10年32例三胎妊娠的临床分析

目的 分析三胎妊娠的临床特点和影响妊娠结局的因素,为多胎妊娠的围产期保健和并发症防治提供参考,以改善多胎妊娠的妊娠结局.方法 1997年1月1日至2006年12月31日10年间我院28周后共分娩了三胎妊娠共32例(分娩孕周均<37周),选择与每例三胎妊娠在相同月份分娩的同孕周的2～3例双胎妊娠(共68例)及单胎妊娠(共89例)作为对照,比较母儿并发症等情况.结果 10年中三胎妊娠发生率前5年为0.05%,后5年为0.07%(P<0.05).三胎妊娠组孕产妇的各种并发症发病率(如妊娠期高血压疾病、低蛋白血症、贫血)均显著高于双胎及单胎组(P>0.05).三胎妊娠组新生儿各种并发症(如湿肺、肺炎及新生儿窒息等)与双胎及单胎组差异无统计学意义(P>0.05).三胎、双胎及单胎妊娠组的围产儿死亡率分别是135.4‰、60.2‰及56.2‰(P>0.05).三胎、双胎妊娠组剖宫产率分别为90.6%及91.2%,明显高于单胎组的48.3%(P<0.01).三胎妊娠组阴道分娩与剖宫产分娩两组的新生儿死亡率(70.6‰和3/7)、呼吸窘迫综合征发生率(4.7%和3/7)和颅内出血发生率(11.8%和3/7)比较差异有统计学意义(P<0.01或<0.05).结论 多胎妊娠较单胎及双胎妊娠孕妇易发生并发症;早产可能是造成三胎妊娠不良妊娠结局的主要因素;剖宫产可作为三胎妊娠的首选分娩方式.     

双羊膜囊三胎妊娠围产期管理及妊娠结局9例分析

目的:通过围产期管理策略及妊娠结局分析,探讨双羊膜囊(DA)三胎妊娠最佳临床治疗方案。方法:回顾性分析2012年1月至2020年3月四川大学华西第二医院产科收治的9例DA三胎孕妇临床资料。结果:9例DA三胎中4例为双绒毛膜双羊膜囊(DCDA)三胎,5例为单绒毛膜双羊膜囊(MCDA)三胎。分别于孕12～18⁺⁵周经产前超声诊断。孕期规律产检的病例大多数围产期结局预后良好,而2例产检不规律病例围产期结局差。3例DCDA三胎分别于孕16周、17周和17⁺¹周行选择性减胎术(心腔内注射氯化钾),其中2例合并联体双胎,1例合并多发畸形。共2例行畸形胎儿体内激光治疗,1例为DCDA三胎合并双胎动脉反向灌注序列征(TRAPS),另一例为MCDA三胎合并双胎儿TRAPS。9例DA三胎共分娩11例活产儿,体健,存活至今。结论:DA三胎应早期诊断,临床诊疗中需由多学科团队进行详细评估及监测。依据个体化差异,规范产前检查,严密监护胎儿情况,必要时实施选择性减胎术及适时终止妊娠以获得良好的围产期结局。     

妊娠合并甲状腺功能低减患者的临床分析

目的 探讨妊娠合并甲状腺功能低减(甲减)患者的围产期发病率、药物治疗剂量及母婴结局.方法 收集我院1995年1月-2006年5月收治的31例妊娠合并甲减患者的临床资料,31例患者均在产科高危门诊定期保健,每1.0～1.5个月监测1次甲状腺功能,并与内分泌科合作调整患者的左旋甲状腺素剂量.对患者的围产期保健、药物治疗量及母婴结局进行回顾性分析.结果 (1)发病率:我院近11年来妊娠合并甲减的发病率为1.27‰(31/24 327)[0.19‰(1/5251)～2.32‰(15/6456)].(2)左旋甲状腺素用量:左旋甲状腺素的平均剂量孕前、孕早期、孕中期、孕晚期、产后分别为(33±35)、(51±36)、(68±42)、(76±42)、(38±34)μg/d,孕早期及产后与孕前比较,差异无统计学意义(P＞0.05);孕中期及孕晚期与孕前比较,左旋甲状腺素应用量明显增加,差异有统计学意义(P＜0.05),整个孕期的左旋甲状腺素平均用量比孕前增加约35%.(3)妊娠结局:31例患者中有5例妊娠期糖代谢异常,发生率为16%(5/31);1例胎儿六指畸形,1例新生儿窒息(Apgar评分1分钟7分,5分钟10分);31例患者中无一例围产儿死亡,无新生儿先天性甲减.结论 妊娠合并甲减发病率逐年升高.孕期需及时增加左旋甲状腺素用量,对改善妊娠合并甲减患者的妊娠结局具有良好的治疗作用.     

