产程活跃期停滞86例病因分析与护理

抽取初产妇单胎头位活跃期停滞者(停滞组)及同期分娩的初产妇单胎头位产程正常者(正常组)各86例，对两组产妇潜伏期、胎方位、产力、分娩方式、产妇心理状态、母婴并发症及新生儿平均出生体重进行比较。结果 正常组上述各项指标均明显优于停滞组(P＜0．05，P＜0．01)。提示在骨盆正常情况下，停滞组主要原因是新生儿体重和胎位异常，产妇的心理因素和潜伏期长短亦起重要作用。应加强产前检查、处理及心理护理，保证正常分娩及母婴安全。     

环境因素对低出生体重儿发生率的影响

目的探讨影响低出生体重儿发生的环境因素，从而在孕早期采取有效的干预措施预防低出生体重儿的发生。方法采用病例对照研究方法选择896例新生儿，于出生后24h对其母亲进行问卷调查和收集病史资料，按新生儿体重情况分为早产低出生体重儿组（早产组）、足月小样儿组和对照组。结果单因素分析显示，三组新生儿父亲吸烟、饮酒、不良情绪、孕前接触油漆、孕前6个月每日看电视时间与使用计算机时间及新生儿母亲被动吸烟、孕期每日看电视时间与使用计算机时间9个因素比较，差异有显著性意义（P〈0．05，P〈0．01）；Logistic回归模型一（早产组与对照组）结果显示：新生儿父亲吸烟、不良情绪、孕前接触油漆尤其能增加早产的相对危险度；Logistic回归模型二（足月小样儿组与对照组）结果显示：新生儿父亲吸烟、孕前6个月每日看电视时间、不良情绪，新生儿母亲被动吸烟增加足月小样儿发生的相对危险度。结论环境因素与低出生体重闻存在密切相关性，护理人员提供适宜的孕前保健与孕期健康教育是预防低出生体重儿发生的重要干预手段。     

低风险初产妇入产房时机对分娩结局及产程的影响

目的 探讨基于“新产程标准及处理的专家共识”的低风险初产妇选择送入产房的时机对分娩结局和产程的影响。 方法 将401例产妇纳入回顾性队列研究。根据临产后送入产房时宫口扩张情况分为宫口扩张＜3 cm为A组（n=207）,3~＜6 cm为B组（n=132）,≥6 cm为C组（n=62）。比较三组产妇的临床基本情况、分娩结局及三组阴道分娩产妇的产程时长。采用logistic多因素回归分析不同时机入产房对分娩结局的影响;运用Kaplan-Meier法绘制三组产妇的产程时长曲线图,采用Cox多因素回归分析产妇在不同时机进入产房对产程时长的影响。 结果 新生儿出生体质量,产妇剖宫产率、产程中缩宫素使用率、无痛分娩率三组间存在统计学差异（均P＜0.05）。多因素logistic回归分析结果显示,B、C组剖宫产率、缩宫素使用率、无痛分娩率显著低于A组（均P＜0.05）。 三组阴道分娩产妇第一产程时长、总产程时长差异有统计学意义（均P＜0.05）,两两比较A组＞B组＞C组（均P＜0.05）。Kaplan-Meier曲线显示:产妇入产房的不同时机对第一产程时长和总产程时长有影响（均P＜0.05）;以A组作为参照,多因素Cox回归分析显示：第一产程时长B组的HR（95%CI）为1.527（1.191,1.958）,P＜0.05;C组的HR（95%CI）为5.230（3.711,7.370）,P＜0.05;总产程时长B组的HR（95%CI）为1.410（1.102,1.804）,P＜0.05;C组的HR（95%CI）为4.367（3.118,6.118）,P＜0.05。 结论 低风险初产妇基于“新产程标准及处理的专家共识”选择宫口扩张≥6 cm进入产房,可以减少不必要的产科医疗干预,缩短产程,降低无痛分娩率、缩宫素使用率及剖宫产率。     

