Serum concentration of pregnancy-associated plasma protein A in the first trimester of pregnancy

Serial assays of pregnancy-associated plasma protein A were done in 12 subjects before the first missed menstrual period through 10 to 16 weeks' gestation. It was found that the concentration of pregnancy-associated plasma protein A remained at prepregnancy levels until 6 to 10 weeks after the last menstrual period. Thereafter the concentration increased rapidly. It is surmised that pregnancy-associated plasma protein A is a maternal protein, the synthesis of which is stimulated by pregnancy.     

Placental biopsy in the third trimester of pregnancy.

Forty-two women with abnormal ultrasound findings after 27 weeks' gestation underwent a placental biopsy. In 39 cases, a karyotype was obtained from a direct preparation within 48 h, five abnormal karyotypes being detected (four trisomies and a triploidy). One confirmed placental mosaic was also detected. In one case, a small terminal deletion of chromosome 7 was not detected at the time due to the quality of the preparation. A karyotype can be obtained from a direct preparation in the third trimester in over 90 per cent of cases, the quality of the preparation allowing the reliable detection of abnormalities of chromosome number. We believe that this technique may be usefully, reliably, and safely employed in the third trimester of pregnancy by those with an interest in antenatal ultrasound diagnosis who do not have immediate access to a cytogenetics laboratory and who feel that cordocentesis is inappropriate for their situation.     

Amniocentesis in the third trimester of pregnancy

BACKGROUND: Amniocentesis in the third trimester, which reduces risks of procedure-related miscarriage but still allows termination of affected fetuses, may be applicable in some pregnancies. The implications of deferring amniocentesis include complications, delivery before the test and increased amniotic fluid culture failure rates. We investigated the indications, complications, karyotype results and laboratory failure rates of third-trimester amniocentesis. METHODS: We studied all women who underwent third-trimester amniocentesis from 2000 to 2006. Data were collected from ultrasound databases, computerised records and individual chart review. RESULTS: We reviewed 165 pregnancies that underwent amniocenteses after 28 weeks. Median maternal age at amniocentesis was 32 years and median gestation, 32(+2) weeks. Indications included malformation (60/165), soft markers (37/165), maternal request (12/165), and positive screening test (11/165). Of the 49 women(29.7%) who declined second-trimester amniocentesis, 24.5% had twins and 38.8%, malformations. Amniocentesis was not offered to 116 women: 57/116 (49.1%) third-trimester referrals, 25/116 (21.5%) diagnosed late and the remainder, low-risk indications. Fetal karyotype was abnormal in 17 cases (10.3%). Seven women who initially declined amniocentesis had abnormal results compared with one advised to have late amniocentesis. Culture failure rate was 9.7%, however results were obtained by Quantitative fluorescent polymerase chain reaction (QF-PCR) from 164/165 samples. Complication rate was 1.2%. CONCLUSION: For late diagnoses and for low-risk indications, third-trimester amniocentesis is an acceptable option, especially when utilising QF-PCR with cytogenetic culture.     

Parathyroidectomy in the third trimester of pregnancy

The objective of this study was to estimate the incidence of complications when primary hyperparathyroidism (PHPT) is treated by parathyroidectomy in the third trimester of pregnancy. After searching the literature published through/including January 2005, we identified and analyzed 16 cases of PHPT treated surgically after 27 weeks of gestation. Parathyroid adenomas were detected in 81.2% of cases, hyperplasia in 6.3%, and carcinoma in 12.5%. Only one case failed surgical therapy. The postoperative incidence of clinically significant complications from the surgery was as low as 5.9% in fetuses and 0% in mothers. The incidence of clinically significant complications resulting from delayed diagnosis or postponed surgery ranged from 17.6% to 23.5% in fetuses and 18.8% to 25.0% in mothers. Postoperative hypocalcemia was detected in 62.5% of mothers and 17.6% of their newborns. All cases were easily treated with calcium replacement. Preeclampsia was diagnosed in 25% of cases. No clinically significant complications have been reported between 1993 and January 2005. This review suggests that parathyroidectomy performed in the third trimester of pregnancy is effective and has less risk than previously reported. Postponing surgery may be hazardous. Postoperative hypocalcemia is common but easily treated. Hyperparathyroidism should be considered a risk factor for preeclampsia. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to summarize the maternal and fetal complications of a delayed diagnosis and/or postponed surgery, recall that surgery of a parathyroid tumor can be safely performed in the third trimester, and describe pregnancy complications of hyperparathyroidism.     

