Disorders In Pregnant Women Research Articles

The management of mood disorders in pregnancy: alternatives to antidepressants

The management of mood disorders during pregnancy is complex due to risks associated with medication use and risks associated with untreated depression. Antidepressant use during pregnancy is an exposure for the unborn child, and it currently remains unclear what long-term repercussions there might be from this exposure, though available data are reassuring. On the other hand, there are risks for both the mother and child of untreated depression during pregnancy. There is a real need for research into nonpharmacological strategies for the prevention of relapse of mood disorders in pregnant women who are off medications. We have reviewed a number of potential candidate interventions including psychotherapies, exercise, light box therapy (LBT), repetitive transcranial magnetic stimulation (rTMS), electroconvulsive therapy (ECT), holistic strategies, and nutritional and herbal supplements. Currently there is a lack of evidence supporting the use of such strategies in the prevention of depressive relapse during pregnancy, though most of these strategies have at least some support for their use in the treatment of a major depressive episode. Carefully conducted research using one or more of these strategies in women who want to discontinue antidepressants for pregnancy is sorely needed.

Treating Opioid Use Disorders During Pregnancy: Historical, Current, and Future Directions

ABSTRACT The historical and current contexts of opioid use disorders during pregnancy are reviewed. There has been a long history of use of opioids by women in the United States, including by prescription prior to 1919. Neonatal abstinence syndrome was first identified coincident with this use. Methadone and more recently buprenorphine have proven to be successful pharmacotherapeutic agents in the treatment of opioid use disorder in pregnant women. However, these medications should be seen as only one ingredient of a comprehensive treatment approach for this population. The 21st century needs to witness a heightened emphasis on the myriad factors that lead to opioid use in women, and a broader education of those professionals who may come in contact with pregnant women with opioid use disorder.