重症急性胰腺炎病程后期并发急性胆囊炎危险因素分析

目的：探讨重症急性胰腺炎（SAP）病程后期并发急性胆囊炎（AC）的危险因素。方法：采用病例对照研究的方法,回顾性收集确诊的20例SAP并发AC（SAP-AC）患者为病例组和86例SAP患者为对照组的各项资料,采用单因素和多因素非条件Logistic回归法筛选危险因素。结果：单因素Logistic回归分析显示Balthazar’CT评分、APACHEⅡ评分、全身并发症、局部并发症、生长抑素时间、EN持续时间、输血、手术等12个变量影响并发AC的发生;多因素Logistic回归分析显示APACHEⅡ评分（OR=1.333）、肠道营养（EN）持续时间（OR=1.020）、胰头部坏死组织感染（OR=3.301）为并发AC的重要影响因素。结论：APACHEII评分越高、EN持续时间越长、胰头部坏死组织感染,其并发AC的风险性就越大,均为危险因素。     

新生儿窒息123例调查分析与对策

目的:探究新生儿室息临床发生原因,对可能造成产后新生儿窒息的危险因素作出判断,方法总结2003.1～2011.3间我院产科经阴道分娩123例窒息新生儿进行回顾性分析,结果:脐带因素;胎儿宫内窘迫窒息率最高,早产、过期产次之;出生体重、孕周、滞产产程延长等因素增加新生儿窒息率.结论:做好孕期保健、产前检查、B超检查脐带、羊水、胎方位情况、严密观察产程、及时纠正胎儿宫内窘迫、做好新生儿复苏准备、降低新生儿窒息率及病死率、提高产科质量及人口素质.     

新疆维吾尔族男性尿道下裂相关危险因素初步探讨

目的:探讨新疆维吾尔族男性尿道下裂发病的相关危险因素。方法:2014年11月~2015年9月期间采用以医院为基础的1∶2的病例对照研究方法,以面对面问卷方式调查73例尿道下裂患儿和146例对照组儿童,运用条件Logistic回归模型对所有调查因素进行分析。结果:多变量Logistic回归逐步分析结果表明,胎儿低出生体重(P=0.003,OR=7.130,95%CI=7.130~1.950)、母亲孕期接触农药(P=0.000,OR=8.197,95%CI=2.632~25.641)、父母近亲结婚(P=0.041,OR=2.632,95%CI=1.042~6.667)将增加男性尿道下裂的风险。结论:胎儿低出生体重、母亲孕期接触农药、父母近亲结婚是新疆维吾尔族男性尿道下裂的独立危险因素。     

即刻剖宫产新生儿入重症监护病房的危险因素

目的 探讨自决定手术到新生儿剖出时间（DDI）＜15 min的即刻剖宫产新生儿入新生儿重症监护病房（NICU）的危险因素。
方法 选择2019年3月至2021年3月行即刻剖宫产的产妇130例,ASA Ⅰ—Ⅲ级。根据新生儿结局分为两组：新生儿入NICU（N组）和新生儿未入NICU（C组）。采用单因素和多因素Logistic回归分析DDI＜15 min的即刻剖宫产新生儿入NICU的危险因素,并采用受试者工作特征曲线(ROC)评价预测效能。
结果 术后转入NICU的新生儿28例(21.5%)。多因素Logistic回归分析显示：产妇合并症增加（OR=1.59,95%CI 1.04～2.43,P=0.03）、新生儿早产（OR=37.38, 95%CI 10.26～139.05, P＜0.01）、新生儿出生后1 min Apgar评分＜8分（OR=11.90, 95%CI 2.81～50.47, P＜0.01）是DDI＜15 min的即刻剖宫产新生儿进入NICU的独立危险因素。根据多因素Logistic回归模型得出ROC曲线,曲线下面积(AUC)为0.84（95%CI 0.77～0.97）,敏感性82.1%,特异性93.1%。
结论 在DDI＜15 min的即刻剖宫产中,产妇合并症数量增加,新生儿早产、出生后1 min Apgar评分＜8分是新生儿进入NICU的危险因素。     

