风湿病及结缔组织病

901667 强的松治疗幼年型类风湿性关节炎的长期随访观察/韩文荣…∥实用儿科杂志。-1990,5(3)。-148 报告2例幼年型类风湿性关节炎患儿长期服琳强的松,随方4年,未发生任何副作用。例l,岁时因高热、皮疹及又节炎曾诊断为变应性亚败血症,经治疗后缓解。     

妊娠与类风湿关节炎

类风湿关节炎是一种自身免疫性疾病,目前认为其可能与感染、遗传、内分泌等因素有关。妊娠期RA诊断缺乏特异性诊断指标,主要依靠临床症状诊断。约75%的女性患者在妊娠期症状得到改善。妊娠期RA的用药应依据病情活动性进行,TNF抑制剂有望成为妊娠期RA的治疗药物。     

类风湿性关节炎的用药体会

目的：探讨类风湿性关节炎的临床用药方法。方法：回顾性分析我院自2007年3月-2010年5月收治的125例类风湿性关节炎患者的临床资料,所有患者均采用自拟祛风化湿汤加减治疗,疗程为4周,观察治疗效果。结果：连续治疗1个疗程后,本组125例RA患者显效69例,有效42例,无效14例,1个疗程总有效率为88．8％;连续治疗2个疗程后,显效75例,有效46,无效4例,2个疗程总有效率为96．8％。本组患者临床症状及实验室指标均有不同程度改善,随访观察12个月,复发3饲,其余均未复发。结论：综合应用祛风湿药、活血化瘀药及补肾药治疗类风湿性关节炎效果理想,值得临床推广应用。     

妊娠期用药FDA五级分类法

妊娠期用药对母儿的安全性历来为医生和孕妇所关心。在妊娠期孕妇难免不使用药物；据统计，妊娠期用药的妇女高达80％左右，所以不但是妇产科医生，还有内、外科医生都应该知道各科常用药物是否可以在孕期使用和如何使用。     

白虎桂枝汤加味治疗湿热痹阻型幼年类风湿性关节炎的疗效分析

目的观察白虎桂枝汤加味联合西医基础疗法治疗湿热痹阻型幼年类风湿性关节炎的临床疗效分析。方法选择2012年8月至2016年8月河南南阳市第一人民医院儿科收治住院的幼年类风湿性关节炎患儿43例,随机分为观察组22例和对照组21例。观察组给予白虎桂枝汤加味联合布洛芬片口服进行治疗,对照组单纯采用布洛芬口服治疗,4周为1个疗程,观察两组患儿临床症状、体征、实验室指标变化及疗效。结果观察组退热时间、关节肿痛缓解时间、肝脾回缩时间均短于对照组,差异有统计学意义(P0.05)。观察组治疗后血沉、C反应蛋白、γ干扰素、IgG、滑膜厚度低于对照组,白细胞介素4高于对照组,差异有统计学意义(P0.05)。观察组临床总有效率为95.4%(21/22),显著高于对照组61.9%(13/21),差异有统计学意义(P0.05)。结论白虎桂枝汤加味联合西药治疗湿热阻络型幼年类风湿性关节炎疗效显著,值得进一步推广应用。     

妊娠期糖尿病药物治疗新进展

随着经济和生活方式的改变,全球妊娠期糖尿病(gestational diabetes mellitus,GDM)的发病率呈上升趋势,越来越多的GDM患者需要接受孕期咨询和治疗,药物治疗是GDM综合治疗措施中的一个重要组成部分[1].妊娠期间可供临床使用的降糖药物有两大类:一类是胰岛素,另一类是口服降糖药.胰岛素是目前公认的、惟一能够在妊娠期使用的降糖药物,也是妊娠期首选的降糖药物.     

