D. Luton

Management of Thyroid Dysfunction during Pregnancy and Postpartum: An Endocrine Society Clinical Practice Guideline

OBJECTIVE The aim was to update the guidelines for the management of thyroid dysfunction during pregnancy and postpartum published previously in 2007. A summary of changes between the 2007 and 2012 version is identified in the Supplemental Data (published on The Endocrine Societys Journals Online web site at http://jcem.endojournals.org). EVIDENCE This evidence-based guideline was developed according to the U.S. Preventive Service Task Force, grading items level A, B, C, D, or I, on the basis of the strength of evidence and magnitude of net benefit (benefits minus harms) as well as the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. CONSENSUS PROCESS The guideline was developed through a series of e-mails, conference calls, and one face-to-face meeting. An initial draft was prepared by the Task Force, with the help of a medical writer, and reviewed and commented on by members of The Endocrine Society, Asia and Oceania Thyroid Association, and the Latin American Thyroid Society. A second draft was reviewed and approved by The Endocrine Society Council. At each stage of review, the Task Force received written comments and incorporated substantive changes. CONCLUSIONS Practice guidelines are presented for diagnosis and treatment of patients with thyroid-related medical issues just before and during pregnancy and in the postpartum interval. These include evidence-based approaches to assessing the cause of the condition, treating it, and managing hypothyroidism, hyperthyroidism, gestational hyperthyroidism, thyroid autoimmunity, thyroid tumors, iodine nutrition, postpartum thyroiditis, and screening for thyroid disease. Indications and side effects of therapeutic agents used in treatment are also presented.

Use of ultrasound to distinguish between fetal hyperthyroidism and hypothyroidism on discovery of a goiter.

To determine whether sonography can be used to distinguish hyperthyroidism from hypothyroidism in pregnancies with fetal goiter.

Management of fetal thyroid goitres: a report of 11 cases in a single perinatal unit.

Fetal thyroid goitres may reveal hormonal imbalance. This can jeopardize neurological development and fetal outcome even when early postnatal treatment is provided. We report a series of 11 goitres diagnosed antenatally in women with past or present thyroid disorders or discovered fortuitously on ultrasound scan. Fetuses presented with hyperthyroidism in three cases and hypothyroidism in eight. Hypothyroidism was iatrogenic in five cases, due to maternal anti‐thyroid drugs. Hyperthyroidism was induced by transplacental transfer of thyroid stimulating antibodies (TSHrab). Accurate diagnosis of fetal thyroid status was obtained by fetal blood sampling but this invasive method was deemed necessary only in four cases as maternal clinical and biological data and ultrasound signs provided sufficient information to infer the type of thyroid disorder in the remaining patients. Fetal therapy relied on reduction of maternal antithyroid medication and, in selected cases, intra‐amniotic injection of levothyroxin in hypothyroidism, and on administration of antithyroid drugs in hyperthyroidism. All newborns were healthy and none displayed consequences of severe thyroid imbalance. No caesarean section was performed for dystocia. Fetal thyroid goitres can be managed successfully with selected use of invasive diagnostic and therapeutic techniques. Copyright

Pregnancy in women with known and treated Budd–Chiari syndrome: Maternal and fetal outcomes

BACKGROUND/AIMS Budd-Chiari syndrome (BCS) mainly affects women of childbearing age. We aimed to clarify whether pregnancy, a thrombotic risk factor, should be contraindicated in patients with known and treated BCS. METHODS A retrospective study of pregnancy in women with known and treated BCS. RESULTS Sixteen women had 24 pregnancies. Nine women had undergone surgical or radiological treatment. Anticoagulation was administered during 17 pregnancies. Seven fetuses were lost before gestation week 20. Deliveries occurred between week 20 and 31 in two patients, week 32 and 36 in eleven and after week 37 in four. There was one stillbirth, but 16 infants did well. Factor II gene mutation was a factor for a poor outcome of pregnancies. In two patients, symptomatic thrombosis recurred during pregnancy or postpartum. All patients were alive after a median follow-up of 34 months after the last delivery. Bleeding at delivery, although non-lethal, occurred only on anticoagulation therapy. CONCLUSIONS When known and treated BCS is well controlled, pregnancy should not be contraindicated as maternal outcome, and fetal outcome beyond gestation week 20, are good. The risk-benefit ratio of anticoagulant therapy needs to be further clarified. Patients should be fully informed of the persistent risks of such pregnancies.