侧俯卧位预防持续性枕后及枕横位的临床观察

为探讨同侧侧俯卧位预防持续性枕后及枕横位的临床效果，于1999年2月至2000年4月，将先兆临产至潜伏期经B超诊断为枕后位、枕横位的216例产妇随机分为两组，观察组108例产妇采取同侧侧腐卧位，对照组108例按常规产科护理，不作体位指导。结果观察组82例（75．93％）胎方位转位成功，顺产率72．22％，难产率27．78％，总产程时间平均529min。对照组44组例940．74％）转位成功，顺产率33．33％，难产率66．675，总产程平均时间707min。两组比较，差异有极著性意义（均P＜0．005），提示在产程中实行同侧侧俯卧位是预防持续性枕后位是枕横位，降低难产率的有效办法。     

胆囊结石相关危险因素的探讨

目的 探索胆囊结石发生的相关危险因素,为防治胆囊结石提供理论依据。方法 回顾性分析北京协和医院2007年1月至2010年5月间体检者的临床资料,对其中的4087例胆囊结石患者（病例组）和20 435例无胆囊结石体检者（对照组）按照年龄、性别进行1∶5配比以作病例对照研究。对计数资料采用x2检验,计量资料采用t检验;对相关危险因素先用单因素条件Logistic回归分析方法筛选出有统计学意义的可疑危险因素,再用多因素条件Logistic回归法进行分析。结果单因素分析显示,糖尿病、收缩压、舒张压、甘油三酯、高密度脂蛋白胆固醇及体重指数6个因素在病例组与对照组之间差异有统计学意义(P＜o.05)。多因素分析证实,去除了年龄、性别的影响后,糖尿病、收缩压、高密度脂蛋白胆固醇及体重指数仍与胆囊结石显著相关,其比值（95％可信区间）分别为0.825 (0.736～0.925)、0.908 (0.828～0.996)、1.211 (1.056～1.389)和0.746 (0.691～0.805)。总胆固醇、低密度脂蛋白胆固醇在病例组与对照组间之差异无统计学意义(P＞0.05)。结论 糖尿病、收缩压增高、高密度脂蛋白胆固醇降低及肥胖是胆囊结石形成的独立危险因素。因此,应该通过控制糖尿病、减轻体重、控制血压、调整血脂等措施来预防胆囊结石的发生。     

腹腔镜可调节胃束带术后行胃束带取出术影响因素分析

目的 探讨哪类单纯性肥胖患者适宜采用腹腔镜可调节胃束带术.方法 回顾性分析2003年11月-2013年3月上海第二军医大学长海医院微创外科40例行腹腔镜下胃束带取出术患者的临床资料,并收集2006年1月-2008年10月行LAGB手术目前无再次手术的40例病例作为对照组进行病例对照研究.采用x2检验和多因素Logistic回归分析方法对需接受胃束带取出术常见危险因素进行分析.结果 病例组与对照组年龄、性别差异无统计学意义(P＞0.05)；使用非条件Logistic回归进行分析得出体重指数≥35 kg/m2、术后就诊次数＜3次/年和存在基础上消化道疾病为胃束带取出术的危险因素(Wald值=3.908、7.375、5.209,P＜0.05).结论 胃束带取出术的主要危险因素有体重指数、术后年就诊次数、基础上消化道疾病,在使用该术式治疗单纯性肥胖时应充分考虑上述因素.     

Accidental contact burns of the upper limb in children with obstetric brachial plexus injury

The denervated limb of the child with obstetrical brachial plexus injury is theoretically at risk of contact burns. A prospective study was designed to document the incidence and clinical presentation of these burn injuries in a series of 127 birth palsy cases. The study group included 90 Erb's and 37 total plexus palsy cases. Accidental burns occurred in 11% of total palsy cases and 1% of the Erb's palsy group. All injuries were contact burns and confined to the denervated limb. When the circumstances of the burn injury where investigated, it was concluded that injury to the denervated limb was either due to poor motor control, insensibility or a combination of both factors. Finally, treatment and prevention of these injuries are discussed.     

