丽水市2016-2019年低出生体重发生情况及影响因素分析

目的 分析丽水市2016-2019年低出生体重发生情况及其影响因素,为减少低出生体重发生率制定干预措施提供依据。方法 回顾性分析丽水市妇幼保健院2016-2019年分娩的934例低出生体重儿发生的临床数据,采用多因素Logistic 回归分析低出生体重发生的危险因素。结果 2016-2019年妇幼保健院共分娩活产19 535例胎儿,其中低出生体重儿934例,发生率为4.78%;2016-2019年低出生体重儿发生率差异无统计学意义(χ²_趋势= 0.019,P=0.891);多因素Logistic 回归显示, 早产(OR=46.283,95%CI:38.408～56.773)、双胎(OR=7.023,95%CI:5.347～9.223)、女婴(OR=1.549,95%CI:1.304～1.841)、妊娠高血压(OR=4.945,95%CI:3.262～7.498)、胎膜早破(OR=1.305,95%CI:1.053～1.618)、胎儿窘迫(OR=2.103,95%CI:1.515～2.919)、胎盘早剥(OR=1.651,95%CI:1.152～2.366)、农村户籍(OR=1.274,95%CI:1.014～1.601)是发生低出生体重的危险因素(P<0.05)。结论 丽水市低出生体重发生率低于全国平均水平,应注重加强农村户籍、妊娠合并高血压和双胎孕妇的围生期管理,避免早产、胎膜早破、胎盘早剥的发生,从而减少低出生体重的发生。     

Another Step Toward Hepatitis C Elimination: An Economic Evaluation of an Irish National Birth Cohort Testing Program

ObjectivesWe aimed to evaluate the cost-effectiveness of offering once-off birth cohort testing for hepatitis C virus (HCV) to people in Ireland born between 1965 and 1985, the cohort with the highest reported prevalence of undiagnosed chronic HCV infection.MethodsSystematic and opportunistic HCV birth cohort testing programs, implemented over a 4-year timeframe, were compared with the current practice of population risk-based testing only in a closed-cohort decision tree and Markov model hybrid over a lifetime time horizon. Outcomes were expressed in quality-adjusted life-years (QALYs). Costs were presented from the health system’s perspective in 2020 euro (€). Uncertainty was assessed via deterministic, probabilistic, scenario, and threshold analyses.ResultsIn the base case, systematic testing yielded the largest cost and health benefits, followed by opportunistic testing and risk-based testing. Compared with risk-based testing, the incremental cost-effectiveness ratio for opportunistic testing was €14 586 (95% confidence interval €4185-€33 527) per QALY gained. Compared with opportunistic testing, the incremental cost-effectiveness ratio for systematic testing was €16 827 (95% confidence interval €5106-€38 843) per QALY gained. These findings were robust across a range of sensitivity analyses.ConclusionsBoth systematic and opportunistic birth cohort testing would be considered an efficient use of resources, but systematic testing was the optimal strategy at willingness-to-pay threshold values typically used in Ireland. Although cost-effective, any decision to introduce birth cohort testing for HCV (in Ireland or elsewhere) must be balanced with considerations regarding the feasibility and budget impact of implementing a national testing program given high initial costs and resource use.     

利用信息技术提高河南省出生缺陷防治管理水平

目的总结通过信息平台,提高出生缺陷防控水平的经验和挑战。方法回顾性总结系统中出生缺陷三级预防措施落实,沿胎儿生命周期获取功能和代谢障碍缺陷个案的数据并进行总结分析。结果平台促进了出生缺陷三级预防措施落实。系统包括11912例有遗传病或缺陷儿家族史的孕妇信息,433例染色体和基因异常胎儿产前诊断记录,7977例结构、功能和代谢障碍儿的体检记录,1266例听力障碍儿;553例苯丙酮尿症儿,2627例先天性甲低代谢障碍儿,并提供随访等技术支持。结论通过信息技术,实现河南省内母代和子代信息互连,建成了出生缺陷从医院监测发展为人群监测的省级平台。     

Diverse Effects of Combinations of Maternal-Neonatal VDR Polymorphisms and 25-Hydroxyvitamin D Concentrations on Neonatal Birth Anthropometry: Functional Phenocopy Variability Dependence,Highlights the Need for Targeted Maternal 25-Hydroxyvitamin D Cut-Offs during Pregnancy