不同病因妊娠合并重度肺动脉高压临床分析

目的:探讨不同病因妊娠合并重度肺动脉高压(PAH)围产期的监护及妊娠终止时机和方式。方法:收集2014年1月至2019年12月于广州医科大学第三附属医院ICU收治的妊娠合并重度PAH患者28例的临床资料,分析其病因、临床特点及妊娠结局。结果:(1)28例妊娠合并重度PAH患者中,病因为先天性心脏病占最大比率10例(35.7%),其次是风湿性心瓣膜病7例(25.0%),特发性肺动脉高压(IPAH)居第3位6例(21.4%),肺栓塞2例(7.1%),子痫前期2例(7.1%),系统性红斑狼疮相关性PAH 1例(3.6%)。(2)先天性心脏病、风湿性心瓣膜病、子痫前期、系统性红斑狼疮相关性PAH的孕妇预后良好,无一例死亡;6例IPAH患者中3例好转,3例死亡,病死率高达50.0%,均为病情极其危重由外院急诊转入本院,未进行规律的产前检查,并在产后并发了大出血;2例肺栓塞患者,1例预后良好,1例死亡,为在外院顺产后因重度心力衰竭转入本院,呼吸循环衰竭死亡。(3)共计26例围产儿(均为早产儿),其中存活围产儿22例,死胎4例;医源性流产儿2例。先天性心脏病孕妇的存活围产儿占87.5%(7/8),IPAH孕妇的存活围产儿占83.3%(5/6),而新生儿窒息发生率高达80.0%(4/5),且新生儿出生平均体质量较低为1656±552 g。结论:不同病因妊娠合并重度PAH的母婴结局不同,未规律行产前检查的IPAH患者预后较差,病死率最高,母婴结局最差,而先天性心脏病孕妇及围产儿的预后相对较好。规范化、全程、多学科的孕产妇管理是降低重度PAH孕产妇病死率的有效方法,是改善母婴结局的关键。【     

妊娠合并甲状腺功能亢进临床分析

目的 探讨甲状腺功能亢进(甲亢)患者孕前及妊娠期治疗是否能减少妊娠并发症、降低胎儿丢失率及改善母要结局.方法 回顾性分析我院1995年1月至2005年12月共11年间60例妊娠合并甲亢患者孕前及妊娠期治疗及母婴结局.60例患者分为三组:甲亢病史组(Ⅰ组):19例有甲亢病史,孕期监测甲状腺功能未复发组;治疗满意组(Ⅱ组):28例曾应用抗甲状腺药物治疗,终止妊娠时甲状腺功能正常;治疗不满意组(Ⅲ组):13例孕期未系统治疗,就诊时间晚、病情重,终止妊娠时甲状腺功能异常.结果 (1)妊娠合并甲亢进入围产期的发病率为2.25‰(52/23 104),因病情严重28周前终止妊娠8例,胎儿丢失率为11.8%(8/60);(2)Ⅰ组无妊娠并发症发生;(3)Ⅲ组与Ⅱ组相比,重度子(癎)前期(53.9%和10.7%)、甲亢性心脏病(38.5%和3.6%)、胎盘早剥(23.1%和3.6%)的发生率和胎儿丢失率(46.2%和7.1%)均有显著增加(P＜0.05);(4)Ⅲ组与Ⅱ组相比,并发重度子(癎)前期的OR=9.72(95%CI:1.53-71.21)、甲亢性心脏病OR=16.88(95%CI:1.45-826.42)、胎盘早剥OR=8.1(95% CI:0.54-440.44)、胎儿丢失OR=11.14(95%CI:1.45-126.39);(5)Ⅲ组新生儿平均体重明显低于Ⅱ组和Ⅰ组[(2550±573)g和(3211±717)g、(3186±492)g,P＜0.05];(6)Ⅲ组中有一例新生儿发生甲状腺功能减退;三组均无孕妇及围产儿死亡、无新生儿畸形.结论 重视甲亢的孕前及孕期治疗,能有效降低孕期并发症、减少胎儿丢失率及改善围产期母儿结局.     