A retrospective analysis of risk factors for clavicle fractures in newborns with shoulder dystocia and brachial plexus injury: A single-center experience

ObjectiveWe aimed to analyze the risk factors for clavicle fractures in newborns with shoulder dystocia and brachial plexus injury and to determine whether their incidence is associated with local characteristics.MethodsThis study was conducted as a retrospective trial between January 2017 and December 2018. Patients with clavicular fracture who were hospitalized in the neonatal intensive care unit of a community hospital were retrospectively analyzed. The clavicular fracture cohort was first divided into two groups and then two subgroups: patients with/without shoulder dystocia and patients with/without a brachial plexus injury. Peripartum and neonatal risk factors of these patients were reviewed using the patient information system. Any additional neurological or musculoskeletal trauma was noted. A multivariate logistic regression analysis was performed to determine independent predictors of shoulder dystocia and brachial plexus injury.ResultsA total of 46 patients with shoulder dystocia in 25 (54%) and brachial plexus injury in 12 (26%) were included in the study. The birth weight of patients with shoulder dystocia was 4,164.2±412.7 g, and that of patients without was 3,535.8±865.2 g (p=0.003). In 11 of 14 patients (44%) in whom labor was induced and whose infant had a fractured clavicle, the infant also had shoulder dystocia (p=0.029). Brachial plexus injury was found in 8 (66.7%) of 14 infants who were born by induced labor and who had a clavicular fracture (p=0.002). The regression analysis revealed that age and induction of labor were independent risk factors for brachial plexus injury (odds ratio=1.599 and 81.862, respectively). Gestational weight gain (p=0.003) and neonatal birth weight (p=0.047) were also found as independent risk factors for shoulder dystocia.ConclusionEvidence from this study has shown that not only birth age or birth weight but also excessive weight gain by mother and induction of labor may increase the risk of clavicula fracture with brachial plexus palsy. Advanced maternal age, multiparity, and deliveries after 39 weeks seem to be risk factors for a clavicular fracture with a brachial plexus injury.Level of EvidenceLevel IV, Therapeutic study     

Risk factors for anal sphincter disruption during child birth

Background and aims  The objective of our study was to analyse the risk factors in a cohort of women who suffered anal sphincter disruption (third-degree tear) and compare the results with a similar cohort of women who underwent an uncomplicated vaginal delivery (without a clinically detectable laceration) during the same period. Materials and methods  A retrospective analysis was carried out on 54 women (group 1) who suffered a third-degree tear and 71 women who had undergone uncomplicated vaginal delivery during the same period (group 2). The risk factors considered were forceps delivery, parity, second stage of labour longer than 1 h, episiotomy, birth weight over 4 kg, gestational age and maternal age at delivery. The Cleveland Incontinence Score was completed. Results  Multiple logistic regression analysis of obstetric risk factors for third-degree perineal tear indicated forceps delivery (p = 0.0001), primiparity (p = 0.004), foetal birth weight over 4 kg (p = 0.030) and delay in the second stage of labour (p = 0.031) to be significant risk factors for a third-degree tear. Mediolateral episiotomy was shown to be a significant protective factor (p = 0.0001). Gestational age and the maternal age at delivery (p = 0.340) were not shown to be significant risk factors (p = 0.336). Conclusion  Primary prevention and identification of women with risk factors is recommended. In some cases, counselling regarding the potential risks and benefits of both vaginal and caesarean delivery may be appropriate.     