Vitamin D receptor (VDR) polymorphisms have been associated with a plethora of adverse pregnancy and offspring outcomes. The aim of this study was to evaluate the combined effect of maternal and neonatal VDR polymorphisms (ApaI, TaqI, BsmI, FokI, Tru9I) and different maternal and neonatal 25(OH)D cut-offs on neonatal birth anthropometry. This cross-sectional study included data and samples from a cohort of mother–child pairs at birth. A detailed neonatal anthropometry analysis at birth was also conducted. Different 25(OH)D cut-offs for neonates and mothers were included, according to their vitamin D status at birth: for neonates, cut-offs of [25(OH)D ≤ 25 and > 25 nmol/L] and [25(OH)D ≤ 50 nmol/L] were adopted, whereas for mothers, a 25(OH)D cut-off of [25(OH)D ≤ 50 and > 50 nmol/L)] was investigated. Following this classification, maternal and neonatal VDR polymorphisms were evaluated to investigate the potential different effects of different neonatal and maternal 25(OH)D cut-offs on neonatal birth anthropometry. A total of 69 maternal-neonatal dyads were included in final analysis. Weight, neck rump length, chest circumference, abdominal circumference, abdominal circumference (iliac), high thigh circumference, middle thigh circumference, lower arm radial circumference, and lower leg calf circumference of neonates who had the TAQl SNP TT genotype and maternal 25(OH)D < 50 nmol/L were significantly higher than that of neonates who had the Tt or tt genotypes (p = 0.001, Hg = 1.341, p = 0.036, Hg = 0.976, p = 0.004, Hg = 1.381, p = 0.001, Hg = 1.554, p = 0.001, Hg = 1.351, p = 0.028, Hg = 0.918, p = 0.008, Hg = 1.090, p = 0.002, Hg = 1.217, and p = 0.020, Hg = 1.263, respectively). Skin fold high anterior was significantly lower in neonates who had the BSMI SNP BB genotype compared to that of neonates with Bb or bb genotypes (p = 0.041, Hg = 0.950), whereas neck rump length was significantly higher in neonates who had the FOKI SNP FF genotype compared to that of neonates who had Ff or ff genotypes (p = 0.042, Hg = 1.228). Regarding neonatal VDR polymorphisms and cut-offs, the abdominal circumference (cm) of neonates who had the TAQI SNP TT genotype and 25(OH)D < 25 nmol/L were significantly higher than that of neonates who had the Tt or tt genotypes (p = 0.038, Hg = 1.138). In conclusion, these results indicate that the maternal TAQI VDR polymorphism significantly affected neonatal birth anthropometry when maternal 25(OH) concentrations were <50 nmol/L, but not for a higher cut-off of >50 nmol/L, whereas this effect is minimally evident in the presence of neonatal TAQI polymorphism with neonatal 25(OH)D values <25 nmol/L. The implication of these findings could be incorporated in daily clinical practice by targeting a maternal 25(OH)D cut-off >50 nmol/L, which could be protective against any effect of genetic VDR variance polymorphism on birth anthropometry.     

Maternal Vitamin C and Iron Intake during Pregnancy and the Risk of Islet Autoimmunity and Type 1 Diabetes in Children: A Birth Cohort Study

Our aim was to study the associations between maternal vitamin C and iron intake during pregnancy and the offspring’s risk of developing islet autoimmunity and type 1 diabetes. The study was a part of the Finnish Type 1 Diabetes Prediction and Prevention (DIPP) prospective birth cohort including children genetically at risk of type 1 diabetes born between 1997–2004. The diets of 4879 mothers in late pregnancy were assessed with a validated food frequency questionnaire. The outcomes were islet autoimmunity and type 1 diabetes. Cox proportional hazards regression analysis adjusted for energy, family history of diabetes, human leukocyte antigen (HLA) genotype and sex was used for statistical analyses. Total intake of vitamin C or iron from food and supplements was not associated with the risk of islet autoimmunity (vitamin C: HR 0.91: 95% CI (0.80, 1.03), iron: 0.98 (0.87, 1.10)) or type 1 diabetes (vitamin C: 1.01 (0.87, 1.17), iron: 0.92 (0.78, 1.08)), neither was the use of vitamin C or iron supplements associated with the outcomes. In conclusion, no association was found between maternal vitamin C or iron intake during pregnancy and the risk of islet autoimmunity or type 1 diabetes in the offspring.     