The Safety of Methimazole and Propylthiouracil in Pregnancy

Hyperthyroidism is a common disorder in pregnant women and is often caused by Graves disease. In pregnant women, the incidence of hyperthyroidism is 0.2% to 0.3%, and Graves disease accounts for 85% of cases. Untreated hyperthyroidism has serious risks, including preeclampsia, thyroid storm, heart failure, miscarriage and stillbirth, prematurity, intrauterine growth restriction, and neonatal thyrotoxicosis. Thyroid dysfunction is often treated with propylthiouracil (PTU) or methimazole (MMI), but both drugs readily cross the placenta with similar kinetics of placental transfer. Propylthiouracil has been the drug of choice during pregnancy because MMI is associated with teratogenic effects. Over the last 20 years, several reports have raised concerns about hepatotoxicity caused by PTU, and it has been the subject of a “black box warning.” This literature review was undertaken to assess the maternal and fetal risks of treatment with MMI and PTU during pregnancy. PubMed, EMBASE, TOXNET, TOXLINK, DART, Medscape, EBSCO, and Google sought English and non-English publications, with searches limited to human data and clinical trials. Reference lists of relevant articles and all selected articles were hand-searched to identify additional trials. Thirty-one of 2468 publications identified were reviewed to evaluate the adverse effects of MMI or PTU and included cohort and case-control studies and case reports or case series. No randomized controlled trials were identified. Several retrospective cohort studies addressed MMI teratogenicity, but only a few of these identified cases with one of the features associated with fetal MMI. Two case-control studies investigated an association between MMI and specific malformations. In 1 study, prenatal exposure to maternal hyperthyroidism treated with MMI was identified in 16.4% of cases (10/61) and only 1.1% (2/183) in the control group. The data suggested that prenatal exposure to maternal hyperthyroidism and treatment with MMI were associated with choanal atresia (CA). Methimazole-related adverse fetal outcomes were reported in numerous case reports/series. Fifteen cases with aplasia cutis congenita, 12 with CA, and 3 with other features of MMI embryopathy were described. Several cohort studies of PTU exposure during pregnancy met inclusion criteria. One assessed 115 PTU-exposed pregnancies and 1141 controls exposed to nonteratogenic drugs and found comparable rates of major anomalies (1.3% for PTU exposure and 3.2% for controls; P = 0.5). Hypothyroidism was present in 9.5% of fetuses or neonates (56.8% of whom had goiter). Neonatal hyperthyroidism, possibly resulting from maternal disease, was found in 10.3%. Goiters diagnosed prenatally by ultrasound were successfully treated in utero by adjusting the maternal dose of PTU. Neonatal thyroid function generally became normal during the first month of life without treatment. One study examined the intellectual development of 31 subjects aged 4 to 23 years, born to women with Graves disease; 15 were exposed to MMI (40–140 mg/wk), and 16 were exposed to PTU (250–1400 mg/wk) during pregnancy. The exposed and unexposed groups did not differ in total IQ. No differences were apparent between those exposed to MMI or to PTU or between those exposed to higher or lower doses. All children were euthyroid at birth, and none had goiter. Over the past 20 years, 22 serious cases of liver injury in adults (resulting in 9 deaths and 5 liver transplants) have been reported to the Food and Drug Administration (FDA) and to the Adverse Event Reporting System. In 2010, the FDA made the following recommendations: (1) PTU should not be prescribed as the first-line treatment agent in children or adults; (2) because of MMI teratogenicity, PTU should be prescribed for hyperthyroidism during the first trimester of pregnancy, at least until more is known regarding the teratogenicity of MMI; (3) PTU is recommended over MMI in life-threatening thyrotoxicosis or thyroid storm because of its superiority in inhibiting peripheral conversion of T4 to T3; and (4) PTU can be used in individuals who have had adverse responses to MMI (other than agranulocytosis) and for whom radioiodine or surgery are not options. In neonates, the most significant case described neonatal hepatitis that was positive for newborn lymphocyte transformation test for PTU, which suggests an immunologic reaction to PTU through lymphocytes. Because PTU and MMI cross the placenta and are detected in fetal circulation, PTU treatment should be discontinued after the first trimester of pregnancy. In conclusion, uncontrolled maternal hyperthyroidism may cause congenital malformations and adverse pregnancy outcomes. In most case reports of MMI-associated embryopathy, MMI exposure occurred in the first trimester and mostly in mothers with uncontrolled thyrotoxicosis. Choanal atresia and aplasia cutis congenita have not been reported in association with PTU treatment. The possible teratogenic effect of MMI cannot be ignored, and use of the drug should be avoided in the first trimester. Propylthiouracil may not be a human teratogen. However, a major concern with PTU treatment is the potential for serious hepatotoxicity. Pregnant women with hyperthyroidism should receive PTU during the first trimester and MMI thereafter.

Alcohol‐use disorders during and within one year of pregnancy: a population‐based cohort study 1985–2006

To examine alcohol-use disorders in pregnant women and the extent of under-reporting. Population-based cohort study. Western Australia. Women with a birth recorded on the Western Australian Midwives Notification System (1985-2006). Mothers with an International Classification of Diseases 9/10 alcohol-related diagnosis, indicating heavy alcohol consumption, recorded on population-based health datasets (non-Aboriginal n=5,839; Aboriginal n=2,583) were identified through the Western Australian data-linkage system. This 'exposed' cohort was frequency matched (on maternal age, year of birth of offspring, Aboriginal status) with comparison mothers without an alcohol-related diagnosis (non-Aboriginal n=33,979; Aboriginal n=8,005). Trends in maternal alcohol diagnoses in relation to pregnancy for non-Aboriginal and Aboriginal women. The proportion of children diagnosed with fetal alcohol syndrome (FAS) who had a mother with an alcohol diagnosis recorded during pregnancy. The proportion of Aboriginal mothers in Western Australia with an alcohol diagnosis (23.1%) is ten times greater than for non-Aboriginal mothers (2.3%). There has been a six-fold increase in the percentage of non-Aboriginal births with a maternal alcohol diagnosis recorded during pregnancy and a 100-fold increase for Aboriginal births. Around 70% of the mothers of children diagnosed with FAS did not have an alcohol diagnosis recorded during pregnancy and 18% of the mothers had no record of an alcohol diagnosis. Maternal alcohol exposure during pregnancy is significantly under-ascertained. Given the severe risks to the fetus from heavy prenatal alcohol exposure, assessment and recording of alcohol use should be routinely undertaken in maternity and other health settings.