Brachial plexus root avulsions

The majority of adult brachial plexus palsies are posttraumatic injuries caused by high-energy forces, usually involving motor vehicles. In infants, brachial plexus palsies commonly represent obstetrical injuries following excessive traction on the plexus during complex or difficult delivery. Most adult injuries, and occasionally those in infants, represent brachial plexus root avulsion injuries that carry serious ramifications from the standpoint of permanent disability of a paralyzed extremity, prolonged recuperation, and significant socioeconomic impact. Modern-day management of root avulsions should focus on early, aggressive microsurgical reconstruction of the brachial plexus, combining various neurotizations with intraplexus and extraplexus ipsilateral and contralateral nerve donors, utilization of vascularized nerve grafts, and finally the use of free vascularized and neurotized muscles. When these multistage microsurgical management techniques are applied early (with complete avulsions) they may often result in significant return of neurologic function, especially in young patients. Amputation should be looked upon as an option only when these newer microsurgery techniques have failed.     

Risk factors for obstetric anal sphincter injuries (OASI) at a tertiary centre in south India

Introduction and hypothesis

Despite several studies that have reported risk factors for obstetric anal sphincter injuries (OASI), data from the Indian subcontinent are scarce. The purpose of this study was to identify risk factors for these sphincter injuries in an Indian population.

Methods

This was a case–control study within a retrospective cohort of vaginal deliveries at a tertiary care facility. All vaginal births beyond 24 completed weeks of gestation and birth weight ≥500 g from January 2008 to December 2012 were identified from the hospital electronic database. Cases were women with OASI sustained during vaginal delivery; the rest constituted controls. Potential risk factors for occurrence and severity of OASI were assessed initially using bivariate analysis and then a logistic regression model.

Results

The incidence of sphincter injury was 2.1% of vaginal births and 1.1% of all deliveries, and major-degree (3c and 4th-degree) tears constituted 20.9% of tears. After adjusted analysis, significant predictors for injury included primiparity, delivery at or beyond 41 weeks of gestation, epidural analgesia, instrumental delivery, shoulder dystocia, birth weight ≥4000 g, and head circumference ≥35 cm. Episiotomy protected against sphincter injuries, particularly in forceps and ventouse deliveries. Shoulder dystocia was significantly associated with major-degree tears, while episiotomy appeared to be protective.

Conclusion

Risk factors are similar to those in other population groups; however, primiparity appears to be associated with lesser risk and forceps delivery with greater risk of sphincter trauma than previously reported.

     

Obstetric trauma. A current problem?

Advances in obstetric practice have decreased birth traumas in the last years, although they are still an important chapter in neonatal age. Between 1993-1998 a total of 21,375 stillborns were registered with a total of 309 birth injuries in 303 neonates (1.44%). The diagnoses were: 2 liver subcapsular hematomas, 105 cephalohematomas, 16 parietal fractures, 11 subdural hemorrhages, 107 clavicular fractures, 10 miscellaneous fractures, 8 soft tissue injuries, 25 facial nerve injuries and 25 braquial palsy. About relation between type of labor and birth trauma was found that clavicular fracture and cephalic vaginal delivery were associated in 50% of the cases, cephalohematoma and forceps in 51%, braquial palsy and vaginal delivery in 44% and forceps in 36%. High weight at birth was another risk factor for entities such as clavicular fracture and braquial palsy. We conclude that birth trauma is a pathology with a relevant incidence and their epidemiology factor had to be known.     

Microsurgical reconstruction of obstetric brachial plexus palsy

The incidence of obstetric brachial plexus palsy is not declining. Heavy birth weight of the infant and breech delivery are considered two important risk factors and Caesarean section delivery seems to be a protective factor. There are two clinical appearances, that is, paralysis of the upper roots and that of total roots, and Klumpke's palsy involving the C8 and T1 roots is rarely seen. Computed tomography myelography (CTM) is still the best way of visualizing nerve roots. Surgical intervention is needed for 20-25% of all patients and clinical information is decisive for the indication of surgery. Most often, a conducting neuroma of the upper trunk is encountered, and it is believed that neuroma resection followed by microsurgical reconstruction of the brachial plexus gives the best results.     

Obstetrical brachial plexus lesions.

The renewal of interest in brachial plexus surgery has been led by the success of microsurgical techniques in other peripheral nerve repairs. The results in adults remain poor, but in obstetrical palsy the regenerative capacity of babies allows for dramatic recovery after nerve repair or reconstruction. Obstetrical brachial plexus injuries represent a unique group with similar aetiology, age and prognosis.     