冻融胚胎移植周期中不同辅助生殖技术助孕方式和移植不同发育阶段胚胎对出生性别比的影响

目的探讨冻融胚胎移植(frozen-thawed embryo transfer,FET)周期中不同辅助生殖技术(assisted reproductive technology,ART)助孕方式和移植不同发育阶段胚胎对新生儿性别的影响。方法回顾性队列研究分析2010年4月至2018年10月期间于广州市妇女儿童医疗中心生殖中心接受体外受精(in vitro fertilization,IVF)、卵胞质内单精子注射(intracytoplasmic sperm injection,ICSI)和胚胎植入前遗传学检测(preimplantation genetic testing,PGT)治疗并进行FET且成功分娩的患者和新生儿临床资料。比较不同助孕方式及移植不同发育阶段胚胎对新生儿性别的影响。结果①IVF-FET共898对夫妇(920个周期),1166名新生儿,出生性别比为106.7。移植桑葚期前、桑葚期或囊胚期胚胎,出生性别比逐渐增高(99.0,135.4,142.6),但各组间差异无统计学意义(P>0.05)。②ICSI-FET(含PGT)共415对夫妇(433个周期),555名新生儿,出生性别比为111.0。移植不同发育阶段胚胎,出生性别比(116.0、87.2、137.5)差异无统计学意义(P>0.05)。③PGT-FET共33对夫妇(33个周期),33名新生儿,出生性别比为153.8。移植IVF、ICSI或PGT解冻囊胚对出生性别比没有显著影响(P>0.05)。结论在FET周期中,采用IVF技术助孕,移植较晚发育阶段胚胎可能会增加出生性别比的风险;ICSI技术移植不同发育阶段胚胎或移植IVF、ICSI或PGT囊胚对新生儿性别没有显著影响。     

传统炎性标志物对妊娠期肝内胆汁淤积症的诊断及预后预测价值

目的探讨传统炎性标志物对妊娠期肝内胆汁淤积症(ICP)的诊断及预后预测价值。 方法选择2009年1月至2019年1月,于厦门大学附属中山医院消化内科和妇产科确诊的130例ICP患者为研究对象,并纳入ICP组,其中,初产妇为86例,经产妇为44例。根据ICP严重程度,进一步将其分为重度ICP亚组(n＝29)和轻度ICP亚组(n＝101)。选择同期在本院就诊的80例健康孕妇纳入对照组。按照86例初产妇的分娩孕龄,进一步分为ICP早产亚组(n＝37)和ICP足月亚组(n＝49)。采集受试者一般临床资料(年龄、孕龄等),天冬氨酸氨基转氨酶(AST)、丙氨酸转氨酶(ALT)、碱性磷酸酶(ALP)、γ-谷氨酰转肽酶(GGT)、白细胞计数、中性粒细胞计数、淋巴细胞计数、血小板计数、红细胞分布宽度(RDW)、血红蛋白(Hb)、平均血小板体积(MPV)、血细胞比容(HCT)、中性粒细胞与淋巴细胞比值(NLR)、血小板与淋巴细胞比值(PLR)和血清总胆汁酸(sTBA)等。本研究经过厦门大学附属中山医院伦理委员会批准(审批文号：2019076),与所有患者签署临床研究知情同意书。 结果①ICP组和对照组孕妇年龄、中性粒细胞计数、淋巴细胞计数、血小板计数、MPV、ALP、AST、NLR和sTBA比较,差异均有统计学意义(P<0.05)。2组孕妇孕龄、白细胞计数、HCT、Hb、GGT、ALT和PLR比较,差异无统计学意义(P>0.05)。②轻度ICP亚组患者的孕龄大于重度ICP亚组,而轻度ICP亚组患者sTBA浓度低于重度ICP亚组,2组比较,差异均有统计学意义(P<0.05)。此外,2组患者年龄、白细胞计数、中性粒细胞计数、淋巴细胞计数、MPV、HCT、血小板计数、Hb、GGT、ALP、ALT、AST、NLR和PLR比较,差异均无统计学意义(P>0.05)。③NLR、血小板计数和MPV诊断ICP的受试者工作特征曲线(ROC)分析结果：NLR、血小板计数和MPV诊断ICP的曲线下面积(AUC)分别为0.802(95%CI：0.737～0.867,P<0.001), 0.642(95%CI：0.560～0.724,P<0.001)和0.947(95%CI：0.920～0.974,P<0.001);根据约登指数最大原则,NLR、血小板计数和MPV诊断ICP的最佳临界值分别为2.831、254×10⁹/L和9.662 fL,此时其诊断ICP的敏感度分别为71.4%、64.7%和72.2%,特异度分别为81.3%、71.2%和82.5%。④ICP早产亚组与ICP足月分娩亚组孕妇ALT、AST和sTBA水平比较,差异均有统计学意义(P<0.05);而2组孕妇年龄、白细胞计数、中性粒细胞计数、淋巴细胞计数、血小板计数、MPV、PDW、NLR和PLR比较,差异均无统计学意义(P>0.05)。⑤sTBA、ALT、AST预测ICP所致早产的ROC分析结果：sTBA、ALT和AST预测ICP所致早产的AUC分别为0.634(95%CI：0.513～0.751,P<0.05),0.672(95%CI：0.563～0.784,P<0.001)和0.692(95%CI：0.544～0.793,P<0.001);根据约登指数最大原则,sTBA、ALT和AST预测ICP所致早产的最佳临界值分别为48 μmol/L、56 U/L和37 U/L,此时其预测ICP所致早产的敏感度分别为67.2%、62.2%和63.2%,特异度分别为59.6%、41.3%和49.6%。 结论传统炎性标志物NLR、血小板计数、MPV对诊断ICP具有良好准确度,而目前发现的传统炎性标志物对ICP严重程度评估均无价值,sTBA、ALT和AST水平可能对ICP所致早产具有一定预测价值。     

