Factors related to deterioration of renal function after singleton delivery in pregnant women with chronic kidney disease.

OBJECTIVE: This study is designed to evaluate which factors would relate to deterioration of renal function (DRF) after delivery in pregnant women with chronic kidney disease (CKD). MATERIALS AND METHODS: This study included 156 singleton pregnancies of 139 women with CKD at our institution from 2001 to 2010. DRF was defined as the shift of CKD stage into another more severe stage. The relevant variables were compared between women who had DRF (n = 39) and the controls (n = 117). RESULTS: The number of transplantation or dialysis cases after delivery was 5.8%. DRF occurred in 25% of the study patients. From a logistic regression model, the factors that influence DRF were the presence of glomerulonephritis [odds ratio (OR) 3.56, 95% confidence interval (CI) 1.18-10.81], significant proteinuria prior to pregnancy (≥3 g/d or 3+ more dipstick; OR 3.43, 95% CI 1.14-10.33), and treatment with antiplatelet agents (OR 0.30, 95% CI 0.09-0.94). Receiver-operating characteristic curve analysis confirmed that the estimated glomerular filtration rate (eGFR) of 75 mL/min/1.73 m(2) or more before conception is not a risk factor for DRF after delivery (negative predictive value 0.788). CONCLUSION: This was the first report to reveal a clear cutoff value regarding DRF in pregnant woman with CKD. There is an almost 78% risk of developing DRF after delivery in patients showing eGFR of 75 mL/min/1.73 m(2) or more before conception.

Guidelines for obstetrical practice in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2014 edition.

The 'Clinical Guidelines for Obstetrical Practice, 2011 edition' were revised and published as a 2014 edition (in Japanese) in April 2014 by the Japan Society of Obstetrics and Gynecology and the Japan Association of Obstetricians and Gynecologists. The aims of this publication include the determination of current standard care practices for pregnant women in Japan, the widespread use of standard care practices, the enhancement of safety in obstetrical practice, the reduction of burdens associated with medico-legal and medico-economical problems, and a better understanding between pregnant women and maternity-service providers. The number of Clinical Questions and Answers items increased from 87 in the 2011 edition to 104 in the 2014 edition. The Japanese 2014 version included a Discussion, a List of References, and some Tables and Figures following the Answers to the 104 Clinical Questions; these additional sections covered common problems and questions encountered in obstetrical practice, helping Japanese readers to achieve a comprehensive understanding. Each answer with a recommendation level of A, B or C was prepared based principally on 'evidence' or a consensus among Japanese obstetricians in situations where 'evidence' was weak or lacking. Answers with a recommendation level of A or B represent current standard care practices in Japan. All 104 Clinical Questions and Answers items, with the omission of the Discussion, List of References, and Tables and Figures, are presented herein to promote a better understanding among English readers of the current standard care practices for pregnant women in Japan.

Regulation of ghrelin secretion during pregnancy and lactation in the rat: possible involvement of hypothalamus.

We investigated the plasma concentration of ghrelin peptide during pregnancy and lactation in rats. Plasma ghrelin levels on days 10 and 15 of pregnancy were significantly lower than those of the non-pregnant rats. Thereafter, the plasma ghrelin levels on day 20 of pregnancy sharply increased to levels comparable with those in non-pregnant rats. Ghrelin peptide concentrations in the stomach did not change significantly during pregnancy. In the hypothalamus, ghrelin mRNA levels were significantly lower on day 15 of pregnancy than in the non-pregnant rats. Also, plasma ghrelin levels were significantly lower in lactating dams than non-lactating controls on days 3 and 8 of lactation. We examined the possible involvement of prolactin and oxytocin in the regulation of plasma ghrelin concentrations during lactation. Although plasma prolactin levels were decreased by the administration of bromocriptine, plasma ghrelin levels did not differ significantly between vehicle- and drug-treated lactating rats. Administration of haloperidol produced a marked increase in plasma prolactin levels as compared with the non-lactating controls. However, plasma ghrelin levels were not significantly different between vehicle- and drug-treated rats. Administration of an oxytocin antagonist into the lateral ventricle significantly inhibited the increase in the plasma oxytocin level induced by acute suckling. However, plasma ghrelin levels did not significantly between the groups. These observations indicated that the decrease in serum ghrelin is caused by a loss of the contribution of hypothalamic ghrelin. Furthermore, the present results suggested that the suckling stimulus itself, but the release of prolactin or oxytocin, is the factor most likely to be responsible for the suppression of ghrelin secretion during lactation.

Decreased mature adrenomedullin levels in feto-maternal tissues of pregnant women with histologic chorioamnionitis.

