[Acute fatty liver in pregnancy]

This case report of a 31-year-old primiparous woman discusses the importance of early diagnosis and treatment of acute fatty liver in pregnancy (AFLP) to prevent maternal or/and foetal death. AFLP is a rare disease, which is characterised by maternal liver dysfunction and/or failure. Because of similar symptoms and laboratory findings AFLP may mimic and is often mistaken for 1) the more frequent HELLP syndrome with haemolysis, elevated liver enzymes and low platelet levels and 2) and severe pre-eclampsia.

Importance of Individual Elements for Perineal Protection in Childbirth: An Interventional, Prospective Trial

Objective  To analyze the association between each element of a hands-on intervention in childbirth and the incidence of obstetric anal sphincter injuries (OASIS). Study Design  We conducted a prospective, interventional quality improvement project and implemented a care bundle with five elements at an obstetric department in Denmark with 3,000 deliveries annually. We aimed at reducing the incidence of OASIS. In the preintervention period, 355 vaginally delivering nulliparous women were included. Similarly, 1,622 nulliparous women were included in the intervention period. The association of each element with the outcome was estimated using a regression analysis. Results  The incidence of OASIS went down from 7.0 to 3.4% among nulliparous women delivering vaginally ( p  = 0.003; relative risk = 0.48; 95% confidence interval [CI]: 0.30-0.76). Number needed to treat was 28. Logistic regression analysis showed that using hand on the head of the child significantly reduced the risk of OASIS (odds ratio = 0.28; 95% CI: 0.14-0.58). Conclusion  Using a quality improvement framework, we documented the individual elements of the intervention. Hand on the infant's head reduced the risk of OASIS.

[Sinus tachycardia in pregnancy]

Sinus tachycardia may have a definite aetiology, but in the remaining cases inappropriate sinus tachycardia (IST) may be considered. IST is primarily treated in order to improve symptoms. During pregnancy, tachycardia-induced cardiomyopathy is rare; however, it needs urgent attention and treatment due to the risk of fast progression. In Denmark, performing an electrocardiogram is recommended in any pregnant woman, who has palpitations or a persisting heart rate > 100 beats per minute.

[Use of acupuncture for labour augmentation]

INTRODUCTION

In Denmark, 45% of all primiparas and 12% of multiparas with uneventful pregnancies are augmented in order to treat dystocia. Augmentation using oxytocin is associated with uterine hyperstimulation, uterine rupture and foetal death. Currently, no studies show that acupuncture is effective for augmentation.

MATERIAL AND METHODS

A single-blinded randomized controlled trial with women diagnosed with dystocia. In the acupuncture group, the women had acupuncture in SP6, KI3, KI6, BL60, LI4 and acupressure on BL67. The control group received no treatment. The primary outcome was progression in cervical dilatation within two hours. The secondary outcomes were length of labour, length of second stage, use of augmentation, use of analgesia, caesarean section rate and number of instrumental deliveries.

RESULTS

A total of 84 women were randomised. There was no significant difference between the groups with regard to dilatation from randomization to effect assessment (p = 0.54). In the acupuncture group, the mean difference was 1.3 cm (0.69-1.91). In the control group, the mean difference was 1.56 (0.6-2.52). 27% of the women with dystocia delivered spontaneously without augmentation. No major side effects of acupuncture treatment were reported.

CONCLUSION

This study showed no effect of acupuncture treatment for primary or secondary inertia.

[A survey of research funding at Danish regional hospitals]

INTRODUCTION

According to recently passed Danish legislation, all Danish hospitals are obliged to take part in scientific research. As data on financial support for research activities are lacking, we assessed the resources allocated to research from the budget of the central hospital management as a percentage of the total budget at Danish regional hospitals in 2007.

MATERIAL AND METHODS

A postal survey was conducted at 13 hospitals in the Western part of Denmark. The questionnaire comprised items in the following major categories: 1) budget allocated specifically for research and travel grants; 2) employment of scientific and technical support staff; 3) facilities and equipment for research; and 4) research dissemination.

RESULTS

Questionnaires were returned from 11 hospitals. Six hospitals reported to have dedicated fixed amounts on the budget for research, exact figures were reported in four cases only equivalent to 0.1%, 0.3%, 0.3% and 0.6% of the total budget. Most hospitals had associate professors, but only five had full professors. Seven hospitals supplied laboratories and technical facilities, eight hospitals held staff-meetings on a regular basis and four published an annual report on research activities.

CONCLUSION

In the majority of regional hospitals in Western Denmark, less than 0.3% of the total budget administered by the central hospital management was allocated specifically for research. These figures, however, may not be accurate as individual departments may allocate additional resources from local budgets. We recommend that regional hospitals define research strategies and allocate the necessary funding in their budgets.

