世界経済・社会統計 = World development indicators

Multi-Organ, Multi-Lineage Engraftment by a Single Bone Marrow-Derived Stem Cell

Maternal mortality: who, when, where, and why

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1053/jhep.2000.9124

Liver from bone marrow in humans.

The comparison of the immunological state of pregnancy to an immunosuppressed host-graft model continues to lead research and clinical practice to ill-defined approaches. This Review discusses recent evidence that supports the idea that immunological responses at the receptive maternal-fetal interface are not simply suppressed but are instead highly dynamic. We discuss the crucial role of trophoblast cells in shaping not only the way in which immune cells respond to the invading blastocyst but also how they collectively react to external stimuli. We also discuss the role of the microbiota in promoting a tolerogenic maternal immune system and highlight how subclinical viral infections can disrupt this status quo, leading to pregnancy complications.

The unique immunological and microbial aspects of pregnancy

Background Pregnancies complicated by Rh alloimmunization have been evaluated with the use of serial invasive amniocentesis to determine bilirubin levels by measuring in the amniotic fluid the change in optical density at a wavelength of 450 nm (ΔOD450); however, this procedure carries risks. Noninvasive Doppler ultrasonographic measurement of the peak velocity of systolic blood flow in the middle cerebral artery also predicts severe fetal anemia, but this test has not been rigorously evaluated in comparison with amniotic-fluid ΔOD450. Methods We performed a prospective, international, multicenter study including women with RhD-, Rhc-, RhE-, or Fya-alloimmunized pregnancies with indirect antiglobulin titers of at least 1:64 and antigen-positive fetuses to assess whether Doppler ultrasonographic measurement of the peak systolic velocity of blood flow in the middle cerebral artery was at least as sensitive and accurate as measurement of amniotic-fluid ΔOD450 for diagnosing severe fetal anemia. The results o...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa052855

Doppler Ultrasonography versus Amniocentesis to Predict Fetal Anemia

Background and Objectives Intracranial haemorrhage (ICH) of the fetus or newborn is a severe complication of fetal or neonatal alloimmune thrombocytopenia (FNAIT). In order to attain management decisions to prevent ICH, the risk of ICH in successive pregnancies with thrombocytopenia, with or without a history of ICH, must be established.



Materials and Methods We performed a search of medline for ICH cases in untreated FNAIT pregnancies. After exclusion of cases with confounding factors, 24 reports, describing 62 pregnancies of 27 mothers, were eligible. In addition, two mothers with five pregnancies were included from our own case records. Observational studies were examined to estimate the risk of ICH in subsequent FNAIT pregnancies without a history of ICH. Finally, medline was searched for complication rates in the treatment of FNAIT pregnancies.



Results In 52% of the ICH cases, a previous sibling suffered from ICH. The recurrence rate of ICH in the subsequent offspring of women with a history of FNAIT with ICH was 72%[confidence interval (CI): 46–98%] without inclusion of fetal deaths and 79% (CI: 61–97%) with inclusion of fetal deaths. In 48% of the ICH cases, the previous sibling had thrombocytopenia but not ICH. Population studies revealed an overall ICH risk in thrombocytopenic infants of 11% (CI: 0·8–23%) without inclusion of fetal deaths and 15% (CI: 1·5–19%) with inclusion of fetal deaths. Assuming occurrence in 48%, the risk of ICH in a subsequent pregnancy following a history of FNAIT without ICH, was estimated to be 7% (CI: 0·5–13%). Invasive treatment strategies carry a risk of 2·8% (CI: 1·2–4·4%) on complications.



Conclusions The number of eligible publications on ICH in untreated FNAIT pregnancies is strikingly limited. The recurrence rate is high. As sufficient data on successive FNAIT cases without ICH are lacking, the occurrence of ICH in pregnancies with thrombocytopenia, but without ICH in a previous sibling, cannot be predicted. We estimate this risk to be 7%. This risk must be balanced against the risk of interventions in treatment strategies.

