Reviews in Gynaecological and Perinatal Practice最新文献

Fetal growth restriction (FGR) is a common clinical problem that has a significant effect on perinatal morbidity and mortality. In addition, it also adversely influences adult health, as it increases the risk of cardiovascular disease and impaired glucose tolerance. There is growing evidence that genes play a role in the pathogenesis. Karyotypic abnormalities, affecting both the fetus and the placenta, are known to be associated with fetal growth restriction. This not only impacts on clinical management but has also aided the understanding of the mechanisms controlling fetal growth. In particular, there is an increasing appreciation of the role of imprinted genes in growth and development. There is good genetic epidemiological evidence that genes also play a role in the more common, multifactorial fetal growth restriction, seen in the presence of a normal karyotype. The number of candidate genes studies is increasing and includes members of the renin angiotensin system and the insulin-like growth factor axis. The most extensively investigated to date are the inherited thrombophilias and meta-analyses seem to support an association with fetal growth restriction. However, larger studies are urgently required to confirm this association. There is currently no evidence to support screening low-risk pregnant women for inherited thrombophilias, and there are no randomised controlled trials to suggest that treatment with anticoagulants improve outcome. At present screening or treatment should occur only within such trials.

Ovarian hyperstimulation syndrome is a serious and potentially life-threatening complication of infertility treatment. The symptoms are generally triggered by human chorionic gonadotrophin (hCG) following ovulation induction in an in vitro fertilisation cycle. It is believed that the underlying pathology is a shift of protein-rich fluid from the intravascular space to extravascular compartments. The exact aetiology has not been established however it is felt that vascular permeability plays a key role which may be mediated by the immune system, VEGF and the ovarian rennin–angiotensin system. Prevention of the syndrome is important and involves monitoring of patients undergoing ovulation induction, modifying treatment regimens and pharmacological interventions. The management of patients depends upon the severity of the condition. There should be a low threshold for hospital admission where close monitoring, replacement of intravascular volume, thromboprophylaxis and paracentesis (if required) can be effected.

Fetal stem cells can be isolated from fetal blood and bone marrow as well as other fetal tissues. Fetal blood is both a source of haemopoietic stem cells, which proliferate more rapidly than those in cord blood or adult bone marrow, and a source of non-haemopoietic mesenchymal stem cells, which support haemopoiesis and can also differentiate along multiple lineages. Although the placenta was traditionally seen as a barrier separating the genetically distinct mother and fetus, it is now recognised that fetal cells pass into the maternal circulation throughout normal pregnancy. This cell traffic may help establish maternal tolerance to the fetal allograft. The principal mechanism is fetomaternal haemorrhage, as evidenced by the variety of fetal cell types, including stem cells, identified in maternal blood.

Isolation of fetal cells from the maternal circulation in pregnancy has been investigated as an alternative to existing methods of genetic prenatal diagnosis. Fetal stem cells have considerable potential for non-invasive prenatal testing, as they differ in phenotype from other cells circulating in the adult and can be amplified into large numbers for analysis after enrichment from maternal blood. Stem cells isolated from the fetus may be transplanted in utero to treat genetic disease and also show promise as targets for gene therapy, which could be applied to diseases such as osteogenesis imperfecta or muscular dystrophies.

The destination of fetal stem cells after trafficking across the placenta is the subject of much debate. While these cells may persist in blood in undetectable amounts, it is more likely that stem cells engraft in maternal tissues and persist for years after pregnancy, as has been demonstrated by finding fetal mesenchymal stem cells in post-reproductive tissues. Fetal microchimerism, which refers to low levels of fetal cells harboured by the mother, has been associated with the development of autoimmune disease in the mother and with repair of damaged tissues. However, fetal stem cells in maternal tissues could also act as a long-term reservoir of stem cells and may even explain why women live longer than men and why pregnancy protects against susceptibility to some diseases. Cellular trafficking in pregnancy has far reaching biological consequences.

Although outcomes in women's health are not as spectacular as in conditions like cancer, the large number of women who present each year means that the overall impact of these conditions is enormous. Similarly, although suboptimal therapies may not individually be much worse than best practice, the overall effect on a nation's health, wealth and happiness is substantial. There is a therefore a real need to gather evidence as to which, if any, women, benefit from any particular therapy. Well-designed randomised controlled trials (RCTs) help provide reliable evidence on a treatment's effectiveness. In this article, we consider important aspects of designing a good clinical trial; and in particular their application to women's health issues. Designed as an overview of the subject, we consider how large trials need to be; the choice of endpoints; how they should be analysed; and also more practical considerations in running a successful trial. The considerations given here are of use not only to clinicians or researchers preparing to run their own trial, but also to anyone who reads reports of trials, and should help clinicians make informed judgements about evidence presented in published reports.