[Uterine rupture in a primigravid woman at 31st gestational week]

Spontaneous uterine rupture is a very rare obstetric complication. This case report describes spontaneous uterine rupture in a healthy 28-year-old primigravid woman at the 31st gestational week. The woman was hospitalized due to contractions, which eased after rest. Later she had acute abdominal pain followed by an abnormal cardiotocography. An acute caesarean section was performed and a longitudinal posterior uterine wall rupture found. She had no known risk factors explaining the rupture.

Glomerular structural changes in pregnant, diabetic, and pregnant-diabetic rats

Kidneys enlarge both during pregnancy and in diabetes. The enlargement and morphology of glomeruli was studied during pregnancy and in diabetes in order to examine possible similarities, differences, and interactions in the growth in these conditions. Morphometric investigations were performed on glomeruli in pregnant rats, in rats with 2 weeks' diabetes, and in pregnant-diabetic rats. Kidneys were enlarged 22% in the midterm pregnant rats compared with controls, 74% in diabetic rats, and a further 21% in pregnant-diabetic rats. Glomerular volume was enlarged by 26% during midterm pregnancy in normal animals. Diabetes induced an enlargement in glomerular volume of 58% and a further 18% in midterm diabetic animals due to pregnancy. Within the glomerulus, pregnancy in normal animals induced minor non-significant changes. Diabetes induced significant increase in several parameters: mesangial volume and cell volume, capillary and glomerular basement membrane volume, capillary wall surface area, foot process width, filtration slit length, and nuclear number. Pregnancy in diabetic animals induced no significant additional changes. In conclusion, kidney enlargement in pregnancy shows very few glomerular changes in either normal or diabetic animals. Enlargement of glomeruli in diabetes involves hypertrophy and hyperplasia concurrent with several morphological changes within the glomerulus.

Placental growth hormone during pregnancy in a growth hormone deficient woman with type 1 diabetes compared to a matching diabetic control group

In pregnancy, pituitary growth hormone (GH) is gradually replaced by placental growth hormone (hPGH). GH deficient pregnant women may take advantage of GH substitution during pregnancy, but this issue still remains unresolved. Also, in pregnancy diabetes may cause macrosomia. The combination of GH deficiency, GH substitution therapy and type 1 diabetes mellitus may influence pregnancy in unforeseen ways. We present a case of pregnancy in a GH deficient woman with type 1 diabetes who continued on GH replacement until week 21. In gestational week 37 a thin and mildly small-for gestational-age (length 55 cm, +3 SD, 99th centile and weight 2445 g., -1.4 SD, 10th centile) but otherwise healthy boy was born. The patient had levels of serum hPGH at the lower end of the range of values found in a matching group of diabetic women. Serum IGF-I levels were at the upper end of the range of values in the control group. A positive correlation between serum hPGH and IGF-I values was seen in the control group when using the area-under-the-curve (r=0.84; p<0.001). The patient's child had lower birth weight and ponderal index, but was otherwise healthy. Serum IGF-I, but not hPGH, correlated to the absolute birth weight (r=0.63; p=0.015) and the birth weight z-score (r=0.55; p=0.039) in the control group. Serum hPGH and IGF-I declined rapidly after delivery. In conclusion, hPGH correlated to IGF-I in type 1 diabetes mellitus (DM), and IGF-I values correlated to the birth weight. Both type 1 diabetes mellitus and GH deficiency (with GH substitution therapy) may influence fetal growth, and in combination, the net influence may be difficult to predict.

Human placental growth hormone, insulin-like growth factor I and -II, and insulin requirements during pregnancy in type 1 diabetes

Human placental GH (hPGH) replaces pituitary GH during pregnancy. hPGH is correlated to serum IGF-I in normal pregnancies and in pregnancies complicated by fetoplacental disorders. In gestational diabetes and type 2 diabetes no correlation between hPGH and IGF-I has been found. The relationship between hPGH and IGF-I in type 1 diabetes mellitus has not been investigated thoroughly. Furthermore, hPGH may be involved in the development of insulin resistance during pregnancy. In this prospective, longitudinal study, 51 type 1 diabetic subjects were followed with repeated blood sampling during pregnancy (median, 14 blood samples/subject; range, 8-26). Maternal concentrations of serum hPGH, IGF-I, and IGF-II were measured and compared with insulin requirements and birth characteristics. hPGH was detected from as early as 6 wk gestation. In all subjects, a rise in serum hPGH was observed during pregnancy, and the rise between wk 16 and 25 was correlated to the rise between wk 26 and 35 (P < 0.001). From wk 26 onward, the increase in hPGH values was significantly correlated to the birth weight, expressed as a z-score (r(s) = 0.54; P < 0.001), as were the absolute hPGH values. Also, a positive influence of hPGH on placental weight was found. Serum IGF-I values decreased significantly from the first to the second trimester (P </= 0.021). Serum hPGH correlated to serum IGF-I from wk 24-35, and changes in IGF-I followed the increase in hPGH between wk 26 and 35 (r(s) = 0.53; P < 0.001), as did IGF-II (r(s) = 0.37; P = 0.008). Changes in IGF-I and IGF-II between wk 26 and 35 also correlated to the birth weight z-score (P </= 0.020), but only hPGH remained significant in multiple regression analysis. Similar results were found in the subgroup delivering at term. Interestingly, the increase in hPGH was not correlated to the increase in insulin requirements, nor was any consistent relationship revealed during each gestational period. In conclusion, our study suggests a role for hPGH in the regulation of both IGFs and fetal growth in type 1 diabetes. In contrast, the increase in insulin requirements during pregnancy in type 1 diabetic subjects could not be related to hPGH levels.

