邻苯二甲酸酯类化合物与自然流产的研究进展

邻苯二甲酸酯类化合物（phthalic acid esters,PAEs）作为工业用增塑剂,广泛应用于各种生产、生活用品。其特点是产量大、用途广、毒性隐匿,现已成为一类最为普遍的威胁人类健康的环境污染物。作为内分泌干扰物,PAEs可以通过多种途径进入人体并蓄积,干扰机体内分泌,对女性生殖健康产生重要的影响。研究发现,PAEs可能是通过过氧化物酶体增殖物激活型受体γ（PPARγ）影响胎盘的形成及滋养细胞的侵蚀性,从而导致了自然流产的发生。     

Experience of the Hungarian Preconception Service between 1984 and 2010

The objective of this historical account is to summarize the concept, objectives, methods, results and general experience of the Hungarian Preconception Service, Budapest, based on 27 years (1984-2010) and 25,313 women and couples. The service includes counseling and care (examinations and medical interventions) based on three steps: (1) preconception screening for reproductive risk factors ("reproductive health check-up"), (2) a 3-month preparation for conception, because conception is when some major developmental events, such as the sex of the conceptus and the foundation of health and many diseases, are determined, and (3) achievement of optimal conception and better protection of the embryo in early pregnancy. With normal prenatal care, pregnant women visit clinics between the 7th and 12th gestational weeks, but the embryo has passed through his/her most vulnerable period before the 10th week, and thus prenatal care is too late to reduce the risk of congenital abnormalities. The new primary health care infrastructure for preconception care is performed by qualified and trained nurses and midwifes. Couples at risk are selected and are referred to specialists who can reject or confirm the supposed risks and treat the couples if necessary as part of their secondary health care. The most important results of the Hungarian preconception service were (i) a significant reduction in the rate of preterm births (5.0% vs. 9.2%) which has been linked mainly to preconception screening of sexually transmitted infections of female participants followed by appropriate treatment, (ii) a very significant reduction of congenital abnormalities (2.9% vs. 4.0%), particularly neural-tube defects and cardiovascular malformations, due to periconception multivitamin supplementation, (iii) reduction of smoking among female participants, (iv) involvement of male partners in the family planning health system, (v) much improved identification of couples at high risk and greater access to the secondary care of specialists. In conclusion, the Hungarian experience demonstrates the feasibility and usefulness of preconception care in the prevention of adverse birth outcomes including congenital abnormalities and preterm births.     

The effect of a local promotional campaign on preconceptional lifestyle changes and the use of preconception care

Purpose: The objective of this study was to investigate the effect of a local promotional campaign on preconceptional lifestyle changes and the use of preconception care (PCC).

Material and methods: This quasi-comparative study was carried out between February 2015 and February 2016 at a community midwifery practice in the Netherlands. The intervention consisted of a dual track approach (i) a promotional campaign for couples who wish to conceive and (ii) a PCC pathway for health care providers. Questionnaires were collected from a sample of women who received antenatal care during the pre-intervention (n?=?283) and post-intervention (n?=?257) period. Main outcome measures were preconceptional lifestyle changes and PCC use (defined as searching for information and/or consulting a health care provider).

Results: Women who were exposed to the intervention were significantly more likely to make at least one lifestyle change during the preconception period [adjusted OR 1.56 (95% CI 1.02–2.39)]. Women were especially more likely to preconceptionally reduce or quit [adjusted OR 1.72 (95% CI 1.05–2.83)] their alcohol consumption after exposure to the intervention. Although non-significant, it appeared that women who were exposed to the intervention more often prepared themselves for pregnancy by means of independently searching for preconception health information [adjusted OR 1.13 (95% CI 0.77–1.65)] or consulting a health care provider regarding their wish to conceive [adjusted OR 1.24 (95% CI 0.81–1.92)].

Conclusions: Exposure to a local promotional campaign targeted at preconceptional health was associated with improved preconceptional lifestyle behaviours, especially with regard to alcohol consumption, and has the potential to improve the use of PCC.     