Role of HLA-G and other immune mechanisms in pregnancy

AbstractPregnancy loss (abortion) and pre-eclampsia represent the most common disorders in pregnant women. Besides infection, there are anatomical, endocrinological, genetic and immunological factors that can induce pregnancy disorders. Because the exact mechanisms of physiological pregnancy maintenance are still not clearly understood, the search for genes and proteins fulfilling this role is still in progress. One of the immune molecules that plays a beneficial role in pregnancy is the nonclassical HLA-G molecule. The molecule is mainly expressed on trophoblast cells in the foetal placenta and induces the immune tolerance of the foetus via its interaction with inhibitory receptors on maternal NK cells and CD8+ T lymphocytes. In relation to pregnancy disorders, associations between HLA-G polymorphism, HLA-G level and HLA-G function were described. Thus, the HLA-G molecule can be used as a new diagnostic marker and, potentially, for the future therapy of pregnancy disorders.

1840 – Pharmacokinetics of lithium during delivery and in the neonatal period. A preliminary data

Lithium has been used in the treatment of bipolar disorder in pregnant women. However, information on the pharmacokinetics of lithium during perinatal period is scarce. To study pharmacokinetics of lithium during delivery and in the neonatal period. A prospective, observational and naturalistic study was conducted at the PERINATAL PSYCHIATRY PROGRAM CLÍNIC-BARCELONA, from 2005 to 2012. We included all consecutive cases of pregnant women with bipolar disorder I or II (n = 22), and on maintenance treatment with lithium monotherapy (n = 13) or polytherapy (n = 9) during pregnancy who elected artificial feeding. Lithium plasma concentrations in maternal blood and umbilical cord were detected. Lithium plasma concentrations in infants (n = 16) at delivery and in the neonatal period were obtained to calculate elimination half-life, which was estimated by lineal regression. Technique: AVL 9180 electrolyte analyser using a lithium-selective electrode (detection limit =0.10 mEq/L). Women did not fulfil diabetes criteria pre-pregnancy and during pregnancy. Attending to neonatal outcomes, infants exposed to polytherapy had a higher weight at birth (percentils) than those exposed to lithium alone [53.38 (33.40) vs. 70.22 (26.25)]. No statistically significant differences were found in umbilical cord:maternal plasma concentration ratio between those treated with lithium monotherapy and women treated with polytherapy (1.05 vs. 1.08). The lithium mean elimination half-life (SD) in infants was 6.73 (9.12) days. Lithium crosses placental barrier almost completely. Elimination half-life in neonates exposed to lithium in utero was 6.73 days. Moreover, lithium treatment during pregnancy requires therapeutics monitoring in exposed dyads.

The prevalence and associated risk factors of sleep disorder-related symptoms in pregnant women in China

The sleep disorder in pregnant women remains unfamiliar to perinatal care providers, resulting in lack of appropriate care. This study was designed to investigate the prevalence of sleep disorder-related symptoms in pregnant women and to identify the associated risk factors. Married pregnant women were enrolled from their first trimester and followed up until delivery. Nonpregnant married healthy women were selected as controls. A survey questionnaire was administered to each of them. We successfully performed a survey to 1,993 pregnant women and 598 nonpregnant women. The overall prevalence of sleep disorder-related symptoms in pregnant women was significantly higher than the controls (56.1 vs. 29.9 %, P < 0.05). There was higher prevalence of snoring (30.2 %), observed sleep apnea (1.1 %), mouth breathing (23.7 %), nocturnal arousal (46.5 %), insomnia (35.1 %), and daytime sleepiness (52.6 %) in pregnant women. There were no significant differences of the prevalence of bruxism (7.0 vs. 6.7 %), sleep talking (8.1 vs. 7.2 %), and sleep walking (0.4 vs. 0.2 %) between the two groups (P > 0.05). Nocturnal sleep time (8.0 ± 1.3 h) was less in the third trimester compared with the nonpregnant women (8.2 ± 1.1 h) (P < 0.05). Smoking (OR = 3.39), drinking (OR = 2.40), allergic rhinitis/asthma (OR = 1.71), an obvious difference in neck circumference (OR = 1.11), and waistline (OR = 1.07) changes between the first and third trimesters were the risk factors for sleep disorder-related problems. There is a high prevalence of sleep disorder-related symptoms in pregnant women. Our data may provide a baseline for prevention and treatment of sleep disturbances in pregnant women.