210例乳腺癌患者的危险因素分析

目的:通过对乳腺癌患者临床资料的调查分析,了解乳腺癌的临床流行病学特征,探讨乳腺癌发病的相关危险因素,为乳腺癌的预防提供一定的参考依据。方法:采用病例对照研究方法,选取2005年1月—2012年1月经病理学确诊的乳腺癌患者210例作为病例组,同时随机选择同期已证实为良性乳腺疾病的210例患者作为对照组,采用统一设计的调查表,由经过统一培训的调查员对研究对象进行面对面的问卷调查。单因素分析采用单因素条件Logistic回归分析,多因素分析采用条件Logistic回归模型进行统计分析,探讨与乳腺癌的发病有关的危险因素。结果:单因素分析结果显示,文化程度高、接触职业性有害物质、被动吸烟、绝经年龄大、流产、肿瘤家族史、长期精神压抑、负性生活事件、肉类烟熏食物摄入次数多这9个因素是乳腺癌的危险因素;体育运动、初潮年龄晚、月经规律、生育孩子次数多、母乳喂养、母乳喂养持续时间长以及蔬菜摄入次数多这7个因素是乳腺癌的保护因素。多因素分析结果显示,文化程度高、绝经年龄大、肿瘤家族史、负性生活事件、肉类摄入次数多是乳腺癌的危险因素;初潮年龄晚、月经规律、母乳喂养持续时间长、蔬菜摄入次数多为保护因素。结论:乳腺癌患者住院治疗人数呈显著增加趋势,其发生与患者的居住环境、生活方式和习惯、女性生理与生育、家族史、饮食因素、精神心理因素密切相关,因此对其的预防应采取具有针对性的综合性措施。     

Shoulder contracture and osseous deformity in obstetrical brachial plexus injuries

BACKGROUND: The purposes of this study were to determine the prevalence of and the association between shoulder contracture and osseous deformity in a cohort of children with an obstetrical brachial plexus injury and to identify the risk factors for these complications. METHODS: In a retrospective cohort study, all children with an obstetrical brachial plexus injury who had been born between January 1991 and January 1998 at one academic medical center and all those with the same diagnosis who had been born elsewhere during the same period and were referred to the medical center within six weeks after delivery were evaluated at fixed time-intervals by one examiner. The patients underwent a final orthopaedic, neurological, and radiographic examination at a mean age of 3.7 years (range, one to seven years). Shoulder contracture was defined as a decrease in the passive range of motion in one or more directions compared with the range on the unaffected side. Osseous deformity was defined as a nonspherical humeral head or an abnormal glenoid. RESULTS: The prevalence of a shoulder contracture of >10 degrees was 56% (twenty-nine of fifty-two patients), and the prevalence of an osseous deformity was 33% (sixteen of forty-eight patients with complete radiographic follow-up). In the children in whom complete neurological recovery was delayed (i.e., recovery was more than three weeks after birth), the prevalence of shoulder contracture was 54% (thirteen of twenty-four patients) and the prevalence of osseous deformity was 26% (six of twenty-three patients). A strong association was noted between shoulder contracture and osseous deformity (p = 0.004). Directly after birth, the presence of a clavicular fracture was the only factor that was associated (p = 0.016) with the development of an osseous deformity (but not with a shoulder contracture). At a later stage, speed and extent of neurological recovery were related to shoulder contracture and osseous deformity. An asymmetric appearance was noticed in children who had a contracture, including those who had complete neurological recovery. CONCLUSIONS: The prevalence of shoulder contracture and osseous deformity in children with obstetrical brachial plexus injury was high, even in those with complete neurological recovery. These complications were strongly associated with one another. No symptom that appeared immediately after birth was identified as a factor that would predict the development of future shoulder contracture. A clavicular fracture was found to be significantly associated with the development of an osseous deformity at a later stage.