Interpregnancy Primary Care and Social Support for African-American Women at Risk for Recurrent Very-low-birthweight Delivery: A Pilot Evaluation

Objectives Very-low-birthweight (VLBW) delivery accounts for the majority of neonatal mortality and the black-white disparity in infant mortality. The risk of recurrent VLBW is highest for African-Americans of lower socioeconomic status. This study explores whether the provision of primary health care and social support following a VLBW delivery improves subsequent child spacing and pregnancy outcomes for low-income, African-American women. Methods This pilot study of mixed prospective-retrospective cohort design enrolled African-American women who qualified for indigent care and delivered a VLBW infant at a public hospital in Atlanta from November 2003 through March 2004 into the intervention cohort (n (1) = 29). The intervention consisted of coordinated primary health care and social support for 24 months following the VLBW delivery. A retrospective cohort was assembled from consecutive women meeting the same eligibility criteria who delivered a VLBW infant during July 2001 through June 2002 (n (2) = 58). The number of pregnancies conceived within 18 months of the index VLBW delivery and the number of adverse pregnancy outcomes for each cohort was compared with Poisson regression. Results Women in the control cohort had, on average, 2.6 (95% CI: 1.1-5.8) times as many pregnancies within 18 months of the index VLBW delivery and 3.5 (95% CI: 1.0-11.7) times as many adverse pregnancy outcomes as women in the intervention cohort. Conclusions This small, pilot study suggests that primary health care and social support for low-income, African-American women following a VLBW delivery may enhance achievement of a subsequent 18-month interpregnancy interval and reduce adverse pregnancy outcomes.     

孕妇学校教学模式改革初探

目的探讨孕妇学校新的教学模式,激发孕妇学习兴趣,提高学习效率。方法将2009年参加孕妇学校的965名孕妇列为试验组,采用新的教学模式,包括以多媒体、提问、实地演练、互动等形式进行教学,组织课后咨询,以及带领孕妇参观医院等。将2008年参加孕妇学校的360名孕妇列为对照组,采用传统的教学模式实施健康教育。结果试验组在孕妇参会率、孕妇学校学员满意度方面比对照组明显提高(P0.01)。结论改革后的孕妇学校教学模式提高了孕妇的学习兴趣和参与意识,提升了医院的形象。     

社区孕前保健网底建设探索研究

背景　我国是出生缺陷高发国家，出生缺陷日益成为突出的公共卫生和社会问题。为降低出生缺陷，相关权威部门颁布并更新了《孕前与孕期保健指南》，国家实行免费孕前优生健康检查。由于宣传力度不够等原因，国家免费政策遇冷。目前社区缺少孕前健康教育专业人员。目的　总结上海市宝山区淞南镇社区卫生服务中心（简称中心）在孕前保健网底建设探索中取得的经验。方法　2018年3-12月，中心利用卫生计生系统合二为一、统一管理的有效模式，将卫生服务、计生指导与管理整合后的社区孕产期保健管理网络为基础，创建社区孕前保健管理网络，培养社区孕前保健管理队伍，广泛宣传孕前优生知识和国家免费孕前优生健康检查政策，将分级诊疗、上下联动的医疗模式运用于孕前保健。于宣传前后，对社区孕前保健管理队伍成员开展孕前优生知识知晓情况的调查；对服务对象开展不良孕产史、国家免费政策知晓情况、孕前优生知识知晓情况、孕前保健知识需求情况、孕前优生健康检查情况的调查。结果　淞南镇共240对夫妇438例接受了孕前保健健康教育服务。宣教后，孕前保健管理队伍成员免费孕前检查服务内容、服用叶酸时间、服用叶酸原因、人工流产后适宜受孕时间知晓率均高于宣教前（P<0.05）。宣教后，438例（100.0%）服务对象均知晓国家免费政策，高于宣教前的359例（82.0%）（P<0.05）。宣教后，服务对象孕前健康准备时间、孕前不宜接触的毒害物、孕前健康准备内容、开始服用叶酸时间知晓情况均高于宣教前（P<0.05）。宣教后，96对（40.0%）夫妇已作或已预约孕前优生健康检查。2017年按照原来的工作模式，免费孕前优生健康检查数未完成目标任务，目标任务83对，实际完成76对；2018年按照新的孕前保健工作模式，免费孕前优生健康检查数超额完成目标任务，目标任务75对，实际完成95对。结论　新创建的社区孕前保健管理网络具有较强的管理能力和专业优势，又具有成熟的社会宣传和政策执行能力，通过分级诊疗、上下联动的医疗模式拓展了社区孕前保健服务内涵，此模式运用前景广阔；对育龄夫妇进行一级干预，符合我国当下的形势需求，其简单易行、操作性较强、经济成本低、作用范围广，值得推广。     

Analysis of TORCH screening results of 330 115 reproductive-age females who underwent pre-pregnancy health examination in Shenzhen北大核心CSCD

