北京地区早产发生现状及早产儿结局的调查分析

目的 探讨北京地区早产发生现状及不同孕周、不同类型早产儿的结局.方法 选择2006年12月1日-2007年5月31日在北京大学第一医院(北大一院)、首都医科大学附属北京妇产医院(市妇产医院)、北京市海淀区妇幼保健院(海淀妇幼)、北京大学第三医院(北大三院)住院分娩的孕28周～36周~(+6)早产产妇955例及其早产儿1066例为研究对象,4家医院同期分娩数为15 197例.结果 (1)早产发生率:早产总发生率为6.3%(955/15 197).其中北大三院的早产发生率为13.1%(150/1142),北大一院的早产发生率为8.1%(125/1549),市妇产医院的早产发生率为5.5%(369/6656),海淀妇幼的早产发生率为5.3%(311/5850).其中北大三院的早产发生率明显高于其他医院(P<0.01).两家综合医院(北大一院及北大三院)的早产率10.2%(275/2691)明显高于两家专科医院(市妇产医院及海淀妇幼)的早产率5.4%(680/12 506),两者比较,差异有统计学意义(P<0.01).(2)早产发生孕周:<34周的早产发生率为28.5%(272/954),≥34周的早产发生率为71.5%(682/954),早产主要发生在孕34周以后.各家医院的早产发生孕周分布有明显不同,其中,海淀妇幼<34周的早产发生率明显低于其他3家医院(P<0.01),北大一院<34周的早产发生率最高(P<0.05),北大三院与市妇产医院相比较,差异无统计学意义(P>0.05).(3)早产发生的原因:在早产的发生原因排序中,未足月胎膜早破(PPROM)早产占首位(405例),其次为医源性早产(340例)和自发性早产(205例).各医院早产发生的原因有所不同,北大三院的医源性早产率明显高于其他各医院(P<0.01);北大一院的PPROM发生率较高而自发性早产率较低.医源性早产的发生原因排序中前4位分别是子痫前期143例(42.0%),胎儿窘迫58例(17.1%),前置胎盘43例(12.6%),胎盘早剥33例(9.7%).(4)各家医院的早产儿结局比较:4家医院由于早产原因、孕周不同,其早产儿结局也存在较大差异,市妇产医院早产儿死亡率最高,为5.4%(22/408),与海淀妇幼(1.3%,4/320)及北大三院(0.6%,1/170)比较,差异有统计学意义(P<0.01);与北大一院(2.4%,3/124)比较,差异无统计学意义(P>0.05).(5)不同孕周的早产儿结局比较:<32孕周的早产儿治愈率显著低于≥32孕周者(P<0.01),≥34孕周的早产儿治愈率为99.6%.<32孕周的早产分娩家属放弃及早产儿死亡率显著高于332孕周者,其中,<32孕周的早产儿死亡率为22.1%,≥34孕周者仅为0.3%,两者比较,差异有统计学意义(P<0.01).(6)不同原因的早产儿结局比较:医源性早产的早产儿死亡率(4.9%)高于PPROM早产(1.6%),两者比较,差异有统计学意义(P<0.05).PPROM、自发性早产及医源性早产3者的早产儿治愈率相互比较,差异无统计学意义(P>0.05).结论 早产儿死亡率较高,尤其是<32孕周的早产儿死亡率更高,这部分早产儿是早产预防的重点;同时,减少医源性早产,积极预防PPROM早产的发生也是降低早产发生率的重要因素.     

Twins in Ancient Greece: a synopsis

This brief outline associates twins with several aspects of life in Ancient Greece. In Greek mythology twins caused ambivalent reactions and were believed to have ambivalent feelings for each other. Very often, they were viewed as the representatives of the dualistic nature of the universe. Heteropaternal superfecundation, which dominates in ancient myths, explains on one hand, the god-like qualities and, on the other hand, the mortal nature of many twins. An assumption is presented that legends referring to twins might reflect the territorial expansions of Ancient Greeks in Northern Mediterranean, around the Black Sea, in Asia Minor, as well as North East Africa. In conclusion, in Greek antiquity, twins have been used as transitional figures between myth and reality.     

Preterm birth seasonality in Greece: an epidemiological study

Objective: Seasonality of preterm birth has been noted, although not conclusively studied. Weather is also thought to play a role. We sought preterm birth seasonality and additionally studied the effect of weather parameters in the preterm birth pattern. Methods: Vital statistics from the Hellenic Statistical Authority were retrieved, covering the years from 1980 to 2008. Additionally, weather data were retrieved for the years of the study. Time series analysis was used to create various statistical models that would be compared to each other for their accuracy to predict preterm birth. Factors used in the modeling included month of birth, gender and weather factors. Results: Preterm birth seasonality was exhibited. Two peaks of higher risk of preterm birth were noted: One during summer and one during winter. Males were more influenced by seasonality and exhibited slightly different seasonal patterns than females, although no higher risk for preterm birth was noted. The best model that described seasonal pattern of preterm birth was the one that included meteorological factors. Notably, extreme (hotter or colder) weather was accompanied by an increase in preterm birth. Conclusions: Evidence for seasonality of preterm birth was shown and extreme weather was associated with a higher incidence of it.     

