Practice Patterns Surrounding Pregnancy After Heart Transplantation.
- 作者列表："DeFilippis EM","Haythe J","Farr MA","Kobashigawa J","Kittleson MM
BACKGROUND:Pregnancy after heart transplantation (HT) is a concern for many female recipients. The International Society for Heart and Lung Transplantation has guidelines regarding reproductive health, but limited data exist regarding providers' attitudes and practices surrounding pregnancy post-HT. METHODS:We conducted an independent, confidential, voluntary, web-based survey sent electronically to 1643 United States heart transplant providers between June and August 2019. RESULTS:There were 122 responses, the majority from cardiologists (n=85, 70%) and nurse or transplant coordinators (n=22, 18%). Thirty-one percent (n=37) of respondents indicated that pregnancy should be avoided in all HT recipients, and only 43% (n=52) reported that their center had a formal policy regarding pregnancy following HT. The most commonly reported contraindications included nonadherence (n=109, 89%), reduced left ventricular ejection fraction (n=104, 85%), coronary allograft vasculopathy (n=86, 70%), prior rejection (n=76, 62%), presence of donor-specific antibodies (n=69, 57%), and prior peripartum cardiomyopathy pretransplant (n=57, 47%). Respondent sex, specialty, transplant volume, or prior experience with pregnancy after HT were not associated with recommendations to avoid posttransplant pregnancy. CONCLUSIONS:Transplant providers' attitudes regarding posttransplant pregnancy vary widely. Despite International Society for Heart and Lung Transplantation guidelines, a significant proportion indicates that pregnancy is contraindicated in all recipients and the majority of programs have no center-specific policy to manage such pregnancies. While the low response rate limits the generalizability of the findings, they do suggest that education on the feasibility of pregnancy post-HT is indicated as many recipients are of, or survive to, childbearing age.
背景: 心脏移植 (HT) 后妊娠是许多女性受者关注的问题。国际心肺移植学会有关于生殖健康的指南，但关于提供者对 HT 后妊娠的态度和做法的数据有限。 方法: 我们在 6月至 2019年8月期间进行了一项独立、保密、自愿、基于网络的调查，以电子方式发送给 1643 名美国心脏移植提供者。 结果: 共有 122 例应答，大多数来自心脏病专家 (n = 85，70%) 和护士或移植协调员 (n = 22，18%)。31% (n = 37) 的受访者表示所有 HT 受者都应避免怀孕，只有 43% (n = 52) 报告说，他们的中心有关于 HT 后妊娠的正式政策。最常报告的禁忌症包括不依从 (n = 109，89%)，左心室射血分数降低 (n = 104，85%)，冠状动脉移植血管病变 (n = 86，70%),既往排斥反应 (n = 76，62%) 、存在供体特异性抗体 (n = 69，57%) 和既往移植前围产期心肌病 (n = 57，47%)。应答者的性别、专业、移植体积或既往 HT 后妊娠经验与避免移植后妊娠的建议无关。 结论: 移植提供者对移植后妊娠的态度差异很大。尽管有国际心肺移植学会的指南，但很大一部分表明所有受者都禁忌怀孕，大多数项目没有专门的中心政策来管理这种怀孕。虽然低反应率限制了研究结果的普遍性，但他们确实表明，关于 HT 后妊娠可行性的教育是指许多受者处于或存活到生育年龄。
METHODS::Maternal lifestyle affects both mother health and pregnancy outcome in humans. Several studies have demonstrated that interventions oriented towards reducing stress and anxiety have positive effects on pregnancy complications such as preeclampsia, excessive gestational weight, gestational diabetes and preterm birth. In this work, we showed that the environmental enrichment (EE), defined as a noninvasive and biological significant stimulus of the sensory pathway combined with voluntary physical activity, prevented preterm birth (PTB) rate in a 41% in an inflammatory mouse model induced by the systemic administration of bacterial lipopolysaccharide (LPS). Furthermore, we found that EE modulates maternal metabolism and produces an anti-inflammatory environment that contributes to pregnancy maintenance. In pregnant mice uterus, EE reduces the expression of TLR4 and CD14 (the LPS receptor and its coactivator protein), preventing the LPS-induced increase in PGE2 and PGF2α release and nitric oxide synthase (NOS) activity. In cervical tissue, EE inhibits cervical ripening events, such as PGE2 release, matrix metalloproteinase (MMP)-9 increased activity and neutrophil recruitment, therefore conserving cervical function. It seems that EE exposure could mimic the stress and anxiety-reducing techniques mentioned above, explaining, at least partially, the beneficial effects of having a healthy lifestyle before and during gestation. Furthermore, we propose that designing an EE protocol for humans could be a noninvasive and preventive therapy for pregnancy complications, averting pre-term birth occurrence and dreaded sequelae that are present in the offspring born to soon.
