Obstetric Medicine最新文献

Background: The severity of intrahepatic cholestasis of pregnancy (ICP) reflects peak maternal bile acid (BA) concentration. However, the course of the disease is unclear.

Methods: Longitudinal observational cohort study of individuals with ICP. Serial BA and alanine aminotransferase (ALT) trajectories were determined according to starting severity. Multiple logistic regression identified variables predictive of subsequent disease severity, validated using data from a randomised controlled trial.

Results: Although highly variable, BA concentrations increased across gestation (p > 0.001). Normal ALT concentration at diagnosis predicted concurrent non-severe disease (negative predictive value 94.2% (91.6-96.1%)). Gestational age and BA concentration at diagnosis somewhat predicted later moderate or severe disease (BA ≥ 40 µmol/L: ROCAUC 0.64 (0.58-0.69); BA ≥ 100 µmol/L: ROCAUC 0.68 (0.62-0.73)), similarly in the validation cohort (ROCAUC 0.70 (0.65-0.76) and 0.69 (0.63-0.76), respectively).

Conclusion: An earlier gestation and higher BA concentration at diagnosis increase the likelihood of more severe disease; however robust prediction is limited.

Hypercalcemia is rare in pregnancy and carries a significant risk for both mother and fetus. A rare cause of hypercalcemia is loss-of-function mutations in CYP24A1, which encodes 24-hydroxylase, responsible for the inactivation of active vitamin D metabolites. Pregnancy-associated upregulation of 1α-hydroxylase, increased parathyroid hormone (PTH)-related peptide, and supplementation with vitamin D can unmask CYP24A1 deficiency. This condition should be suspected in women presenting with unexplained hypercalcemia, suppressed PTH, and a negative secondary workup for malignancy, granulomatous disease, and contributory medications. Management includes intravenous fluids, calcitonin, and avoidance of vitamin D and calcium supplements. Here, we report a case of persistent hypercalcemia despite aggressive hydration and calcitonin therapy. Postpartum genetic testing confirmed a homozygous CYP24A1 mutation, with markedly elevated 1,25(OH)₂D levels. CYP24A1 mutations are a rare but important cause of gestational hypercalcemia. Early recognition and multidisciplinary management can improve maternal and neonatal outcomes.

Tinea corporis is a common fungal infection of the skin, which can affect women of childbearing age. We present a case of tinea corporis that resulted in an emergency caesarean delivery under general anaesthesia due to difficulties with pain management intrapartum. Epidural anaesthesia was contraindicated due to the location of the rash over the lumbar region. This would have been preventable with early treatment. This case highlights the need to diagnose, investigate and treat skin conditions promptly in pregnancy.

Background: Pruritus is a common symptom of intrahepatic cholestasis of pregnancy (ICP) and significantly reduces patients' quality of life (QoL).

Methods: A multinational survey administered through ICP patient support groups was conducted in women with current or previous ICP.

Results: In total, 697 women from the UK, USA, Australia, Canada, New Zealand, and Ireland responded to the survey. 94% had ICP in a previous pregnancy. The median worst itch score (0-10) was 9. Pruritus severity was associated with a higher degree of sleep disturbance, fatigue, and mood changes. 59% reported that pruritus led to disruption of daily activities. 33% reported missing school or work. Most patients were taking ≥2 antipruritic medications and achieved only partial resolution of pruritus.

Conclusion: The results underscore the negative impact of pruritus on QoL in patients with ICP and substantiate the high unmet need for developing safe and effective antipruritic therapies in ICP.

Trial registration: Trial registration is not applicable because this was not an interventional study.

Maternal mortality and severe maternal morbidity have been on an upward trend over the past couple of decades in the USA, contrasting other developed countries. Sleep disturbances are common during pregnancy and vary by group demographics, similarly to severe maternal morbidity. This narrative review focuses on highlighting the association between sleep and sleep impairment with severe maternal morbidity and mortality, as well as with adverse perinatal outcomes, making sleep disturbances a potentially modifiable risk factor for maternal morbidity and mortality. The review will also discuss some sleep interventions that are non-pharmacological and that may hold the prospect for reducing the risk of perinatal outcomes associated with severe maternal morbidity and mortality, without increasing the risk of teratogenicity. We also discuss knowledge gaps and potential focus of future research from testing the impact of sleep modification on pregnancy outcomes to the identification of sleep disturbances and disorders in perinatal care.

Here we present an unusual case of what was initially asymptomatic hypercapnic respiratory failure presenting in pregnancy and the complex investigative journey, culminating in a diagnosis of ryanodine receptor-1-related congenital myopathy. Late pregnancy was complicated by pre-eclampsia and peripartum cardiomyopathy, resulting in an acute decompensation in respiratory function which has resulted in long-term post-partum non-invasive ventilation.

Objective: To compare the safety and efficacy of 12 versus 24-h postpartum magnesium sulfate (MgSO₄) infusion protocol in women with severe preeclampsia.

Methods: This retrospective cohort study analyzed patient outcomes before and after a postpartum magnesium protocol change for cases of severe preeclampsia: 24-h MgSO₄ (Feb-Sep 2021) versus 12-h MgSO₄ (Sep 2021-Feb 2023). The primary outcome was eclampsia; secondary outcomes included magnesium toxicity, maternal complications, postpartum length of stay, ambulation time, and time to Foley catheter removal.

Results: Baseline characteristics were similar. No cases of eclampsia occurred in either protocol. Magnesium toxicity and maternal complications were comparable. Notably, 10 out of the 75 patients in the 12-h protocol required magnesium extension due to persistent preeclampsia symptoms. However, the 12-h protocol was associated with shorter postpartum stay, earlier ambulation, and earlier time to Foley catheter removal.

Conclusion: The 12-h MgSO₄ protocol is as safe and effective as the 24-h protocol. There were no differences in rates of convulsion or negative maternal outcomes between the two protocols.

Sickle cell disease (SCD) is the most common hemoglobinopathy, characterized by hemolysis and vaso-occlusion, resulting in multisystem disease. Pregnant patients with SCD may have preexisting organ dysfunction and SCD-specific pregnancy complications. Risk for adverse maternal or fetal outcomes is significantly elevated in SCD patients, and multidisciplinary care in a center with expertise is essential to minimize complications.

Complete heart block (CHB) in pregnancy is a rare condition, with acquired cases being particularly unusual. The management of CHB is guided by the underlying aetiology, symptoms, and associated risk factors, requiring careful consideration of both maternal and fetal well-being. This review examines the causes and pathophysiological mechanisms of CHB and discusses the pregnancy-related haemodynamic and hormonal changes that may exacerbate cardiac conduction abnormalities. We present the case of a 25-year-old woman diagnosed with acquired CHB at 18 weeks and 6 days of gestation, who underwent successful dual-chamber pacemaker implantation. This case illustrates the key aspects of managing CHB in pregnancy, including comprehensive diagnostic evaluation and careful delivery planning. Given the complexity of this clinical scenario, a multidisciplinary approach, including cardiologists, obstetricians and anaesthetists, is essential for optimising maternal and fetal outcomes. Further research is required to refine clinical guidelines and develop recommendations regarding long-term patient care and the management of subsequent pregnancies.