Human placental growth hormone, insulin-like growth factor I and -II, and insulin requirements during pregnancy in type 1 diabetes

Human placental GH (hPGH) replaces pituitary GH during pregnancy. hPGH is correlated to serum IGF-I in normal pregnancies and in pregnancies complicated by fetoplacental disorders. In gestational diabetes and type 2 diabetes no correlation between hPGH and IGF-I has been found. The relationship between hPGH and IGF-I in type 1 diabetes mellitus has not been investigated thoroughly. Furthermore, hPGH may be involved in the development of insulin resistance during pregnancy. In this prospective, longitudinal study, 51 type 1 diabetic subjects were followed with repeated blood sampling during pregnancy (median, 14 blood samples/subject; range, 8-26). Maternal concentrations of serum hPGH, IGF-I, and IGF-II were measured and compared with insulin requirements and birth characteristics. hPGH was detected from as early as 6 wk gestation. In all subjects, a rise in serum hPGH was observed during pregnancy, and the rise between wk 16 and 25 was correlated to the rise between wk 26 and 35 (P < 0.001). From wk 26 onward, the increase in hPGH values was significantly correlated to the birth weight, expressed as a z-score (r(s) = 0.54; P < 0.001), as were the absolute hPGH values. Also, a positive influence of hPGH on placental weight was found. Serum IGF-I values decreased significantly from the first to the second trimester (P < or = 0.021). Serum hPGH correlated to serum IGF-I from wk 24- 35, and changes in IGF-I followed the increase in hPGH between wk 26-35 (r(s) = 0.53; P < 0.001), as did IGF-II (r(s) = 0.37; P = 0.008). Changes in IGF-I and IGF-II between wk 26-35 also correlated to the birth weight z-score (P < or = 0.020), but only hPGH remained significant in multiple regression analysis. Similar results were found in the subgroup delivering at term. Interestingly, the increase in hPGH was not correlated to the increase in insulin requirements, nor was any consistent relationship revealed during each gestational period. In conclusion, our study suggests a role for hPGH in the regulation of both IGFs and fetal growth in type 1 diabetes. In contrast, the increase in insulin requirements during pregnancy in type 1 diabetic subjects could not be related to hPGH levels.

Diabetic retinopathy in pregnancy during tight metabolic control

BACKGROUND

The relation between retinopathy and the parameters: 24-h blood pressure, glucose control, albuminuria, and outcome of pregnancy was studied before, during, and after pregnancy in women with insulin-dependent diabetes mellitus on tight metabolic control during pregnancy.

METHODS

Prospective study of 112 pregnant women with insulin-dependent diabetes mellitus followed with fundus photography at the Department of Ophthalmology, Arhus University Hospital. Changes in retinopathy were related to 24-h blood pressure, blood glucose, albuminuria, and adverse perinatal outcome.

RESULTS

There was an association between grade of retinopathy and HbAlc before (Spearman's rho=0.49, p<0.04) and after pregnancy (Spearman's rho=0.42, p<0.02), but no such correlation was found at any examination during pregnancy where glycemia was kept tight. Those women who had progression of retinopathy during or after pregnancy had significantly earlier onset of diabetes mellitus (14+/-8 years, range 1-27) than those women with improvement or no progression of retinopathy (19+/-8 years, range 1-36, p<0.04). No association was found between progression of retinopathy and HbA1c, blood pressure, adverse perinatal outcome or any of the other variables studied.

CONCLUSIONS

Tight glycemic control during pregnancy is recommendable to avoid progression of retinopathy. Attention should be given to the period after delivery where the tight regulation may be difficult to achieve. IDDM women should be encouraged to plan pregnancies early in life.

The rôle of ultrasound scan in childhood ovarian tumors

Seven cases with childhood ovarian tumors are presented. All underwent an ultrasound scan which gave the the preliminary diagnosis of ovarian tumor. Treatment differs according to the status of the child and whether malignity is involved. The numerous differential diagnoses must be kept in mind. The management of children with an unexplained abdominal mass should include an ultrasound scan.

[Serum estradiol as a marker in recurrent granulosa-theca-cell tumor]

A case of a granulosa-theca-cell tumour of the ovary in a 39-year-old woman is reported. Despite benign histology and apparently radical operation, tumor growth relapsed twice before apparent cure. Oestradiol in serum proves valuable as a tumour marker and correlates well with tumour relapse.