双胎妊娠第二胎延迟分娩的临床分析

目的:探讨双胎妊娠第二胎延迟分娩的临床情况、处理及妊娠结局。方法:回顾分析2016年6月至2018年12月在华中科技大学同济医学院附属同济医院行双胎妊娠第二胎延迟分娩的8例患者的临床资料。结果:8例双胎妊娠延迟分娩患者中第一胎分娩平均孕周22.29周(16~(+4)～29~(+5)周),平均分娩体重462.5g(150～1400g),5例死胎,2例放弃,1例新生儿存活;第二胎分娩平均孕周23.98周(17~(+3)～30~(+6)周),出生平均体重661.25g(180～1600g),3例死胎,2例放弃,1例新生儿科死亡,2例存活预后良好。分娩间隔时间3～50天,平均11.88天。第一胎分娩后,均予抗感染、保胎、促胎肺成熟等治疗,2例行宫颈环扎术。孕妇中2例术后监测中出现感染给予抗炎治疗,2例因胎盘植入产后出血。结论:双胎妊娠第二胎延迟分娩处理得当可提高第二胎新生儿的存活率及预后,但需把握好指征,严密监测感染及胎儿胎盘情况,早期发现并发症,适时终止妊娠。     

三胎妊娠早孕期减胎术后的围生结局分析

目的:探讨三胎妊娠早孕期选择性氯化钾减胎术后与未减胎单胎或双胎妊娠的围生结局差异。方法:收集广州医科大学附属第三医院2012年1月至2017年10月诊治的181例三胎妊娠孕妇早孕期行胎儿心内注射氯化钾减胎术(减至单胎组103例,减至双胎组78例)和未减胎单胎妊娠、双胎妊娠(未减胎单胎组58例,未减胎双胎组54例)的临床信息,并对比分析围生结局差异。结果:减至单胎组分别与减至双胎组和未减胎单胎组相比,其流产率(16.50%、3.85%、1.72%)和早产率(16.50%、55.13%、3.45%)、分娩孕周(37.37±0.26周、34.60±0.29周、39.05±0.20周)及新生儿出生体质量(2.71±0.06 kg、2.12±0.54 kg、3.07±0.07 kg)比较,差异均有统计学意义(P0.05)。减至双胎组与未减胎双胎组比较,其早产率(55.13%、35.19%)、分娩孕周(34.60±0.29周、36.04±0.27周)及新生儿出生体质量(2.12±0.54 kg、2.37±0.07 kg),差异有统计学意义(P0.05)。结论:尽管减胎术增加了孕妇早产率,但通过选择性减胎控制胎儿的数量来降低孕产期并发症仍是必要的。综合考虑流产率、早产率和胎儿发病风险,保留单胎可能更有利于胎儿围生结局和远期健康结局。     

过期妊娠分娩方式及终止妊娠时间对母婴的影响

为研究过期妊娠(ｐｒｏｌｏｎｇｅｄｐｒｅｇｎａｎｃｙ,ＰＰ)对围产儿的影响,进一步加强围产期的管理,降低其发病率,选择恰当终止妊娠的方式,尽可能减少母婴并发症,我们对ＰＰ与同期妊娠未过期者进行了分析、比较。1　资料与方法11　临床资料　1996年1月至1997年12月在我院住院分娩2811例,妊娠37周2568例,其中ＰＰ208例(Ａ组),42～42 6周152例,43～43 6周40例,44～46 6周16例;妊娠41～41 6周487例(Ｂ组);妊娠37～40 6周1873例(Ｃ组)。3组均为单胎。12　方法　观察Ａ、Ｂ、Ｃ3组孕妇的分娩方式及对母婴的影响。13　统计学处理　采用χ2检验…     