Motherisk Rounds: The Safety of Methimazole and Propylthiouracil in Pregnancy: A Systematic Review

BackgroundHyperthyroidism is one of the most common endocrine disorders in pregnant women, and it can severely complicate the course and outcome of pregnancy. Methimazole (MMI) and propylthiouracil (PTU) are the standard anti-thyroid drugs used in the treatment of hyperthyroidism in pregnancy. Traditionally, MMI has been considered to have clearer evidence of teratogenicity than PTU. Recent studies suggest that PTU can be hepatotoxic, leading to a United States Food and Drug Administration “black box alert.” We wished to systematically review the effects of PTU and MMI during pregnancy, and to compare maternal and fetal safety. MethodsWe conducted a systematic search of PubMed, EMBASE,TOXNET, TOXLINK, DART, Medscape, EBSCO, and Google.Both English and non-English publications were included. Weexcluded studies using anti-thyroid therapies other than PTU andMMI, studies not allowing interpretation of results, and abstracts ofmeetings. ResultsOverall, insufficient statistical power precluded determination of accurate rates of either MMI teratogenicity or PTU hepatotoxicity in cohort studies. However, a case–control study helped identify the relative risk of MMI-induced choanal atresia. A second case–control study failed to show that aplasia cutis congenita is associated with MMI. PTU has been associated with a rare but serious form of hepatic failure. ConclusionMMI causes a specific pattern of rare teratogenic effects after first trimester exposure, while PTU therapy may be followed by rare but severe hepatotoxic sequelae. It is therefore appropriate to use PTU to treat maternal hyperthyroidism during the first trimester of pregnancy, and to switch to MMI for the remainder of the pregnancy.

Antepartum depression and anxiety associated with disability in African women: cross-sectional results from the CDS study in Ghana and Côte d'Ivoire.

BackgroundCommon mental disorders, particularly unipolar depressive disorders, rank among the top 5 with respect to the global burden of disease. As a major public health concern, antepartum depression and anxiety not only affects the individual woman, but also her offspring. Data on the prevalence of common mental disorders in pregnant women in sub-Saharan Africa are scarce. We provide results from Ghana and Côte d'Ivoire.MethodsWe subsequently recruited and screened n = 1030 women in the third trimester of their pregnancy for depressed mood, general anxiety, and perceived disability using the Patient Health Questionnaire depression module (PHQ-9), the 7-item Anxiety Scale (GAD-7), and the World Health Organisation Disability Assessment Schedule II (WHO-DAS 2.0, 12-item version). In addition to estimates of means and prevalence, a hierarchical linear regression model was calculated to determine the influence of antepartum depression and anxiety on disability.ResultsIn Ghana, 26.6% of women showed substantially depressed mood. In Côte d'Ivoire, this figure was even higher (32.9%). Clear indications for a generalized anxiety disorder were observed in 11.4% and 17.4% of pregnant women, respectively. Comorbidity of both conditions was common, affecting about 7.7% of Ghanaian and 12.6% of Ivorian participants. Pregnant women in both countries reported a high degree of disability regarding everyday activity limitations and participation restrictions. Controlled for country and age, depression and anxiety accounted for 33% of variance in the disability score.ConclusionsAntepartum depression and anxiety were highly prevalent in our sample and contributed substantially to perceived disability. These serious threats to health must be further investigated and more data are needed to comprehensively quantify the problem in sub-Saharan Africa.

High prevalence of thyroid dysfunction in pregnant women.