剖宫产术后阴道分娩产妇的临床分析

目的探讨剖宫产术后阴道分娩(VBAC)产妇的母儿结局。 方法选择2016年1月1日至2019年12月31日,四川大学华西第二医院收治的VBAC足月妊娠产妇397例为研究对象,纳入研究组。按照1∶1比例,采用随机数字表法随机抽取同期于本院足月经阴道分娩的非瘢痕子宫产妇397例,作为对照,纳入对照组。观察2组产妇年龄、身高、人体质量指数(BMI)、本次分娩距前次分娩间隔时间、分娩时孕龄,第一、第二、第三产程时间,术中出血量、产后出血(PPH)量(2 h)、PPH率、严重PPH率,以及新生儿出生体重与窒息发生率等指标,并采用成组t检验、Wilcoxon秩和检验、χ²检验和Fisher确切概率法对上述指标进行统计学比较。对2016—2019年本院产妇分娩情况进行分析。2组产妇年龄、身高、BMI、分娩时孕龄等一般临床资料比较,差异均无统计学意义(P>0.05)。本研究遵循的程序符合2013年新修订的《世界医学协会赫尔辛基宣言》要求。 结果①2016—2019年,本院剖宫产术分娩率为58.45%～62.37%,剖宫产术后瘢痕子宫(SUAC)患者再次妊娠的剖宫产术分娩率为93.06%～95.83%,平均为94.60%(10 942/11 567),非SUAC患者的剖宫产术分娩率为50.27%(18 586/36 972)。瘢痕子宫患者为13 963例(28.77%),2017年瘢痕子宫患者所占比例最高,为33.74%(3 361/9 961),此后呈下降趋势。②研究组产妇第一、第二产程时间及术中出血量、PPH量(2 h)、PPH率分别为363 min(212～450 min)、46 min(22～60 min)、312 mL(200～350 mL)、348 mL(230～380 mL)、10.8%(43/397),均显著长于、大于、高于对照组的294 min(180～380 min)、15 min(7～20 min)、231 mL(150～280 mL)、264 mL(180～310 mL)、4.3%(17/397),研究组新生儿出生体重为(3 216±359) g,则显著低于对照组的(3 369±369) g,并且差异均有统计学意义(Z＝4.797、16.065、8.028、8.122,χ²＝12.188,t＝-17.013,均为P<0.001)。③SUAC患者再次妊娠的子宫破裂发生率为1.73/10 000(2/11 567),占VBAC者的0.32%(2/625)。 结论VBAC是可行的,子宫破裂发生率低,但是其PPH风险增加。临床对于此类产妇,产程中应做好监护,积极预防PPH。     