METHODS:PROBLEM:We aimed to investigate the main causes of recurrent miscarriage (RM) in patients with losses after spontaneous gestation (SG) and after in vitro fertilization (IVF). METHOD OF STUDY:A prospective case-control study was conducted. The eligible patients were women who had experienced two or more consecutive abortions after less than 12 weeks gestation, two consecutive losses after SG or two consecutive losses after IVF. All patients were subjected to the following evaluations: karyotyping of the aborted material, alloimmune and autoimmune marker testing, and acquired and hereditary thrombophilia marker testing. RESULTS:In total, 58 patients were eligible: 32 patients with RM after SG and 26 patients with RM after IVF. The factors associated with RM were genetic (29%), immune (14%), thrombophilic (21%), and thrombophilic and immune (24%), and only 12% of the cases were idiopathic. Comparing the two study groups (SG and IVF), all studied factors were similar, except for a higher ANA positivity observed in the SG group (SG 30.4% versus IVF 5.3%, OR 8.6 (CI 1.1 - 21.1, P 0.048). CONCLUSIONS:Our study identified the possibly factors associated with recurrent miscarriage in 86% of the cases, and these factors appear to be similar in patients with recurrent miscarriage after spontaneous gestation and IVF. This study demonstrates that IVF with PGT-A with euploid embryo transfer could reduce abortions by up to 29%, but other factors needs to be investigated even in patients undergoing in vitro fertilization.
METHODS:OBJECTIVES:To evaluate the impact of pre-operative Music Therapy (MT) on pain in first-trimester abortion under local anaesthesia (ALA). DESIGN:Randomised controlled trial comparing patients undergoing a first-trimester ALA with or without a pre-operative MT session. SETTING:University hospital of Angers from November 2016 to August 2017. POPULATION:Patients who underwent first-trimester abortion under ALA. METHODS:Patients allocated to MT group underwent a pre-operative 20 minutes session of MT. MAIN OUTCOME MEASURES:Pain was assessed using a visual analogue scale (VAS) just before the procedure, during the procedure, at the end of the procedure and upon returning to the ward. RESULTS:159 patients were randomised (80 in MT group, and 79 in the control group). 2 patients were excluded from the control group and 6 from the MT group. Therefore, 77 patients were analysed in the control group and 74 in the MT group. The intensity of pain were similar in both the MT group and the Control group just before the procedure (VAS: 4.0±2.9 vs. 3.6±2.5, p=0.78), during the procedure (VAS: 5.3±2.5 vs. 4.9±2.9, p=0.78), at the end of the procedure (VAS: 2.7±2.4 vs. 2.6±2.4, p=0.43) and upon returning to the ward (VAS:1.8±2.0 vs. 1.5±2.0, p=0.84). The difference in pain between entering the department and returning to the room after the procedure was similar between the MT and Control groups (0.3±2.5 vs. 0.3±2.4 VAS levels difference; p=0.92). CONCLUSION:Music therapy session before an ALA procedure resulted in no improvement in patient perception of pain during a first-trimester abortion.