Will it ever be possible to balance the risk of intracranial haemorrhage in fetal or neonatal alloimmune thrombocytopenia against the risk of treatment strategies to prevent it

Comparison of Macrophage Phenotype Between Decidua Basalis and Decidua Parietalis by Flow Cytometry

Objectives

To assess the value of serial ultrasound examinations together with patient instructions to report the onset of symptoms in achieving timely detection of twin-to-twin transfusion syndrome (TTTS) in a cohort of monochorionic diamniotic twin pregnancies, and to evaluate sonographic TTTS predictors.



Methods

Timely detection of TTTS was defined as diagnosis before severe complications of TTTS occurred, such as preterm prelabor rupture of membranes, very preterm delivery (24–32 weeks of pregnancy), fetal hydrops, or intrauterine fetal death. During a 2-year period, a prospective series of 23 monochorionic twin pregnancies was monitored from the first trimester until delivery. At least every 2 weeks we performed ultrasound and Doppler measurements (nuchal translucency thickness, presence of membrane folding, estimated fetal weight, deepest vertical pocket, bladder filling, and Doppler waveforms of the umbilical artery, ductus venosus and umbilical vein). Measurements of TTTS cases were compared with those of non-TTTS cases matched for gestational age. Furthermore, patients were informed about the symptoms caused by TTTS, and instructed to consult us immediately in case of rapidly increasing abdominal size or premature contractions.



Results

In all four TTTS cases, the diagnosis was timely. At the time of diagnosis, one case was at Quintero Stage 1, two at Quintero Stage 2, and one at Quintero Stage 3. Two of the TTTS cases became apparent after the patients' feeling of rapidly increasing girth. The identification of TTTS predictors was successful with respect to one parameter: isolated polyhydramnios in one sac, without oligohydramnios in the other, preceded the ultimate diagnosis of TTTS in two of the four TTTS cases. All other ultrasound measurements of TTTS cases, prior to the diagnosis of TTTS, were within the range of measurements of non-TTTS cases.



Conclusion

Biweekly ultrasound examinations, with special attention to the amniotic fluid compartments of both fetuses, combined with detailed patient instructions to report the onset of symptoms resulted in timely diagnosis of all TTTS cases and appears to be a safe program for monitoring monochorionic twin pregnancies. Copyright © 2006 ISUOG. Published by John Wiley & Sons, Ltd.

https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1002/uog.3819

Timely diagnosis of twin-to-twin transfusion syndrome in monochorionic twin pregnancies by biweekly sonography combined with patient instruction to report onset of symptoms

Objectives
To study the feelings of parents during and after termination of pregnancy (TOP) for fetal anomalies.

Methods
Semi-structured interviews were conducted before TOP, after six weeks and six months after TOP. The study group consisted of 89 couples, treated at our institution between 1994 and 1998, who terminated their pregnancy in the second and third trimester. Eighty-six of them participated in at least one of the three interviews.

Results
Most parents were able to cope with the decisions they had to make, although a struggle between reason and emotion often occurred. Seeing the dead baby and saying farewell gave all parents a good feeling afterward. Feelings such as doubt, guilt, failure, shame, anger, anxiety and relief were experienced during the period of TOP and the following weeks but practically disappeared after six months; these feelings were more prevalent in women. Most of the couples mentioned that their relationship grew closer as a result of the loss and the grief. Relatives offered good support to most parents in the first weeks after delivery, but parents felt that this support lasted too short a time.

Conclusions
Seeing the child and saying farewell and the medical and psychosocial support received from professional caregivers were of great value for the interviewees. Parents found the interviews helpful in the grieving process. Copyright © 2003 John Wiley & Sons, Ltd.

H. H. H. Kanhai

Papers

Doppler Ultrasonography versus Amniocentesis to Predict Fetal Anemia

Will it ever be possible to balance the risk of intracranial haemorrhage in fetal or neonatal alloimmune thrombocytopenia against the risk of treatment strategies to prevent it

Comparison of Macrophage Phenotype Between Decidua Basalis and Decidua Parietalis by Flow Cytometry

Timely diagnosis of twin-to-twin transfusion syndrome in monochorionic twin pregnancies by biweekly sonography combined with patient instruction to report onset of symptoms

Coping with termination of pregnancy for fetal abnormality in a supportive environment.