祛邪通络法治疗幼年类风湿性关节炎1例验案分析

通过典型病例详细分析,介绍王雪峰教授治疗幼年类风湿性关节炎的临床经验。提出治疗本病必顾护其脾胃之气,且中药治疗可解决服用西药所引起的胃肠功能紊乱等不良反应。     

妊娠期妇女门诊用药66096例分析

妊娠期用药对孕妇及胎儿的安全性历来受到医务人员和孕妇的关心。20世纪印年代初，震惊世界的”反应停”事件使人们认识到对成年人较为安全的药物也可能引起胚胎损害，使人们对妊娠期用药更为重视。妊娠期妇女难免不使用药物，据报道，妊娠期用药者高达80％～90％，因此，医务人员掌握各科常用药物可否在孕期使用和如何使用是极为必要的。我们对妊娠期门诊处方用药进行了统计分析，初步探讨了妊娠期门诊用药的情况。     

女性激素与类风湿性关节炎

雌激素的作用主要是促进和维持雌性生殖器的发育,孕酮主要是为受孕作准备,并保证妊娠过程的顺利发展。但女性激素还对糖、脂肪、蛋白质和水盐代谢有不同程度的影响,并参与体内其他一些生理生化代谢过程,即性激素的“性外作用”。雌激素和孕酮能直接或间接影响类风湿性关节炎(RA)     

磁共振检查在妊娠期的应用

妊娠期磁共振(magnetic resonance,MR)检查可以作为超声的有益补充,已广泛应用于非产科、产科母体及胎儿疾病。妊娠期MR检查相对安全,在孕妇或胎儿的获益高于潜在风险时,可以进行MR平扫检查。妊娠期含钆对比剂的使用会增加胎死宫内和新生儿死亡等不良事件的发生风险,因此不推荐妊娠期常规使用含钆对比剂。MR检查的指征和扫描方案在妊娠期可根据需要进行一定调整。MR检查软组织分辨率高、没有电离辐射,在妊娠期可以替代部分辐射性检查用于妊娠合并肿瘤患者。妊娠期母体合并急腹症、瘢痕妊娠和胎盘植入等,以及胎儿疾病,MR检查均可以作为超声的补充,有助于诊断和妊娠期管理。     

Renal angiomyolipoma during pregnancy: review of the literature

The incidence of renal angiomyolipoma (RA) is 0.3% in the general population, and even more infrequent during pregnancy. Pregnancy can increase the risk of rupture, although the causal mechanism is still not clearly defined. We completed a Medline literature search for articles on RA and pregnancy and its complications. We identified 16 articles (all case reports), but selected only 13 because of unavailable data in the 3 other articles. We report the case of a 30-year-old primiparous woman who presented at the emergency ward with a non-reassuring pattern at fetal monitoring; an urgent cesarean section was decided and carried out. After surgery, a wide retroperitoneal hematoma was observed caused by the rupture of an RA. Conservative management by means of arterial embolism was done and the patient was discharged on postoperative day 10. RAs seem to have a higher risk of rupture during pregnancy, but they should be managed conservatively when hemodynamically possible. Individualization of each case is necessary in order to achieve the best outcome for both the mother and fetus.     

Enhancing patient autonomy with risk assessment and invasive diagnosis: an ethical solution to a clinical challenge

The purpose of this study was to describe a clinically based, ethically justified informed consent process for risk assessment and invasive genetic diagnosis that enhances patient autonomy. Appealing to the ethical principle of respect for the autonomy of pregnant women, we show that patients can exercise their autonomy meaningfully in the informed consent process in response to the offer of risk assessment (RA) and invasive diagnosis (ID) and in response to the results of risk assessment. All pregnant patients in the first trimester should be offered both RA and ID. Women will sort themselves, in response, into 4 groups; those who refuse both RA and ID, those who are uncertain about RA, those who accept RA, and those who accept ID. Women who proceed to RA will sort themselves, in response to its results, into 3 groups: women for whom the risk of aneuploidy is acceptable or unacceptable and women who are not certain whether such risk is acceptable. For this last group only, the informed consent process should present information about current controversies of first-trimester and second-trimester further testing to better assess risk. Clinical strategies are identified for the implementation of the varied responses of pregnant women to the offer of RA and ID. Autonomy-enhancing strategies for the evaluation of pregnancy provide the basis for solving the ethical challenge that is presented by the wide variety of evaluation techniques.     

The acute abdomen and the obstetrician

An acute abdomen in pregnancy can be caused by pregnancy itself, be predisposed to by pregnancy or be the result of a purely incidental cause. These various conditions are discussed. The obstetrician often has a difficult task in diagnosing and managing the acute abdomen in pregnancy. The clinical evaluation is generally confounded by the various anatomical and physiological changes occurring in pregnancy itself. Clinical examination is further hampered by the gravid uterus. The general reluctance to use conventional X-rays because of the pregnancy should be set aside when faced with the seriously ill mother. A reluctance to operate during pregnancy adds unnecessary delay, which increases morbidity for both mother and fetus. Such mistakes should be avoided as prompt diagnosis and appropriate therapy are crucial. A general approach to acute abdominal conditions in pregnancy is to manage these problems regardless of the pregnancy.     