无创高频振荡通气在极低出生体重早产儿呼吸窘迫综合征初始呼吸支持治疗中的应用

目的探讨经鼻无创高频振荡通气(NHFOV),在呼吸窘迫综合征(RDS)极低出生体重早产儿初始呼吸支持治疗的临床疗效。 方法选择2018年2月至2020年4月,于徐州市中心医院新生儿重症监护病房(NICU)治疗的92例RDS极低出生体重早产儿为研究对象。采用随机数字表法,将其分为NHFOV组(n＝48,采取NHFOV治疗)及经鼻持续气道正压通气(NCPAP)组(n＝44,采取NCPAP治疗)。对2组RDS极低出生体重早产儿一般临床资料,无创通气治疗前、后动脉血气分析指标,疗效,呼吸支持治疗相关并发症发生率及患儿死亡率,采用成组t检验、χ²检验及Mann-Whitney U检验进行统计学比较。本研究经徐州市中心医院医学伦理委员会审核批准(审批文号：XZXY-LJ-20170328-006),并且与患儿监护人均签署临床研究知情同意书。 结果①一般临床资料比较：2组RDS极低出生体重早产儿的性别、出生胎龄与体重及生后1、5 min Apgar评分,入院日龄及分娩前24 h母亲糖皮质激素使用率等一般临床资料比较,差异均无统计学意义(P>0.05)。② 2组RDS极低出生体重早产儿动脉血气分析指标组间比较：NHFOV组RDS极低出生体重早产儿无创通气治疗后1 h、24 h动脉血二氧化碳分压(PaCO₂)分别为(45.8±6.5) mmHg(1 mmHg＝0.133 kPa)及(40.8±4.7) mmHg,均显著低于NCPAP组的(49.3±5.7) mmHg及(44.2±5.2) mmHg;治疗后1 h、24 h动脉血氧分压(PaO₂)与吸入氧浓度分数(FiO₂)比值(P/F)分别为(198.8±30.5) mmHg及(215.1±32.1) mmHg,均显著高于NCPAP组的(176.4±28.1) mmHg及(190.0±29.7) mmHg,并且上述差异均有统计学意义(t＝2.809、3.301、3.663、3.881,P＝0.003、<0.001、<0.001、<0.001)。③2组动脉血气分析指标分别进行组内比较均为：无创通气治疗后24 h的pH值及治疗后1、24 h的PaCO₂水平,均较治疗前改善,而且治疗后24 h的P/F值高于治疗后1 h,并且差异均有统计学意义(P<0.05)。④无创通气疗效比较：NHFOV组RDS极低出生体重早产儿无创通气治疗后,肺表面活性剂(PS)使用率及有创机械通气率(22.9%、6.3%),均显著低于NCPAP组(45.5%、20.5%),并且差异均有统计学意义(χ²＝5.219、4.084,P＝0.022、0.043)。2组RDS极低出生体重早产儿无创通气时间、柠檬酸咖啡因使用率、频繁呼吸暂停发生率及总用氧时间比较,差异均无统计学意义(P>0.05)。⑤2组RDS极低出生体重早产儿鼻损伤、肺气漏、新生儿坏死性小肠结肠炎(NEC)、Ⅲ~Ⅳ级脑室内出血(IVH)、早产儿视网膜病(ROP)(≥Ⅱ期)及支气管肺发育不良(BPD)发生率,以及患儿死亡率比较,差异均无统计学意义(P>0.05)。 结论与NCPAP比较,NHFOV用于RDS极低出生体重早产儿初始呼吸支持治疗,能改善氧合、减少二氧化碳(CO₂)潴留、减少有创机械通气及PS使用,同时不增加呼吸支持治疗相关并发症发生。     

新生儿个体化发育支持对极低出生体重儿智力和全身运动发育的影响

目的 分析探讨新生儿个体化发育支持对极低出生体重儿智力和全身运动发育的应用效果和作用。 方法 选取2018年12月1日—2019年7月1日期间在湖南省妇幼保健院出生且符合入选标准的极低出生体重儿90例为研究对象,并随机将其分为对照组(n=37)和观察组(即个体化发育支持组,n=53)。收集所有患儿的基本资料,比较两组体质量恢复时间、完全经口喂养时间及胎粪排尽时间,以及两组患儿的全身运动(general movements,GMs)、患儿智力(mental development index,MDI)、心理运动指数(psychomotor development index,PDI)及发育商(development quotient,DQ)情况,评估两组全身运动及智力发育情况。 结果 观察组的体质量恢复时间为(7.86±2.66)d、完全经口喂养时间为(11.77±3.52)d,胎粪排尽时间为(12.19±4.22)d,时间均短于对照组(均P<0.05);观察组体格变化速度情况高于对照组(P<0.05);随访至矫正胎龄12个月后,观察组全身运动情况、智力发育、心理运动发育指数以及发育商评分均优于对照组(均P<0.001)。 结论 新生儿个体化发育支持可以促进极低出生体重儿智力及全身运动的发育,减少异常GMs发生率,可推广应用。