Studies on the concentration of pregnancy-associated plasma protein-A during normal and complicated pregnancy

Pregnancy-associated plasma protein-A was assayed in the blood of 347 women during pregnancy, using a new primary standard of PAPP-A as reference. The protein was assayed by antibody-antigen crossed electrophoresis with the lower limit of confident assay being 9.5 micrograms PAPP-A/ml (13 pmol/ml). PAPP-A was first detected at 14 weeks of gestation; by term it had risen to within the range 20 to 320 micrograms/ml. There was an indication that pregnancies involving a male baby had higher PAPP-A levels in blood than did those involving female babies. In 51 blood samples from 30 patients with gestational diabetes (taken between 28 weeks of pregnancy and term) there was no significant alteration in PAPP-A values compared with controls. In 35 blood samples from 15 patients with insulin-dependent diabetes, levels of PAPP-A were significantly lower than in controls or in gestational diabetes. In 43 blood samples from 35 patients with babies affected with intrauterine growth retardation (between 28 weeks and term), there was no significant difference in PAPP-A levels compared with controls. The effect of insulin on the blood levels of PAPP-A suggests that the concentration of PAPP-A is capable of altering significantly in response to certain physiological changes associated with the control of carbohydrate metabolism.     

Primary hyperparathyroidism during the third trimester of pregnancy.

Primary hyperparathyroidism during pregnancy has been reported in 36 women; 1 new case is reported here. Screening by determining serum calcium levels is a valuable method of diagnosing the disease. Radioimmunoassay of serum parathyroid hormone (PTH) greatly aids in the diagnosis. Amniotic fluid PTH values are discussed. Hyperparathyroidism has a high association with progressive renal insufficiency, renal calculi, hypertension, and bone disease. During pregnancy, there is an increased incidence of stillborns, premature labor, and neonatal tetany. Acute hyperparathyroid crisis may result in maternal death. This is the first reported case surgically treated during the third trimester of pregnancy. Surgery should be considered when the diagnosis is made late in pregnancy, as this may protect the infant from neonatal tetany.     

Fulminant hepatic failure in the third trimester of pregnancy. A case report

There is a paucity of information regarding fulminant hepatic failure during pregnancy, in part because it is such an uncommon event. We encountered a case of fatal hepatic failure secondary to viral hepatitis occurring during the third trimester.     

Gestational diabetes diagnosed in third trimester pregnancy and pregnancy outcome.

BACKGROUND: The clinical significance of gestational diabetes diagnosed in the third trimester is unclear. A prospective observational study was performed on a cohort of women without pre-existing gestational diabetes or other medical disorders to examine the effect of gestational diabetes on pregnancy complications and infant outcome. METHODS: Four hundred and eighty-nine consecutive women were assessed at 28-30 weeks by random glucose screening and/or a 75 g oral glucose tolerance test. The subsequent management was according to established departmental protocols. The outcome of pregnancy was compared among the groups with negative screening, positive screening but normal glucose tolerance, and gestational diabetes which was controlled with diet therapy. RESULTS: Women with gestational diabetes (n=67 or 13.7%) had significantly increased maternal age, pre-pregnancy weight and body mass index, hemoglobin levels at booking and at 36-38 weeks, and incidences of parity >1, pre-eclampsia, and female infants, while the gestational age was shorter and there was no significant difference in the birthweight outcome or neonatal morbidity. CONCLUSIONS: Despite diet treatment, gestational diabetes diagnosed in the last trimester is associated with increased risk of pre-eclampsia and shorter length of gestation, and this is likely to reflect a pathological process rather than the physiological effect of pregnancy on maternal glucose tolerance.     

脐血管前置及其它原因引起的产前出血

脐带是连接胎儿与胎盘的带状器官,一端连胎儿脐轮,另一端附着于胎盘的胎儿面,外面被灰白色、湿润的羊膜覆盖,内有三根血管：一条管腔较大、管壁较薄的脐静脉在中央,其两旁是管腔较小、管壁较厚的脐动脉,血管周围充满基质华通氏胶（Wharton′s jelly)。脐带直径为1.0～2.5cm,平均长50cm。脐血管长于脐带本身,因而呈卷曲和逆时针方向螺旋扭转状。脐静脉血一是经静脉导管直接入胎儿下腔静脉,另一是入胎儿肝循环后经肝静脉入下腔静脉。静脉导管的启闭是由位于脐窝的、受迷走神经支配的括约肌控制。胎儿通过脐带血循环与母体经胎盘进行营养和代谢物质的交换。     