Impfungen in der Schwangerschaft

There is just little experience with the use of vaccines in pregnant females. In principle, recommended vaccinations should be carried out before the beginning of a pregnancy. During pregnancy vaccination should be limited. Vaccines with inactivated components are not contraindicated during pregnancy, although the use should be after a strict medical indication. The other vaccines are contraindicated during pregnancy. If such a vaccination is performed during pregnancy—for example, because the pregnancy was unknown during the immunization — there are no reasons for a pregnancy interruption. For most vaccinations only one theoretically risk of possible fetal endangering is assumed. The outbreak of a viral infectious disease during pregnancy can be prevented by a timely passive immunization, leading to no or just an enervated disease course, thus protecting also the fetus of a possible impairment. Both immunoglobulins as well as hyperimmune serums have, as far as known, no embryo-toxic effect.     

Hormones,pregnancy, and rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disorder that, like most autoimmune diseases, is more common in women than in men. A significant body of evidence implicates gender-specific factors in facilitating the development of RA. Pregnancy has an ameliorating effect on disease activity, while the disease tends to flare in the postpartum period. Estrogen-containing oral contraceptives can modify the disease course or onset, hinting at a role for this hormone in disease pathogenesis. Breast-feeding appears to increase the risk of RA, possibly through the actions of the lactation hormone prolactin. Nonhormonal factors associated with pregnancy may also be important in women with RA, especially the degree of maternal-fetal human leukocyte antigen (HLA) incompatibility. This article reviews data from human clinical and epidemiologic investigations as well as experimental findings in animal models of chronic arthritis. Possible mechanisms by which gender-specific factors modulate immune function are also discussed.     

Ultrasound in the diagnosis of ectopic pregnancy

The majority of ectopic pregnancies can be diagnosed on transvaginal scan before treatment. Diagnosis should be based on positive visualization of an ectopic pregnancy rather the inability to visualize an intrauterine pregnancy. The majority of ectopic pregnancies will be visible on the initial transvaginal scan performed. Those who do not have their ectopic pregnancies visualized on the first examination will be initially classified as having a pregnancy of unknown location. They will then need follow-up until a diagnosis of ectopic pregnancy is confirmed. This review discusses the use of ultrasound in the diagnosis of ectopic pregnancy and the specific criteria for diagnosis of the different types of ectopic pregnancy.     

血液动力学指标预测胎儿缺氧及酸中毒的价值

目的：评价血液动力学指标预测胎儿缺氧及酸中毒的价值。方法：用彩色多普勒超声检测了４６例正常晚期妊娠（正常组）和３２例高危妊娠（高危组）妇女子宫动脉（ＵｔＡ）和胎儿脐动脉（ＵｍＡ）、大脑中动脉（ＭＣＡ）、肾动脉（ＲＡ）的血流速度波型，并且测定高危组脐动脉血气。结果：高危组ＵｔＡ、ＵｍＡ、ＲＡ的阻力指数（ＲＩ）、搏动指数（ＰＩ）及收缩期最大血流速度（Ｓ）与舒张末期血流速度（Ｄ）的比值（Ｓ／Ｄ值）均高于正常组，而ＭＣＡ的ＰＩ及Ｓ／Ｄ值均明显低于正常组（Ｐ＜０．０５）。与ＵｍＡＰＯ２＞２．５ｋＰａ的高危妊娠病例比较，ＵｍＡＰＯ２≤２．５ｋＰａ者ＵｔＡ的Ｓ／Ｄ值、ＵｍＡ的ＰＩ、Ｓ／Ｄ值以及ＲＡ的ＲＩ、ＰＩ、Ｓ／Ｄ值均明显增高，ＭＣＡ的ＰＩ明显降低（Ｐ＜０．０５）。ＵｍＡ及ＲＡ的ＰＩ与ＵｍＡＰＯ２和ｐＨ值呈负相关，与ＰＣＯ２呈正相关；ＭＣＡ的ＰＩ与ＵｍＡ的ｐＨ、ＰＯ２呈正相关，与ＰＣＯ２呈负相关。结论：高危妊娠胎儿缺氧时ＭＣＡ血流阻力降低，而周围血管，特别是肾血管血流阻力明显升高；胎儿血液动力学变化与缺氧及酸碱平衡失调呈良好相关性，可预测胎儿缺氧及酸中毒的程度。     