Maternal thyroid dysfunction during pregnancy has been associated with adverse obstetric and neonatal outcomes. This prospective study evaluates the prevalence of these disorders in pregnant women. Serum levels of TSH, free T4 (fT4), and thyroperoxidase antibodies (TPO-Ab) were measured in 951 women at different gestational ages of pregnancy. Trimester-specific reference ranges for TSH were used to classify pregnant women into five groups: 1) Overt hypothyroidism (OH); 2) Subclinical hypothyroidism (SCH); 3) Isolated hypothyroxinemia (IH); 4) Low TSH (isolated or associated with high fT4); and 5) Normal. A classification was made also according to the lower and upper ranges provided by the manufacturer for thyroid hormones. Pregnant women who were at a high risk of developing thyroid disease were identified. Altogether, 117 women (12.3%) had hypothyroidism and 25 (2.6%) had low TSH. The prevalence of both OH and SCH was higher in the high-risk group than in the low-risk group, but 17.9% of women with hypothyroidism were classified at low-risk. A family history of thyroid disorders and TPO-Ab positivity increased the risk of SCH. Using non-pregnant reference range for TSH, 10.6% of women were misclassificated. The high prevalence of hypothyroidism observed in this study suggests that accurate thyroid screening with trimester specific reference ranges should be warranted, particularly in areas with mild to moderate iodine deficiencies.

Lung ultrasound‐guided management of acute breathlessness during pregnancy

Lung ultrasonography is a standard tool in the intensive care unit and in emergency medicine, but has not been described in the particular setting of the labour ward. During pregnancy, acute respiratory failure and pulmonary oedema are not uncommon life-threatening events. We present two case reports outlining the potential of lung ultrasonography in parturients. In case 1, lung ultrasonography allowed early diagnosis and treatment of acute dyspnoea in a parturient admitted for suspected asthma exacerbation. Lung ultrasonography revealed a 'B-pattern' of vertical lines radiating into the lung tissue, indicating severe pulmonary oedema complicating previously undiagnosed pre-eclampsia. In case 2, a pre-eclamptic patient was managed with combined transthoracic echocardiography and lung ultrasonography. The accuracy of lung ultrasonography in detecting interstitial oedema at a pre-clinical stage allowed adequate fluid resuscitation in this patient who had a high risk of alveolar pulmonary oedema. We believe that these cases strongly support the prospective validation of lung ultrasound for management of lung disorders in pregnant women.

Early pregnancy screening for hypertensive disorders in women without a‐priori high risk

To evaluate the performance of mean arterial pressure, uterine artery pulsatility index and soluble endoglin level alone or in combination in screening for hypertensive disorders in pregnant women without a-priori high risk. This was a nested case-control study of women with singleton pregnancies without a-priori high risk who developed pregnancy-induced hypertensive complications. Women were enrolled into the study at 11-14 weeks' gestation, when mean arterial pressure and uterine artery pulsatility index were recorded and a blood sample was taken for measurement of soluble endoglin. Women were followed up in the clinic to detect development of any hypertensive disorder. Each affected case was matched with two normotensive control women with uncomplicated pregnancies that resulted in phenotypically normal infants. Mean values for each variable were compared between cases and controls. Sensitivities, positive predictive values and negative predictive values at fixed specificity were derived from receiver-operating characteristics (ROC) curves. During the study period, 2120 patients were examined. Of these, 170 (8.02%) were excluded because they were lost to follow-up and in 52 (2.45%) there was fetal death or miscarriage before 24 weeks' gestation. Thus, 1898 cases formed the cohort population. Of these, 89 (4.69%) patients developed complications (study group), including 16 (0.84%) cases with early pre-eclampsia (PE), 60 (3.16%) with late PE and 13 (0.68%) with gestational hypertension (GH). There were 49 (2.58%) cases of spontaneous preterm delivery before 34 weeks. The rest of the cohort population (1760 (92.73%) patients, the base cohort) were not affected by PE or GH. The control group comprised 178 patients. The best model for the prediction of any of the types of hypertensive disorders was one that combined mean arterial pressure with soluble endoglin (area under the ROC curve (AUC), 0.83). The predictive value of the three combined markers was highest for screening for early and late PE (AUC, 0.86 and 0.83, respectively). When each marker was considered alone, the highest prediction of any type of hypertensive disorder was achieved by mean arterial pressure (AUC, 0.73). Sensitivity was lowest for detection of GH when screening both by individual and by combined markers. First-trimester screening can be useful in predicting women at high risk of developing hypertensive disorders of pregnancy but more prospective longitudinal studies are needed.

OP22.01: Utero‐placental interface vascularity in early pregnancy estimated by 3D fractional moving blood volume (3D FMBV) predicts fetal growth restriction

Conclusions: This study shows an association between maternal anxiety in pregnancy and increased uterine artery resistance index, that may explain associations between uterine artery blood flow disorders in pregnant women exposed to stress and fetal intrauterine growth retardation, tissue and organ differentiational disorders et al. Summarizing we can state that chronic stress damages placental barrier in mother-fetus system.