Advanced cervical cancer continues to present a major health care challenge in the developing world. In contrast, in our own culture, the incidence of the disease is falling. However, the condition is presenting at an earlier stage and to younger patients who may wish to preserve their fertility, if possible. The traditional treatment, of radical surgery with adjuvant chemo-radiotherapy or primary chemo-radiotherapy, conflicts with such wishes. Therefore, techniques have been developed in the last 10 years, which aim to preserve fertility without compromising clinical outcome.

The newer techniques, which have been evaluated range from cone biopsy with or without lymphadenectomy through to radical trachelectomy. The latter technique is accumulating evidence of satisfactory oncological outcome, acceptable complication data and successful maternity outcome. However, the obstetric course for these patients is not guaranteed or straightforward. Most recently, treatments incorporating pre-operative chemotherapy followed by cone biopsy with lymphadenectomy have been described. Such a policy is likely to produce more obstetric gains but it must not be at the expense of oncological outcome, unless requested by the patient.

The need for consistent high-quality imaging, histopathology and clinical decision-making supports the concept that such care should only be developed and available in highly specialized centres. The requirement for comprehensive data collection and follow up of oncological variables, obstetric outcome and complication rates should be mandatory. New more conservative methods should only be developed under strict scientific control, using the traditional methods as comparators. However, it is possible that such fertility preserving techniques may be very attractive to some patients, even if they are increasing their risk of recurrent cervical cancer.

This review provides an overview of the background evidence that has led to current recommendations on adhesion reduction management. The extent, epidemiology and financial implications of abdominopelvic adhesions and their related complications is discussed. Strategies for the prevention of adhesions are presented including a review of current anti-adhesion agents. Finally, the potential impact of progressing routine anti-adhesion strategies and indeed the potential impact of not doing this are considered.

Diabetes in pregnancy is associated with significant morbidity and mortality and its prevalence is rising. The management of this condition involves the co-ordinated care of a multi-disciplinary team consisting of endocrinologists, obstetricians, midwives and dieticians. This review concentrates on the control of diabetes in pregnancy, by which both maternal and fetal complications can be minimised. The management of gestational diabetes centres on self-monitoring of blood glucose, diet control and if necessary, insulin treatment. Women with gestational diabetes have a high risk of developing type 2 diabetes later in life and should be counselled on the importance of lifestyle modification. In patients with pre-existing type 1 and 2 diabetes, pre-conception counselling is important to optimise pregnancy outcome. Such counselling also provides an opportunity to screen for pre-existing vascular complications such as retinopathy (which may worsen during pregnancy) and measure baseline markers of glycaemic control such as HbA_1C. Insulin requirements vary during pregnancy and hence daily assessment of blood glucose levels should be performed and the insulin dose adjusted accordingly. Conventional injections of insulin or insulin pumps are both effective in optimising glycaemic control, although the latter is generally used in patients for whom achieving normoglycaemia is challenging. Blood pressure should be regularly monitored and hypertension treated. The evidence for the efficacy of various treatment modalities has been examined in this review. By optimising diabetes management in pregnancy, it is hoped that the pregnant diabetic patient can look forward to a similar pregnancy outcome as that of a normal woman.

Adenomyosis is a benign common gynaecological disorder whose pre-operative diagnosis has previously been elusive. The accuracy of clinical diagnosis is low as the symptoms are non-specific. The advent of high resolution imaging techniques has made an accurate non-invasive diagnosis of adenomyosis possible. Adenomyosis may also co-exist with other pathology. The histopathologic features are varied and contribute to its imaging appearances. An understanding of these features is crucial in the interpretation of the imaging findings. This review focuses on the role of the non-invasive techniques available, their accuracy and the imaging features useful in the diagnosis of adenomyosis on the various modalities. Transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) have emerged as the imaging modalities of choice in evaluating women with suspected adenomyosis. TVS is useful as the initial imaging modality with MRI reserved for cases that are indeterminate at TVS or those with co-existing pathology.

The aim of the fertility work-up is to exclude recognised causes of infertility and to distinguish those couples who have good spontaneous pregnancy prospects from those who have poor prospects. Information gathered by medical history, clinical findings and results of the diagnostic tests should help the clinician in counselling subfertile couples. The initial diagnostic tests for infertility should include a basal body temperature chart or midluteal phase progesterone level, a semen analysis and a test for tubal patency. Ovarian reserve tests can be used in selected cases. More research is needed in the predictive value of the outcome of diagnostic tests in reproductive medicine.