosthetic heart valves

OBJECTIVE: This study was undertaken to evaluate the risks and pregnancy outcome in women with prosthetic heart valves on different anticoagulent regimens. STUDY DESIGN: A retrospective chart review of 82 pregnancies in 33 women with mechanical valve prostheses at a tertiary referral center from 1987 to 2002. The main outcome measures were major maternal complications and perinatal outcome. RESULTS: The valve replaced was mitral (60.6%), aortic (18.2%), and both (21.2%). Fifty-four pregnancies (65.9%) resulted in live births, 9 (11.0%) had stillbirths (all on warfarin), and 12 (14.6%) had spontaneous and 7 (8.5%) therapeutic abortions (all on warfarin). The rate of spontaneous abortion was highest in women on warfarin throughout pregnancy (P < .01). The live birth rate was higher in women on heparin compared with those on warfarin (P < .01), and in those on heparin/warfarin compared with warfarin alone (P < .01). There were no maternal deaths; however, 3 patients had mitral valve thrombosis (2 on heparin and 1 on warfarin) necessitating surgery in 1 patient and medical thrombolysis in 2 patients. Hemorrhagic complications occurred in 5 patients, 4 of whom required transfusion. CONCLUSION: No single anticoagulant regimen confers complete protection from thromboembolic phenomena in pregnancy. Despite a high maternal morbidity rate, the perinatal outcome is acceptable when pregnancy progresses beyond the first trimester.     

Pregnancy outcome in women with morbid obesity.

OBJECTIVE: To study the effects of morbid obesity defined as a first trimester maternal body mass index of >40 on the perinatal outcome. METHODS: One hundred and eighty-eight singleton pregnancies of women with first trimester BMI >40 who delivered at Al-Mafraq Hospital, Abu Dhabi during 1996-1998 were studied. A control group of normal body mass index matched for age and parity were selected and the perinatal variables were compared between groups. Morbidly obese women with diabetes and hypertension antedating the index pregnancy were later excluded and the data were re-analyzed. RESULTS: Morbidly obese women were noted to have significantly adverse perinatal outcomes including hypertensive disorders of pregnancy (28.8 vs. 2.9%, P<0.0001), gestational diabetes (24.5 vs. 2.2%, P<0.0001), cesarean section (15.2 vs. 9.3%, P<0.05) and macrosomia (32.6 vs. 9.3%, P<0.001) compared to non-obese women. However, we noted a significantly lower rate of prematurity in the obese group (0.5 vs. 5.3%, P<0.001). Even when morbidly obese women with (a) diabetes and hypertension antedating the index pregnancy and (b) those who developed gestational diabetes and/or pregnancy-induced hypertension during the index pregnancy were excluded from the analysis, significant differences in the perinatal outcomes still persisted. CONCLUSION: Morbid obesity appears to be an independent risk factor for adverse perinatal outcome.     

Pregnancy and perinatal outcome in women with hyperthyroidism

Objective

To investigate pregnancy outcome for patients with treated hyperthyroidism.

Methods

A population-based study was performed comparing all singleton pregnancies of women with and women without hyperthyroidism at the Soroka University Medical Center, Be'er-Sheva, Israel, between January 1988 and January 2007. Stratified analysis, using a multiple logistic regression model, was performed to control for confounders.

Results

During the study period, there were 185 636 singleton deliveries in the medical center. Of these, 189 (0.1%) were from women with hyperthyroidism. Using multivariate analysis with backward elimination, the following risk factors were significantly associated with hyperthyroidism: placental abruption; cesarean delivery; and advanced maternal age. No significant differences regarding perinatal outcome were noted between the groups. Women with hyperthyroidism had significantly higher rates of cesarean delivery than did women without hyperthyroidism (20.1% vs 13.1%; P < 0.004), even after controlling for confounders.

Conclusions

Treated hyperthyroidism was not associated with adverse perinatal outcome. However, hyperthyroidism was found to be an independent risk factor for cesarean delivery.     

Pregnancy outcome in women with systemic lupus erythematosus

Systemic lupus erythematosus has a predilection for women of childbearing age and may potentially complicate pregnancy. Poor pregnancy outcome in women with systemic lupus erythematosus has been principally ascribed to the presence of renal involvement. Maternal risks have been more difficult to evaluate because of the unpredictable nature of the disease and limited individual experience. The present study reports the outcome of 108 pregnancies in 39 women affected by systemic lupus erythematosus with and without renal manifestation of the disease. Prematurity, small-for-gestational-age birth weight, stillbirth, and spontaneous abortion occurred more frequently in women after the diagnosis of systemic lupus erythematosus was made. Those women with renal involvement had an even further increase in spontaneous abortions as well as a decrease in successful pregnancy outcome (P less than .05). Morbidity in this group of women was rare in the immediate postpartum period, but increased morbidity and mortality did occur in the first two years after delivery.     