Anticonvulsants and drugs for neurological disease

The use of anticonvulsant drugs in pregnancy presents unique challenges to clinicians and their patients. The need for control of maternal epilepsy must be balanced with the fetal and neonatal risks associated with anticonvulsant drugs. Anticonvulsant drugs may have potential effects on embryogenesis, neurological development, growth and subsequent paediatric progress. Drug selection and dose adjustment must be appropriate and based on a combination of known maternal and fetal risks as well as the clinical status of the patient. Overall, no one drug can be specifically recommended but monotherapy with most of the recognized first-line drugs will result in a satisfactory outcome. Polytherapy is associated with an increase in congenital malformations and should be avoided if possible. It is possible that newer second-line agents, for example, gabapentin, may be safer as add-on therapy.Neurological disorders such as migraine, and the less common conditions of myasthenia gravis and multiple sclerosis, may require the use of drugs which have not been well studied in pregnancy. Information is provided about the use of drugs to control symptoms and prevent disease progression in these disorders during pregnancy.     

Do's and don'ts in treating amenorrhea in women taking the minipill

3 conditions may be responsible for absence of menstruation in women taking the minipill: pregnancy, extrauterine pregnancy, or endometrial atrophy which is the most frequent cause but should be treated only after the other 2 possibilities are excluded. The most frequent cause of pregnancy while taking minipills is error in pill consumption due to forgetting, but malabsorption due to vomiting less than 2 hours after taking the pill or an interaction with some other medication may be responsible. The possibility of extrauterine pregnancy should be systematically considered, and the possibility that a micropill and not a minipill is involved should be ruled out. With a sequential minipill contraceptive efficacy does not reach 100% but iatrogenic amenorrhea is infrequent because of the strong dose of ethinyl estradiol. In the case of a preexisting amenorrhea that does not respond to the estrogen or progestin dose, a prolactin adenoma may be suspected. After 2 consecutive beta tests of pregnancy 8 days apart have been negative, it may be concluded that endometrial atrophy is the cause of the amenorrhea. Unprotected sexual relations should be avoided and the patient should be given a fast-acting combined oral contraceptive such as Lutestral to induce bleeding, after which the minipill can be resumed. If unprotected intercourse occurs there is a risk of pregnancy since amenorrhea and anovulation are not synonymous. A morning after pill can be used if the unprotected sexual relations occurred within the last 72 hours. If a pill was forgotten or probably forgotten before the emenorrhea, the most prudent attitude would be to consider the pill to have been ineffective during the preceding 21 days and to test for pregnancy. Unprotected intercourse should be avoided, a fast-acting combination pill should be prescribed to induce bleeding, and the minipill should then be resumed. Amenorrhea in the 1st month of use after an abortion is not significant. This secondary effect of the minipill should be explained to the patient to avoid unnecessary worry.     

Drugs and the fetus

PURPOSE OF REVIEW: Few drugs are licensed in pregnancy, and data on drug use in pregnancy are mainly retrospective and uncontrolled. Pregnancy exposure has increased recently to new classes of drugs, as they have been shown to be effective and well tolerated outside of pregnancy. RECENT FINDINGS: Anti-nausea therapies, H2-receptor and proton pump inhibitors appear to be safe. Metformin is being trialed for treatment in gestational diabetes and initial reports appear encouraging. Concern has been raised about statins in early pregnancy and should be avoided. New antiepileptic medication appears effective with low risk of abnormality. However, when combined with valproate, risks are still high. Selective serotonin reuptake inhibitors for depression appear to be effective, with likely low risk for teratogenesis, although neonatal behavioural syndrome following their use in the third trimester is a concern. Angiotensin II inhibitors should be avoided in the second and third trimesters of pregnancy. Smoking cessation programmes need to be reevaluated. SUMMARY: Information about safety of drugs and caution about prescribing in pregnancy should continue. Until large clinical trials are performed, the risk/benefit ratio of drugs during pregnancy will remain uncertain.