Experimental gestational hypothyroidism evokes hypertension in adult offspring rats

Gestational hypothyroidism is a prevalent disorder in pregnant women. We aimed to investigate the impact of experimental gestational hypothyroidism (EGH) on cardiovascular and autonomic nervous systems (ANS) in the offspring of rats. EGH was induced with methimazole (MMI) 0.02% in drinking water from day 9 of gestation until birth. Sixty day old offspring from MMI-treated dams (OMTD, n=13) or water-treated dams (OWTD, n=13) had femoral arteries surgically assessed for the measurements of heart rate (HR), mean (MAP), systolic (SAP) and diastolic arterial pressure (DAP), and spontaneous baroreflex sensitivity (BRS). To investigate the balance of ANS, we established the high (HF) and low frequency (LF) bands of pulse interval (PI) and LF band of SAP spectrum. OMTD had increased MAP (130.2 ± 2.0 vs 108.8 ± 3.0 mmHg, p<0.001), SAP (157.3 ± 2.9 vs 135.7 ± 4.5mm Hg, p<0.001) and DAP (109.7 ± 1.9 vs 88.4 ± 2.6 mmHg, p<0.001) when compared to OWTD, and had lower HR (355.1 ± 8.9 vs 386.8 ± 9.2 bpm, p<0.05). After spectral analysis of PI and SAP, only LF band of SAP spectrum was higher (7.2 ± 0.8 vs 4.0 ± 0.6 mmHg(2), p<0.01) in OMTD under spontaneous condition. Despite bradycardia, EGH promotes spontaneous hypertension in 60 day old offspring, probably due to increased sympathetic modulation of vessels, which is suggested by the higher LF of SAP. These findings suggest a critical role of maternal THs in the development of fetal cardiovascular and autonomic nervous systems.

PP158. Hypertensive disorders in pregnant women affected by type I diabetes

Type I diabetes in pregnancy is associated with an increased incidence of hypertensive disorders. The aim of the present study was to evaluate the incidence of hypertensive disorders in pregnant women affected by type I diabetes and pregnancy outcome in women with and without hypertension. One hundred seventy two pregnancies in 150 women affected by type I diabetes were assessed. Twelve pregnancies were excluded (8 because of spontaneous abortions, 1 for voluntary abortion and 3 twin pregnancies), and 160 pregnancies were considered for the study. Twenty-five pregnancies (15.6%) were complicated by hypertensive disorders: 4.4% by chronic hypertension (CH), 5% by gestational hypertension (GH), 4.4% by preeclampsia (PE) and 1.8% by preeclampsia superimposed on chronic hypertension (PE+CH); 32% of the women presented a vascular disease (renal or retinal disease). The diabetic women with hypertensive complications were compared with diabetic women without hypertension. The main results are shown in Table 1. Significant differences in mean birth weight and mean gestational age were found. The group affected by preeclampsia showed 14.7% of small for gestational age (SGA) neonates (birth weight percentile less than 10th pc), and 57.1% of large for gestational age (LGA) neonates (birth weight percentile greater than 90th pc), two of them were over 4000 g. Only one case of very preterm delivery (<32 weeks) was observed in the sample. As expected, the incidence of hypertensive disorders in population affected by type 1 diabetes is higher than in general population and a poor pregnancy outcome was observed in this group of women. However, the neonatal outcome of women affected by preeclampsia is not different from that observed in women without hypertensive complications (diabetic controls) in terms of mean birth weight despite a significantly lower mean week gestation at delivery.