Pregnancy outcomes in women with chronic hypertension: a population-based study

OBJECTIVE: To determine the pregnancy outcomes associated with maternal chronic hypertension. STUDY DESIGN: Retrospective, population-based cohort study of maternal and infant discharge records linked to birth records in California from 1991 to 2001 were examined for demographics and pregnancy outcomes, and comparisons were made between those with and without chronic hypertension. One randomly selected pregnancy per subject was included. RESULTS: The number of women who delivered with chronic hypertension (0.69% incidence) was 29,842. As compared to non-chronic hypertensive patients, fetal and neonatal mortality and in-hospital maternal mortality were increased (ORs and 95% CIs 2.3, (2.1, 2.6); 2.3, (2.0, 2.7); and 4.8, (3.1, 7.6) respectively). Major maternal morbidity was increased: stroke, OR 5.3, (3.7, 7.5); renal failure, OR 6.0, (4.4, 8.1); pulmonary edema, OR 5.2, (3.9, 6.7); severe preeclampsia, OR 2.7, (2.5, 2.9); and placental abruption OR 2.1, (2.0, 2.3). Neonatal morbidity was increased as well: fetal growth restriction, OR 4.9, (4.7, 5.2); prematurity, OR 3.2, (3.1, 3.3); low birth weight, OR 5.4, (5.2, 5.5); very low birth weight, OR 6.5, (6.2, 6.8); and respiratory distress syndrome, OR 4.0, (3.8, 4.2). CONCLUSION: Pregnant women with chronic hypertension have significantly increased risks of maternal and perinatal morbidity and mortality. Women with this condition should be treated as high risk with appropriate maternal and fetal surveillance.     

妊娠合并心脏病伴肺动脉高压患者的妊娠结局

目的 探讨妊娠合并心脏病伴肺动脉高压患者的妊娠结局。方法 收集1996年1月至2004年8月间,我院产科收治的61例妊娠合并心脏病伴肺动脉高压患者的临床资料（其中先天性心脏病36例,风湿性心脏病21例,心律失常1例,原发性肺动脉高压性心脏病2例,系统性红斑狼疮性心脏病1例）,根据肺动脉压力情况分为轻度组32例[30-49mmHg（1mmHg=0．133kPa）],中度组23例（50～79mmHg）,重度组6例（t〉80mmHg）,分析各组心脏病种类、心功能级别、终止妊娠孕周和方式以及母儿结局。结果 （1）轻度组心功能Ⅰ-Ⅱ级者23例,中度组心功能Ⅰ、Ⅱ、Ⅲ、Ⅳ级的发病例数分别为9、5、5、4例,重度组心功能Ⅲ-Ⅳ级者5例。（2）风湿性心脏病患者中,中、重度肺动脉高压者11例,占52％（11／21）;发生严重心功能衰竭者9例,占43％（9／21）,先天性心脏病患者中,以轻、中度肺动脉高压者为主（97％,35／36）,且以心功能Ⅰ-Ⅱ级者为主（81％,29／36）。（3）轻度组足月妊娠24例,新生儿平均体重为2744g;中度组足月分娩11例,早产8例,医源性流产4例;重度组足月分娩1例,早产3例,医源性流产2例。各组围产儿疾病发生率比较,差异无统计学意义（P〉0．05）。（4）妊娠合并心脏病伴肺动脉高压者的分娩方式以刮宫产分娩为主,占79％（48／61）。（5）孕产妇死亡率为2％（1／61）,医源性胎儿丢失率为13％（8／61例）。结论 随着肺动脉压力的升高,孕妇心功能衰竭的发生率随之增加,围产儿疾病发生率和胎儿丢失率也明显增加;妊娠合并风湿性心脏病患者中、重度肺动脉高压的发生率高于先天性心脏病患者;手术终止妊娠是比较安全的分娩方式。     

Pregnancy outcome and complications in women with spina bifida

OBJECTIVE: To describe the antenatal complications, mode of delivery and outcome of pregnancy in women with spina bifida. STUDY DESIGN: Case series of women known to have attended the spina bifida clinic at the Royal Children's Hospital. Medical records, postal questionnaire and telephone interview were utilized to collect data on the effect of pregnancy on the health of women and the effect of spina bifida on pregnancy outcome. RESULTS: Of 207 women born between 1945 and 1975, 23 reported having a pregnancy, and 17 who had completed pregnancies agreed to participate. The 17 women had a total of 29 pregnancies, with 23 pregnancies progressing to births. Fourteen of 17 women had antenatal admissions, with wheelchair-dependent women requiring more-frequent and longer admissions. Recurrent urinary infections in pregnancy occurred in women with a prior history of urinary infections; stomal problems occurred but were not serious; mobility was reduced for two women during pregnancy, with full recovery afterwards; and preexisting pressure sores worsened during pregnancy. Vaginal deliveries occurred in one in five pregnancies of women who were wheelchair dependent and in ten of eighteen pregnancies in independently mobile women, including seven of eight pregnancies of independently mobile women without ileal conduits. Cesarean sections were accompanied by postoperative complications in 10 women. CONCLUSION: Women with spina bifida who become pregnant generally have a positive outcome, with relatively low complication rates.