131例双胎妊娠并发重度子痫前期的妊娠结局

目的 探讨双胎妊娠并发重度子痫前期孕产妇的临床特点及其妊娠结局.方法 研究对象为2007年6月至2011年6月期间,四川大学华西第二医院收治的703例重度子痫前期病例,其中双胎妊娠131例,单胎妊娠572例.采用回顾性分析的方法,比较双胎组和单胎组孕妇的年龄、规律产检次数、发病孕周、分娩孕周、平均延长孕龄、血压值及实验室检测结果等临床指标,比较胎盘早剥、产后出血、子宫胎盘卒中、子痫、HELLP综合征(hemolysis,elevated liver enzymes,and low platelets syndrome)等产科并发症,以及心功能衰竭、肺水肿、低蛋白血症、视网膜病变、颅内出血和肾功能不全等并发症发生情况.比较双胎组和单胎组围产儿的结局,包括早产率、围产儿死亡率、新生儿重症监护室(neonatal intensive care unit,NICU)转入率,以及胎儿窘迫、新生儿缺血缺氧性脑病(hypoxie ischemic encephalopathy,HIE)、新生儿窒息、肺炎、高胆红素血症和低血糖等疾病的发生率.采用t检验、x2检验、校正四格表的x2检验或Fisher精确概率法进行统计学分析.结果 双胎组重度子痫前期发病率高于单胎组[5.03％(131/2604)与1.94％(572/29 452),x2=106.40,P＜0.001].双胎组和单胎组的平均发病孕周分别为(33.6±1.8)周和(34.4±2.0)周,平均分娩孕周分别为(34.6±2.9)周和(35.6±3.2)周,平均延长孕龄分别为(6.4±0.3)d和(7.4±0.5)d,双胎组均早于单胎组(t=2.364、3.902和5.314,P均＜0.05).双胎组与单胎组胎盘早剥[9.9％(13/131)与4.2％(24/572)]、心功能衰竭[11.5％ (15/131)与3.2％ (18/572)]、肺水肿[4.6％(6/131)与0.9％(5/572)]、产后出血[16.0％(21/131)与7.0％ (40/572)]、子宫胎盘卒中[5.3％(4/131)与0.5％(3/572)]发生率比较,双胎组均高于单胎组(x2=7.013、16.430、9.505、10.990和17.650,P均＜0.01).双胎组与单胎组早产率[77.1％ (202/262)与29.9％(171/572)]、新生儿HIE发生率[8.4％(22/262)与4.7％(27/572)]、新生儿NICU转入率[76.2％(205/262)与58.4％(332/572)]比较,双胎组均高于单胎组(x2=162.000、4.392和31.980,P均＜0.05).结论 双胎妊娠较单胎妊娠更易发生重度子痫前期,且更易发生严重并发症,导致围产儿不良结局.临床应重视双胎妊娠的管理,一旦发生妊娠期高血压疾病应积极治疗并预防并发症,根据病情适时终止妊娠.     

三胎与单胎妊娠胎儿生长发育的比较

目的　探讨三胎妊娠的胎儿发育规律及平均孕周的特点。方法　采用超声测量三胎妊娠的胎儿与单胎妊娠胎儿不同孕周的双顶径、股骨长 ,比较三胎妊娠胎儿的发育状况、出生体重及分娩孕周与单胎妊娠胎儿的差异值。结果　三胎妊娠的胎儿从孕 2 8周起 ,双顶径及股骨长的平均值低于单胎妊娠胎儿 (差异均值分别为 2 1mm和 3 1mm ,P <0 0 1)。三胎妊娠的新生儿出生体重明显低于单胎妊娠的新生儿 (P <0 0 1)。 3 6 2 %的三胎妊娠的新生儿出生体重低于同孕周的第十百分位数 ;95 7%的三胎妊娠胎儿在 3 6周之前分娩 ,平均分娩孕周数为 (3 4 0± 1 6)周 ,较单胎妊娠胎儿的 (3 9 0± 1 6)周明显提前。结论　三胎妊娠胎儿有着与单胎妊娠胎儿不同的发育规律 ,其平均孕周较单胎妊娠明显缩短 ,新生儿出生体重明显降低     