Adrenomedullin (AM) gains its bioactivity by amidation at its C-terminal, forming "mature AM." The mature AM and the expression of AM receptor component mRNAs, receptor activity-modifying protein 2 and calcitonin receptor-like receptor, from feto-maternal tissues of normal pregnant women and women with histologic chorioamnionitis were examined to clarify the pathophysiological features of this intrauterine infection. Samples of the placenta and fetal membranes were obtained from 10 normal pregnant women and eight women with histologic chorioamnionitis under informed consent. Mature AM in the fetal membranes was significantly lower in patients with chorioamnionitis than in normal pregnant women. On the other hand, there were no differences in mature AM levels in the placenta between the two groups. The total AM levels as a sum of mature and immature AM were not significantly different between the two groups in either area. The ratio of mature AM/total AM was significantly decreased in the fetal membranes of the patients with chorioamnionitis compared with normal pregnancies, but not in the placenta. Also, levels of mature AM were negatively correlated with C-reactive protein concentrations. The present results thus suggested that mature AM may have some role in chorioamnionitis.

Pregnancy complicated with pure red cell aplasia: a case report.

A 31-year-old Japanese pregnant woman had no remarkable previous medical and family histories except for artificial abortion in 1993. A full-term normal infant was subsequently delivered in 1998. In this pregnancy, she began to experience general fatigability with a hemoglobin concentration of 8.5 g/dl at 19 weeks of gestation. Although she had been treated with intravenous iron, the hemoglobin decreased to 6.0 g/dl. She was referred to our hospital at 34 weeks of gestation. The laboratory data were as follows on this admission; hemoglobin 5.1 g/dl, RBC 128 x 10(4)/l, reticulocytes 1.1%, WBC 7.1 x 10(9)/l, platelet count 229 x 10(9)/l, folic acid 5.6 ng/ml, serum vitamin B12 200 pg/ml, ferritin 184 ng/ml, parvovirus B19 (-). A bone marrow aspiration revealed normal granulopoiesis and megakaryocytes, but almost complete absence of erythropoietic precursors. A diagnosis of pure red cell aplasia was made due to these findings. Treatment with prednisone (50 mg/day) and blood transfusion was started before delivery. She was delivered transvaginally at 37 weeks of gestation. The neonate was a normal female infant without anemia (hemoglobin 17.9 g/dl) and the 1 minute Apgar score was 8. Her hemoglobin level rose to 12.1 g/dl spontaneously two weeks after delivery.

[Adrenomedullin in pregnancy].

In this study, we used the animal model of preeclampsia. The blood pressure in animals receiving L-NAME at 25 mg/day were significantly higher compared to that of rats receiving saline solution only. In addition, L-NAME treated rats showed a high fetal mortality as compared with intact rats. Also, we demonstrated infusion of AM reverse the hypertension and decrease in pup mortality induced by L-NAME during pregnancy. We showed that the AM mRNA levels predominantly exists in a high level in the placenta, uterus and ovary as compared with other tissues. These evidences suggest that AM may have a possible important role during pregnancy. In conclusion, the present study suggest that L-NAME-induced elevated blood pressure and increased fetal mortality can be reversed by low dose of AM. Thus AM may play an important role in the regulation of blood pressure, the blood supply to the utero-placental unit and fetal development.

Alteration of plasma ghrelin levels associated with the blood pressure in pregnancy.

Ghrelin, an endogenous ligand for the growth hormone secretagogues, was originally isolated from rat stomach. It stimulates the release of growth hormone from primary pituitary cell cultures. We investigated the plasma concentration of ghrelin peptide in 16 nonpregnant women, 18 normal pregnant women, 20 patients with pregnancy-induced hypertension, and 10 postpartum women. The plasma concentration of ghrelin in nonpregnant women was 239.5+/-16.9 fmol/mL. The plasma concentration of ghrelin in normal pregnant women at the third trimester was 127.1+/-5.6 fmol/mL. There was negative correlation between plasma ghrelin concentration and systemic blood pressure in normal pregnant women (systolic: r=-0.564, P<0.05; diastolic: r=-0.610, P<0.01). Pregnant women with pregnancy-induced hypertension (177.9+/-14.6 fmol/mL, P<0.05) also had significantly higher levels of ghrelin compared with those of normal pregnant women. In addition, there was a significant correlation between plasma ghrelin levels and systemic blood pressure (systolic: r=-0.482, P<0.05; diastolic: r=-0.466, P<0.05). These results suggest for the first time that ghrelin might have some role in cardiovascular control during normal pregnancy and in pathophysiological conditions in pregnancy, such as pregnancy-induced hypertension.