OS039. Early prediction of preeclampsia with maternal parameters,SVEGF-R1, PLGF, Inhibin-A and PAPP-A in general population: Results from the MSPE study

complication of pregnancy and cause of maternal and perinatal morbidity and mortality worldwide. The prevalence of chronic hypertension in pregnant women is of 1–5%. The diagnosis is based on the anamnesis data or increase in pressure of up to 140/90 mmHg or more before the 20th week of pregnancy. Objectives: To Establish the clinical significance of pepaBapHo training of women with chronic hypertension of I–II stage II of the degree of risk of CHF 0–I and identify opportunities for drug prevention hypertensive complications in pregnant women. Methods: The Hypertensive disorders in pregnant women divided into three categories: chronic hypertension, gestational hypertension and preeclampsia. The study included 177 women with chronic hypertension of I–II stage II of the degree of risk of chronic heart failure 0–I receive pepaBapHy the preparation of the group (observations) and 100 women with chronic hypertension of I–II stage II of the degree of risk of chronic heart failure 0–I do not receive pre-conceptional training (a comparison group). The age of patients in both groups did not differ, ranging from 18 to 42 years (Me 28 years). Results: The course of pregnancy in the investigated groups complicated: pre-eclampsia (48.02% and 67.0%, respectively, in groups I and II), the threat of termination of pregnancy (45.2% and of 64.0% , respectively), early preeclampsia (28.2% and 35.0% , respectively). Chronic fetal hypoxia of the fetus were observed in 33.9% and 40.0% of women, respectively, delay the development of the fruit – by 16.9% and 20.0%, foetoplacental insufficiency – by 22.6%, 31.0%. Premature births ended 16.9% and 24.0% of pregnancies, respectively. In 100% of the women in the focus groups method of delivery was operation caesarean section in the lower segment of the uterus. The readings from the mother’s side was the failure of a scar on the uterus, narrow pelvis, shoulder of the cervix, detachment normally situated placenta, extra-genital pathology of the mother in the stage of decompensation. From the fruit of the main indications were: acute fetal hypoxia of the fetus, delay the development of the fetus rights violations in the utero-placental basin. Conclusion: Pre-conceptional preparation of women with chronic hypertension, including the treatment of chronic infections with the phenomena of bacterial vaginosis, regulation of violations ofmenstrual function creates a favorable background for the normal course of pregnancy. A careful medical supervision and timely delivery are the key factors in the treatment of arterial hypertension in pregnant women.

PP090. The contribution of podocyturia to the evaluation of ongoing glomerular disorder in pregnant women with kidney graft (preliminary results)

IntroductionProgressive proteinuria and glomerulosclerosis characterize chronic allograft nephropathy. However, the causes are not fully elucidated. Injury of parietal epithelial cells in glomeruli, the podocytes, is the initiating cause of many renal diseases, leading to proteinuria with possible progression to glomerulosclerosis. Podocytes are highly specialized cells, with an important role in maintaining the glomerular filtration barrier and producing growth factor for mesangial cells and endothelial cells. With their foot processes they cover the glomerular basement membrane, and form slit diaphragms with neighboring podocytes. The potential role of podocytes in the failing transplanted kidney is unknown. ObjectivesTo evaluate podocyturia as a functional marker in pregnant women with kidney grafts. MethodsTwenty pregnant women with kidney grafts had their urine samples cytocentrifugated and evaluated by indirect immunofluorescence. The slide was incubated for 45’ at room temperature with fluorescein (FITC) anti-rabbit IgG secondary antibody (Sigma-Aldrich, EUA). Then Vectashield (mounting medium for fluorescence) with DAPI (4’6-diamino-2-fenilindol dihidrocloreto) were applied H-1200 (Vector laboratories, inc, USA). The podocytes and the total number of cells were counted in 15 fields photographed under 400x magnification with a digital camera coupled to an epifluorescence microscope DM1000 (Leica, Germany) connected to a computer. The results were expressed as podocyte/total cells (%) per area of higher cell concentration (hot spots) in the field of 400x detected by staining of nuclei and cytoplasm. (Grant FAPESP 08/56338-1). ResultsThe mean age of the women was 26years. The urinalysis was performed at the third trimester of gestation; 11 did not exhibit urinary podocytes and 9 had podocyturia. There was also a relationship between blood pressure levels, proteinuria and the excretion of podocytes. ConclusionUrinary podocyte number, blood pressure and proteinuria were associated. We observed that urinary podocyte excretion occurs in pregnant women with kidney transplant almost synchronously with higher systolic and diastolic blood pressure and higher mean levels of proteinuria. The detection of podocyturia in these women could be useful for early diagnosis and follow-up of glomerular injury, eventually preeclampsia. It may be also associated to its severity or activity, although additional studies are necessary to confirm these aspects.