Toll样受体与子宫内膜及子宫内膜异位症

子宫内膜异位症(EMs)发病机制尚未完全阐明.大量研究表明,免疫因素在EMs的发病机制中起重要作用.EMs免疫应答异常主要是巨噬细胞数量和活性增加及其分泌产物,如生长因子、细胞因子和血管生成因子的改变.Toll样受体(TLRs)识别特异性的病原体相关分子模式,启动和介导免疫应答,在固有免疫中发挥重要作用,并诱导产生适应性免疫反应.TLRs在正常子宫内膜中的生理作用以及在EMs中的相关研究已逐步开展,对其深人认识和研究将为EMs诊断、治疗和预后判断提供新思路和手段.     

Toll样受体与子宫内膜及子宫内膜异位症

子宫内膜异位症（EMs）发病机制尚未完全阐明。大量研究表明,免疫因素在EMs的发病机制中起重要作用。EMs免疫应答异常主要是巨噬细胞数量和活性增加及其分泌产物,如生长因子、细胞因子和血管生成因子的改变。Toll样受体（TLRs）识别特异性的病原体相关分子模式,启动和介导免疫应答,在固有免疫中发挥重要作用,并诱导产生适应性免疫反应。TLRs在正常子宫内膜中的生理作用以及在EMs中的相关研究已逐步开展,对其深入认识和研究将为EMs诊断、治疗和预后判断提供新思路和手段。     

Pharmacokinetics and endometrial and tubal tissue penetration of cefalotin and cefazolin

The pharmacokinetics and concentrations of the two antibiotics cefazolin and cefalotin were studied during gynecologic operations in endometrial and tubal tissue. The patients received 0.05 g/kg of the antibiotics by intravenous injection. Under the given conditions, pharmacokinetic calculation of the plasma elimination gave half-lives of 24.8 min for cefalotin and of 63 min for cefazolin. Fitting of the tissue levels to the Bateman function showed that the two antibiotics diffuse rapidly into both tubal and endometrial tissue and attain peak concentration levels between 10 and 25 min. In both tissues the concentrations of cefazolin were higher than those of cefalotin. Higher tissue concentrations of cefazolin could also be demonstrated in experiments of longer duration.     

Psychological and pharmacological treatments of mood and anxiety disorders during pregnancy and postpartum. Review and synthesis

The aim of this article is to review the main methods of treatment of anxious and depressive disorders during pregnancy and the postpartum. To this end, we analyse recent publications about the use and efficacy of psychotherapy and psychosocial interventions (cognitive behavioural therapy, interpersonal psychotherapy, psychoanalytical therapy) in the perinatal period. We also review recent papers about the use of psychotropic medication during pregnancy and breast-feeding, with special emphasis on clinical trials. We particularly focus on the risk/benefit assessment of antidepressants, mood stabilisers, antipsychotics and benzodiazepines, in terms of teratogenicity, and impact on neonatal adaptation and neuropsychological development. Various treatment modalities are presented and discussed. It appears that psychotherapies have proved their efficiency on most pre- and postpartum anxious and depressive disorders and represent a first line treatment in most cases. Psychopharmacological treatment is indicated for severe anxious and depressive disorders. The risks of such medication, especially antidepressants, may have been overestimated in the past. Provided reasonable precautions are taken and mothers and future mothers receive clear information on the potential risks and benefits, psychotropic medication could be more broadly prescribed during pregnancy and the breast-feeding period.     

Israeli and British women's wellbeing and eating behaviours in pregnancy and postpartum

Objectives: The study had two main objectives: (a) track changes in self-esteem, eating behaviours and body satisfaction from early pregnancy to 24 months postpartum and (b) to compare changes by context (Israel vs. UK) and maternal body mass index (BMI).