Influence of Amnioinfusion in aModel of in utero Created Gastroschisi s in the Pregnant Ewe

Objective: Recent studies on the management of human fetal gastroschisis have produced two major findings: (1) there is an inflammatory response in the amniotic fluid of these fetuses, and (2) amniotic fluid exchange designed to disrupt the inflammatory loop seems to have a favorable impact on the immediate and late outcome of these early operated neonates. To test this hypothesis, we used serial amniotic fluid exchanges in a model of gastroschisis developed in the ewe. Methods: Gastroschisis was created at midgestation in 21 lamb fetuses by an in utero technique. Saline was amnioinfused in some fetuses every 10 days to term. Fetuses were sacrificed on day 145 by cesarean section. Extra-abdominal bowels with fibrous peel were processed for histologic examination. Comparisons were done between fetuses without gastroschisis (controls), fetuses with gastroschisis and amnioinfusion, and fetuses with gastroschisis without amnioinfusion. Results: Of 21 fetuses operated, 8 died in utero or were stillborn; 5 were not amnioinfused, and 8 underwent amnioinfusion. Thickness of bowel muscularis (μm) was 92.6 ± 20.2 for controls, 126.2 ± 21 for the amnioinfused fetuses, and 182.8 ± 58.3 for the nonamnioinfused fetuses (p = 0.001). The same significant results were obtained for thickness of serous fibrosis (p = 0.02) and plasma cell infiltration (p = 0.015). Conclusions: We have created a model of gastroschisis suitable for experimentation in the fetal sheep. Our amnioinfusion data in this model indicate a clear improvement of the deleterious process. This finding correlates well with recent data on amnioinfusion as a therapeutic approach to human gastroschisis.

Risk of synechiae following uterine compression sutures in the management of major postpartum haemorrhage

Please cite this paper as: Poujade O, Grossetti A, Mougel L, Ceccaldi P, Ducarme G, Luton D. Risk of synechiae following uterine compression sutures in the management of major postpartum haemorrhage. BJOG 2011;118:433–439.

Amniotic fluid inflammatory proteins and digestive compounds profile in fetuses with gastroschisis undergoing amnioexchange

Objective  In gastroschisis, an inflammatory process related to the presence of digestive compounds may be involved in intestinal damage. We measured the amniotic fluid concentrations of total protein, ferritin and amylase, lipase, γ‐glutamyl transferase and bile acids before each amnioexchange performed in women whose infants had gastroschisis. We estimated the correlation among total proteins, ferritin and digestive compounds and postnatal outcome.

Prognostic factors of prenatally diagnosed gastroschisis.

OBJECTIVE To evaluate the prognosis of prenatally diagnosed gastroschisis. STUDY DESIGN In a retrospective study, we analyzed the clinical and echographic data of gastroschisis. These data were correlated with fetal outcome including delivery, surgical procedure, follow-up in the neonatal intensive-case unit and in the gastropediatric unit. RESULT Twenty cases were analyzed. The overall survival rate was 85%. Classical criteria were analyzed (maximal bowel dilatation, thickening of bowel wall). Fetuses with both severe perivisceritis and meconium-stained amniotic fluid were born earlier than fetuses with mild perivisceritis and normal amniotic fluid (p < 0.01). CONCLUSION Our data suggest that an inflammatory response could follow bowel exposure to amniotic fluid. This response could lead to perivisceritis and premature birth. This hypothesis is currently under investigation.

Pregnancy outcomes among women with Marfan syndrome

To determine cardiac and obstetric outcomes among women with Marfan syndrome (MS) whose pregnancies were managed in accordance with the French national guidelines.

High Atopobium vaginae and Gardnerella vaginalis Vaginal Loads Are Associated With Preterm Birth

BACKGROUND Bacterial vaginosis is a risk factor for preterm birth. The various conventional methods for its diagnosis are laborious and not easily reproducible. Molecular quantification methods have been reported recently, but the specific risk factors they might identify remain unclear. METHODS A prospective multicenter national study included pregnant women at risk of preterm birth. A quantitative molecular tool using a specific real-time polymerase chain reaction assay and serial dilutions of a plasmid suspension quantified Atopobium vaginae, Gardnerella vaginalis, lactobacilli, Mycoplasma hominis, and the human albumin gene (for quality control). RESULTS In 813 pregnancies, high vaginal loads of either or both of A. vaginae and G. vaginalis were associated with preterm birth (hazard ratio [HR], 3.9; 95% confidence interval {CI}, 1.1-14.1; P = .031). A high vaginal load of A. vaginae was significantly associated with shortened time to delivery and therefore pregnancy length. These times were, respectively, 152.2 and 188.2 days (HR, 5.6; 95% CI, 1.5-21.3; P < .001) before 22 weeks, 149.0 and 183.2 days (HR, 2.8; 95% CI, 1.1-8.2; P = .048) before 28 weeks, and 132.6 and 170.4 days (HR, 2.2; 95% CI, 1.1-4.6; P = .033) before 32 weeks. After multivariate analysis, A. vaginae levels ≥10(8) copies/mL remained significantly associated with delivery before 22 weeks of gestation (adjusted HR, 4.7; 95% CI, .2-17.6; P = .014). CONCLUSIONS High vaginal loads of A. vaginae and G. vaginalis are associated with late miscarriage and prematurity in high-risk pregnancies. A high vaginal load of A. vaginae (DNA level ≥10(8) copies/mL) identifies a population at high risk of preterm birth. Further studies that both screen for and then treat A. vaginae are needed. CLINICAL TRIALS REGISTRATION NCT00484653.