Lessons Learned from a Randomized Trial of Fixed and Escalating Contingency Management Schedules in Opioid-Dependent Pregnant Women

Background: Contingency management (CM) has shown promise for treating substance use disorders in pregnant women. Methods: A randomized clinical trial compared the relative efficacy of three conditions on the measures of opioid and cocaine abstinence and days retained in treatment. A total of 133 pregnant patients attending treatment for substance use disorders were randomized either to an escalating reinforcement condition, a fixed reinforcement condition, or an attendance control condition. Conditions were compared on drug abstinence rates and days retained in treatment. Results: As expected, the pooled escalating + fixed conditions received a greater total amount of voucher money than the control condition mean [M = 392.40 (SE = 40.47) vs. 219.74 (SE = 39.78)], respectively; p < .001. However, the escalating and fixed conditions did not differ on the outcome variables of drug abstinence and treatment retention. Conclusions: The CM conditions examined in the current study did not emerge as superior to the control condition. The lack of significant differences among study conditions may be attributed, in part, to study sample size. Additionally, methodological issues related to the CM intervention may also have compromised outcomes, including delay in reinforcement following the target behavior and limited contact with the reinforcer. Scientific Significance: This study highlights the importance of key CM implementation features, including immediate reinforcement, and adequate access to the reinforcer. It may also be that the reset feature for missing samples in CM interventions is an essential contingency for promoting behavior change.Trial registration: ClinicalTrials.gov identifier: NCT00497068.

Insulinoma diagnosed in the postpartum: clinical and immunohistochemical features

Insulinomas are rare pancreatic β-cell tumors with an estimated incidence of 1:250.000 persons/year. We present a novel case of insulinoma manifesting immediately after childbirth. Eight days after delivery, a 21-year-old, previously healthy woman presented paresthesia in hands, upper and lower limbs muscle weakness with difficult walking, which worsened during breastfeeding sessions. Laboratory tests showed blood glucose levels between 37 and 55 mg/dL with inappropriately normal insulin levels (7.78 μUI/mL; normal range: 5–29). An abdominal computed tomography showed a nodular lesion measuring 2 cm at the head of the pancreas. Tumor enucleation resulted in complete resolution of hypoglycemia. Histopathological and immunohistochemical analysis were consistent with an insulinoma. About 27 cases of insulinoma associated with pregnancy have been reported to date, mostly diagnosed before the 16th week. The beginning of symptoms soon after delivery is less common. Understanding the interactions between pancreatic β-cell function and all the physiological metabolic and hormonal adaptations associated with gestation is essential for the adequate management of hypoglycemic disorders in pregnant women.

Screening for thyroid dysfunction during pregnancy

Introduction: Thyroid disorders are among the common endocrine disorders in pregnant women. It is now well established that not only overt but subclinical thyroid dysfunction can also have adverse effects on fetal and maternal outcome. Maternal hypothyroidism during pregnancy raises serious concern about long-lasting psycho-neurologic consequences for the progeny, due to the risk of insuf-ficient placental transfer of maternal thyroid hormones to the developing fetus during the first half of gestation. To validate the need of antenatal screening for maternal thyroid dysfunction this study was undertaken to know the prevalence of thyroid dysfunction among pregnant women in Central India. Materials and Methods: In this ongoing study so far 73 patients in the first trimester of pregnancy have been recruited from Matru Seva Sangh Hospital. Detailed history and examination were done. Serum thyroid-stimulating hormone (TSH) estimation was done by the immunoradiometric assay method. Results: Out of 73 patients, 30 (41%) had TSH less than 2 mIU/ml, 35 out of 73 (47.95%) had TSH between 2 mIU/ml and 4 mIU/ml. The TSH value of more than or equal to 4 mIU/ml was seen in 8/73 (10.96%). Two patients also had gestational diabetes. TSH levels were more than 2 in both. Conclusions: Prevalence of hypothyroidism is more than 10%. As per recommendations all patients with TSH levels more than 2 should be evaluated for free T4 and thyroid antibody estimation. Screening for thyroid dysfunction should be done early in pregnancy. Looking at the high percentage of abnormal TSH in pregnancies, universal screening should be considered.