Objective To analyze the results of TORCH screening for reproductive-age females who underwent pre-pregnancy health examination in Shenzhen to guide scientific pregnancy preparation. Methods Cross-sectional study was performed on the TORCH screening results of 330 115 reproductive-age females who participated in free pre-pregnancy health examination in Shenzhen from January, 2013 to December, 2019. The ?2 test was used to analyze the differences of TORCH screening results among reproductive-age females in different years, administrative regions and demographic characteristics. Results The overall positive rates of screening for rubella virus (RV)- IgG, cytomegalovirus (CMV)-IgG, CMV-IgM, toxoplasma gondii (TOX)-IgG and TOX-IgM among reproductive-age females in Shenzhen were 85.54% (282 377/330 115), 96.36% (318 088/330 115), 0.31% (1009/330 115), 3.12% (10 292/330 115) and 0.64% (2114/330 115), respectively. Compared with 2013 to 2016, the average positive rates of RV-IgG and CMV-IgG among reproductive-age females in Shenzhen increased (P=0.003, P<0.001), while the average positive rates of TOX-IgG and TOX-IgM decreased from 2017 to 2019 (P<0.001). There were statistically significant differences in the positive rates of the five antibodies among different administrative regions (all P<0.001). Except for the differences in the positive rates of CMV-IgM and TOX-IgM among women of different ages, there were statistically significant differences in the positive rates of these five antibodies among reproductive-age females with other demographic characteristics (all P<0.05). There were statistical differences in the positive rates of TORCH antibodies among women with different demographic characteristics in different years. Conclusion Compared with 2013 to 2016, the positive rates of RV-IgG and CMV-IgG in reproductive-age females in Shenzhen from 2017 to 2019 were on the rise, while the positive rates of TOX-IgG and TOX-IgM were on the decline. The positive rates of these five antibodies were different among different administrative regions and among reproductive-age females with different demographic characteristics, which suggested that plans should be made according to local conditions and different objects in order to strengthen the awareness of eugenics and reduce the risk of congenital intrauterine infection with TORCH of the fetus during the propaganda and education of eugenics. © 2020 Chinese Medical Journals Publishing House Co.Ltd. All Rights Reserved.     

Attitudes towards Genetic Information Delivered by High-Throughput Sequencing among Molecular Geneticists,Genetic Counselors,Medical Advisors and Students in France

High-throughput sequencing technologies performed in the clinical setting have the potential to reveal diverse genetic information. Whether it is initially targeted or unsolicited, strictly medical or not, or even information on a carrier status as part of preconception screening, access to genetic information needs to be managed. The aim of the current study was to gather potential attitudes of various stakeholders towards the sharing of genetic information from next-generation sequencing, and more specifically towards incidental findings, predictive findings, non-medical information and carrier status. Answers from a total number of 1631 individuals belonging to four different groups (45 molecular geneticists, 65 genetic counselors, 56 medical advisors to the state insurance plan, and 1465 university students) were collected through online questionnaires. Overall, the study reflects preferences towards the return of health risks related to serious diseases when effective treatment is available and information on reproductive risks. The importance of the perceived medical utility, both for disease prevention and treatment, was the main distinguishing feature. Attitudes from genetic health professionals were found more reluctant to receive a wide range of information. Hands-on experience with the practice of genetic testing is likely to influence perception of the utility of the genetic information that should be delivered. At the same time, perceptions of preconception genetic carrier screening brought out less differences between participants. Better understanding of the underlying interest in genomic information and thorough education on its value and usage are key elements to the adoption of future guidelines and policy that respect bioethical principles.     

Challenges of preconception genetic testing in France: A qualitative study

Preconception genetic testing is carried out to inform couples on their carrier status for recessive or X-linked genetic disease, and aims to extend their possible reproductive choices. These genetic tests are available in several countries and are currently being considered in France in the context of bioethics laws revision, raising multiple medical, ethical, and societal concerns. To provide insights into questions relative to preconception genetic testing implementation, we conducted, through a qualitative research methodology, individual and group interviews in families with experience of genetic disease, physicians and researchers in the human and social sciences, and an ethics committee. In particular, the respondents agreed on the importance of a free test and an informed choice. The economic stakes of the test appeared to be a major determinant of its development for the participants. The use of genetic data has been a source of raised fears of a eugenic drift. The remaining questions were relative to the pathologies to be tested, the access to the test, its supervision, the role of physicians and in particular of primary care professionals. Based on individual opinions and collective debates, our work delimits the challenges of preconception genetic testing implementation in France through a qualitative methodology, providing further data necessary to its introduction in the health care system.