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A cupric pregnancy – thirteenth time lucky

机译:铜妊娠–第十三次幸运

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We describe a patient with a background of unexplained recurrent miscarriages who was diagnosed with Wilson's disease and subsequently gave birth to two children after treatment was commenced.DECLARATIONSCompeting interestsNone declaredFundingNoneEthical approvalWritten informed consent to publication has been obtained from the patient or next of kinGuarantorDJNContributorshipThe patient in this case report is under the care of DJN who had the original idea of this report and contributed to the relevant literature search; TY was supervised by DJN, performed a large proportion of the relevant literature search and wrote and revised the report; GD was the obstetrician in charge of the patient and contributed expert opinion in her field; MM was responsible for harvesting and performing analysis on placental tissues from the patient, also providing expert opinion in his fieldReviewerSadia MalickIntroduction Section:Recurrent miscarriage is a less recognized feature of Wilson's disease and adequate treatment can alter the outcome of pregnancies favourably. Wilson's disease is a recessively inherited disorder of copper metabolism due to mutations in the ATP7B gene, which encodes for a copper-transporting P-type ATPase. Recurrent miscarriage is a complication of untreated Wilson's disease. It has been reported that miscarriages can predate neurological symptoms,1 and treatment with copper chelation improves the rate of successful pregnancies.1,2Case report Section:In May 2007, a 41-year-old woman of Pakistani origin presented with a three-year history of tremor. She had two other siblings affected with Wilson's disease, and their parents were consanguineous. She presented late because she moved between cities frequently. On examination, she had very obvious Kayser-Fleischer rings in both eyes (Figure 1). She had action tremor of both upper limbs and an unsteady ataxic gait.DownloadOpen in new tabDownload in PowerPointFigure 1 Kayser-Fleischer ring in the right eye of our PatientInvestigations confirmed the strong clinical suspicion of Wilson's disease. Serum copper was 0.6 mg/L (0.7-1.6 mg/L). Serum caeruloplasmin was 0.13 g/L (0.2-0.5 g/L). Urinary copper excretion was 124 μg/24 hr (<50 μg/24 hr). All other serological tests including liver enzymes were normal. Magnetic resonance imaging of the brain showed diffuse abnormal high signal in both thalami, cerebral peduncles, midbrain and pons consistent with Wilson's disease. Gene sequencing of ATP7B gene showed that she was heterozygous for c.3008 C > T; p.Ala1003Val novel amino acid change.However, her other main clinical problem was recurrent miscarriages. Up to the age of 34 years, corresponding to four years prior to onset of neurological symptoms, she had 10 miscarriages, all in the first trimester. Her menarche occurred aged 15, and her first pregnancy and miscarriage aged 18. Previous investigations including tests for antiphospholipid syndrome and exploratory laparoscopy and hysteroscopy revealed no causes for her miscarriages.Penicillamine was commenced in June 2007. She responded neurologically but compliance was poor due to side-effects and anxieties of teratogenicity. She was found pregnant six months into suboptimal therapy, her first on treatment, at 16 weeks gestation when she stopped treatment herself. She had cervical incompetence diagnosed at 19 weeks, likely to be caused by repeated endoscopic removal of products of reception for her previous miscarriages. She gave birth to a male infant of 574 g at 24 weeks gestation by emergency Caesarean section due to spontaneous rupture of membrane and cord prolapse. He died unexpectedly aged eight weeks due to aspiration pneumonia. An autopsy was declined, and placental copper was 0.33 μg/g (0.2-0.5 μg/g). She became pregnant for the 12th time in March 2009, and was admitted to hospital under the obstetrician for strict bed rest to avoid complications from cervical incompetence. She remained fully compliant with medication (pe
机译:我们描述了一名患有无法解释的反复流产的背景的患者,该患者被诊断出患有威尔逊氏病并在治疗开始后随后生下了两个孩子。案例报告由DJN负责,DJN拥有本报告的初衷,并为相关文献搜索做出了贡献; TY受DJN的监督,进行了大量相关文献检索并撰写和修改了报告; GD是负责患者的妇产科医生,并在其领域贡献了专家意见。 MM负责收集患者的胎盘组织并进行分析,并在该领域提供专家意见。威尔逊氏病是铜代谢的隐性遗传疾病,归因于ATP7B基因的突变,该基因编码运输铜的P型ATP酶。反复流产是未经治疗的威尔逊氏病的并发症。据报道,流产可早于神经系统症状1,而铜螯合治疗可提高成功妊娠率。1,2病例报告科:2007年5月,一名来自巴基斯坦的41岁妇女被判三年震颤史。她还有两个兄弟姐妹患有威尔逊氏病,他们的父母是近亲的。她来晚了,因为她经常在城市之间移动。经检查,她的两只眼睛都有非常明显的Kayser-Fleischer环(图1)。图1患者右眼的Kayser-Fleischer环证实了对威尔逊氏病的强烈临床怀疑。血清铜为0.6 mg / L(0.7-1.6 mg / L)。血清铜蓝蛋白为0.13 g / L(0.2-0.5 g / L)。尿铜排泄为124微克/ 24小时(<50微克/ 24小时)。包括肝酶在内的所有其他血清学检查均正常。大脑的磁共振成像显示,与威尔逊氏病相符的丘脑,脑柄,中脑和脑桥均弥漫着异常高信号。 ATP7B基因的基因测序表明,她的c.3008 C> T是杂合的。 p.Ala1003Val新氨基酸改变。但是,她的另一个主要临床问题是反复流产。直到34岁(对应于神经症状发作之前的4年),她在早三个月都有10次流产。她的月经初潮发生在15岁,她的第一次怀孕和流产是在18岁。以前的检查包括抗磷脂综合症,探索性腹腔镜检查和宫腔镜检查均未发现流产的原因。青霉素胺于2007年6月开始使用。她的神经反应良好,但依从性差致畸性的副作用和焦虑。当她停止治疗时,在妊娠第16周时,她被接受了次优治疗六个月,这是她第一次接受治疗。她在第19周被诊断出宫颈功能不全,这很可能是由于以前的流产反复在内窥镜检查中取出接收产品引起的。由于膜和脐带脱出自发破裂,她在紧急剖腹产时在妊娠24周时生下了574 g的男婴。由于吸入性肺炎,他意外死亡,死于八周。尸检下降,胎盘铜为0.33μg/ g(0.2-0.5μg/ g)。她于2009年3月第12次怀孕,并因严格的卧床休息而住院,以防止宫颈功能不全引起并发症。她仍然完全服药(PE

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