Background: High maternal BMI is associated with negative body image and restrained eating, which are experienced differently across cultures.

Methods: 156 pregnant women were recruited from Israel and the UK. Seventy-three women were followed up every six months from early postpartum and until 24 months following birth. Women completed questionnaires assessing self-esteem (RSEQ), body image (BIS/BIDQ) and eating behaviours (DEBQ) and self-reported weights and heights so that BMI could be calculated.

Results: Women with higher BMI had higher levels of self-esteem and were less satisfied with their body. Healthy-weight women were more likely to lose all of their retained pregnancy weight compared to overweight and obese women. Self-esteem, body image and eating behaviours remained stable from pregnancy until 24 months postpartum. No significant differences were found for any measure by context.

Conclusion: BMI was the strongest predictor of self-esteem and body dissatisfaction and a higher BMI predicted less weight loss postpartum.     

Placental ischemia and changes in umbilical and uteroplacental arterial and venous hemodynamics

Objective: To relate Doppler velocimetry findings in fetoplacental and uteroplacental circulation to placental histomorphology. Material and methods: In 14 uncomplicated and 31 high-risk pregnancies Doppler velocimetry was performed in umbilical artery and vein, and in maternal uterine veins and arteries during the second half of gestation. Histopathology of the placentas was examined, especially for signs of ischemia and inflammation. Results: All fetuses in uncomplicated pregnancies had normal flow velocity waveforms in umbilical artery; in the high-risk group, 18 fetuses had abnormal flow (increased PI or absent/reverse end-diastolic flow). The latter group had more often high ischemic score and infarctions in the placenta than found in pregnancies with normal umbilical artery flow (p?<?0.001 and p?=?0.02, respectively). Similarly, the abnormal uterine artery flow pattern (uterine artery score 3–4) occurred more often with high ischemic score and placenta infarctions (p?<?0.001 and p?<?0.001, respectively). No significant associations were found between the uterine venous flow type and placental ischemia. Conclusion: Placental ischemic morphological changes were associated with Doppler ultrasound signs of increased resistance to arterial blood flow, both on the fetal and maternal sides of the placenta. No significant relation to the uterine venous flow velocities was found.     

Prostacyclin and thromboxane in gynecology and obstetrics

The gynecologic and obstetric implications of the smooth muscle-relaxing, antiaggregatory prostacyclin and its endogenous antagonist, thromboxane A2, are reviewed. In addition to the vascular wall and circulating platelets, which are primary sources for prostacyclin and thromboxane A2, respectively, reproductive tissues produce great amounts of these prostanoids, evidently for the regulation of the vascular tone and/or vascular platelet interaction. Several gynecologic and obstetric disorders are characterized by abnormalities in prostacyclin and/or thromboxane A2. In primary menorrhagia the uterine release of prostacyclin is increased, and consequently menstrual blood loss can be reduced with various prostaglandin synthesis inhibitors. Prostacyclin relaxes the nonpregnant myometrium in vitro and may also do so in vivo, although intravenous infusion of prostacyclin has no effect upon the uterine contractility in nonpregnant or pregnant subjects. Patients with pelvic endometriosis may have increased levels of prostacyclin and thromboxane A2 metabolites in the peritoneal fluid. The prostacyclin/thromboxane A2 balance shifts to thromboxane A2 dominance in patients with gynecologic cancer. During pregnancy the production of prostacyclin and thromboxane A2 increases in the mother and fetoplacental tissue. Preeclampsia and other chronic placental insufficiency syndromes are accompanied by prostacyclin deficiency in the mother and in fetomaternal tissues and by an overproduction of thromboxane A2, at least in the placenta. These changes may account for the vasoconstriction and platelet hyperactivity, which are pathognomonic for hypertensive pregnancies. By directing the prostacyclin/thromboxane A2 balance to prostacyclin dominance (by dietary manipulation, administration of prostacyclin and/or its analogues, drugs with prostacyclin-stimulating and/or thromboxane A2-inhibiting action), it may be possible to prevent and/or treat hypertensive pregnancy complications in the future.