妊娠期子宫破裂的识别与急救

子宫体部或下段于妊娠期或分娩期发生不同程度的裂伤称为子宫破裂（rupture of uterus）。国内报道发生率为1.4%。国外报道为0.08‰。妊娠期子宫破裂一般较少见,国外文献统计共121例,国内文献报道不足20例,国外文献报道破裂最早为孕4个半月,国内文献报道的最早为孕167周。     

前置胎盘的期待治疗

前置胎盘期待疗法已有70多年的历史,随着围产医学的发展,胎儿临护手段的进步,使期待疗法更增添了积极的因素。期待治疗和采用放宽剖宫产指征是处理前置胎盘,降低母儿病死率最关键的两上要点^[1]。     

前置胎盘胎盘早剥对母儿的影响

正常妊娠时,胎盘附着于子宫体的前壁、后壁或侧壁,如果胎盘附着子宫下段部分或全部覆盖在子宫颈内口上,则称为前置胎盘。前置胎盘是妊娠晚期出血的主要原因之一,是妊娠期的严重并发症,如处理不当,就可危及母亲和胎儿的生命。因此,对母儿有很大的危害。     

植入性胎盘的诊断与处理

植入性胎盘是产科较为少见的危重症,其发生率为9.5/10万^[1]。植入性胎盘常常导致严重性的出血、子宫穿孔和继发感染,故急症子宫切除的机会和围产期发病率高,甚至威胁产妇的生命。     

髂内动脉结扎在晚期产后出血中的应用价值

晚期产后出血为妇产科较为常见的疾病,一般是指分娩24小时后至产褥期内发生的子宫大量出血或异常阴道出血^[1]。若处理不当可危及病人生命,文献报道晚期产后出血的发生率为0.28^%[2]。晚期产后出血的主要原因是胎盘残留和（或）胎膜残留、宫腔感染、子宫胎盘附着部位复旧不良及剖宫产后切口愈合不良大出血,同时产道损伤也是导致晚期产后出血的原因之一。目前随着剖宫产率的上升,子宫切口感染、裂开所致的晚期产后出血也愈来愈引人瞩目。据报道剖宫产后子宫切口裂开出血的发生率为1.26%^[3]。对于晚期产后出血的治疗,除必要的抗炎、止血、抗休克治疗外,临床有如下几种紧急处理方法：①清宫术;②髂内动脉结扎术;③子宫切除术;④经皮髂动脉造影栓塞术。上述治疗方法中,髂内动脉结扎术是一个有悠久历史的手术,是妇产科急性大出血的有效止血方法之一,在有手术条件的医院均可使用,是妇产科工程师必须掌握的一种急救手术。本文将对该方法做一详细介绍。     

妊娠晚期出血终止妊娠的时机及方式的选择

妊娠晚期出血是产科的常见并发症,主要包括前置胎盘、胎盘早剥、血管前置及胎盘边缘血窦破裂,其中以前置胎盘和胎盘早剥最常见。这些并发症往往起病急、进展快、病情重,若处理不当可直接威胁母儿生命安全。正确选择终止妊娠的时机和方式,可明显降低母儿围产期病死率。     

胎盘早期剥离并发症的诊断与处理

胎盘早期剥离(placenta abruptio)是孕晚期出血的重要原因之一,是妊娠期严重并发症,往往起病急、发展快、如果处理不及时,可威胁平儿生命。轻型胎盘早剥临床上常无典型症状,而重型胎盘早剥常出现凝血功能障碍、肾功能衰竭、子宫胎盘卒中及产后出血等并发症,本文就上述并发症的诊断及处理作一简述。     

介入治疗在产后出血中的应用

胎儿娩出后24小时内阴道流血量超过500mL以上,称为产后出血;分娩24小时后,产褥期内发生的子宫大量出血称为晚期产后出血。产后出血为产妇死亡的重要原因之一,在我国仍居首位。产妇一旦发生产后出血,预后严重,休克重且持续时间长者,即使获救仍有可能发生严重的继发性垂体前叶功能减退后遗症。大部分的产后出血经保守治疗可治愈,但少数难治性产后出血患者,为挽救生命需行子宫切除术,切除子宫不但意味着生殖功能的永久丧失,而且会导致严重的并发症。自从1979年介入治疗成功地应用于产后出血的治疗后,这种情况得到彻底改善。下面详细阐述产后出血介入治疗的有关问题。     

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 (5%), 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.