胎儿纤维连接蛋白对先兆早产孕妇发生早产的预测价值

目的研究胎儿纤维连接蛋白（fetal fibronectin，fFN）对先兆早产孕妇发生早产的预测价值，及与宫颈长度联合应用时对早产的预测意义。方法联合国内三家医院对有先兆早产症状的孕妇进行阴道后穹窿分泌物中fFN的测定及宫颈的超声检测，追踪这些孕妇的妊娠结局。结果（1）共检测122例先兆早产孕妇，75例fFN阳性，阳性率为61.5％。（2）阳性孕妇中7d内、14d内、37周前分娩率分别为22．7％（17／75）、41．3％（31／75）、65．3％（49／75）；阴性孕妇则分别为0％（0／47）、0％（0／47）、12．8％（6／47）。对于7d内、14d内和37周内分娩的阴性预测值分别为100％、100％和87．2％。（3）50例孕妇同时进行了宫颈长度的测量。以宫颈长度≤26mm为异常。50例中fFN（＋）和宫颈长度同时异常者7d内、14d内、37周前分娩率分别为13．3％（2／15）、40．0％（6／15）、93．3％（14／15），均显著高于fFN（＋）而宫颈长度正常的孕妇。宫颈长度异常而fFN阴性者中无一例14d内分娩。二者同时异常预测先兆早产孕妇发生早产的敏感性为70％，特异性为97．2％，阳性预测值为93．3％，阴性预测值为85．4％。结论（1）在先兆早产孕妇中阴道后穹窿分泌物fFN阳性对先兆早产孕妇发生早产有一定的预测意义，阴性预测短期内不发生早产的价值较大。（2）fFN测定与宫颈长度联合应用可以提高37周前早产阳性预测结果，但对短期内发生早产的预测意义不大。     

胎膜早破致早产266例临床分析

目的探讨早产性胎膜早破的临床处理及母儿结局。方法回顾分析。1993年1月～2002年12月因胎膜早破而早产的266例孕妇，对部分孕妇的宫颈分泌物进行培养并对感染性病因分组比较，采用SAS软件进行计算机统计分析。结果感染为导致胎膜早破的主要原因之一，且与胎膜早破及宫内感染密切相关(P＜0．05)。联合应用抗生素及宫缩抑制剂等适当保胎治疗可延长孕周，保胎组与无保胎组间宫内感染及剖宫产率的差异有显著性(P＜0．05)，＜35孕周的孕妇促胎肺成熟的差异有显著性(P＜0．05)，围生儿死亡的差异有显著性(P＜0．05)。结论早产性胎膜早破的主要病因是感染，应用抗生素及糖皮质激素可改善母儿预后。     

Preterm birth and developmental problems in the preschool age. Part I: minor motor problems

Nearly half of very preterm (VP) and extremely preterm (EP) infants suffers from minor disabilities. The paper overviews the literature dealing with motor problems other than cerebral palsy (CP) during infancy and preschool age. The term “minor motor problems” indicates a wide spectrum of motor disorders other than CP; “minor” does not mean “minimal”, as a relevant proportion of the preterm infants will develop academic and behavioural problems at school age. Early onset disorders consist of abnormal general movements (GMs), transient dystonia and postural instability; these conditions usually fade during the first months. They were underestimated in the past; recently, qualitative assessment of GMs using Prechtl’s method has become a major item of the neurological examination. Late onset disorders include developmental coordination disorder (DCD) and/or minor neurological dysfunction (MND): both terms cover partly overlapping problems. Simple MND (MND-1) and complex MND (MND-2) can be identified and MND-2 gives a higher risk for learning and behavioural disorders. A relationship between the quality of GMs and MND in childhood has been recently described. The Touwen infant neurological examination (TINE) can reliably detect neurological signs of MND even in infancy. However, the prognostic value of these disorders requires further investigations.     

Cervical pathways for racial disparities in preterm births: the Preterm Prediction Study

Abstract

Purpose: Racial disparities in preterm birth have been long recognized, but the social and biological mechanisms for these differences are unclear. Our analysis had three goals: (1) to determine the relation between race and other social risk factors and cervical structure; (2) to determine whether social factors mediate the relation between race and cervical structure; and (3) to determine whether racial disparities in preterm birth (PTB) are mediated through changes in cervical structure observed earlier in pregnancy.

Materials and methods: Data from the Maternal Fetal Medicine Unit network Preterm Prediction Study were used to examine the relation between race and other social factors and cervical properties throughout pregnancy in 2920 black and white women. Outcomes included cervical length and dilation; cervical score (cervical length–internal dilation); and whether membranes protruded at 22–24 and 26–29 weeks. Race, education, income, insurance type, and marital status were examined as predictors of the outcomes using linear and logistic regression, adjusting for age, BMI, parity, and smoking. Mediation analysis was used to examine whether (a) any social factors explained racial differences in cervical properties, and (b) whether cervical properties mediated racial differences in risk for preterm birth.

Results: Shorter cervical length, especially at a subject’s first visit, was associated with black race (adjusted beta ?1.56?mm, p?<?.01) and lower income (adjusted beta ?1.48, p =.05). External dilation was not associated with social factors, while internal dilation was associated with black race and lower education. Black race and marital status were associated with lower cervical score. There was no evidence of mediation of the racial effect on cervical properties by any social factor. Shorter cervical length, dilation, and score were all associated with preterm birth (p?<?.01). Mediation analysis indicated that each of these mediated the effect of race, but explained a small proportion of the total effect (15–25%).

Conclusions: Race, and, to a lesser extent, other social factors are correlated with adverse cervical properties. This pathway could explain a proportion of the racial disparity in preterm birth.     

Impact of chorioamnionitis on short- and long-term outcomes in very low birth weight preterm infants: the Neonatal Research Network Japan

Objective: To evaluate the short- and long-term outcomes among very low birth weight (VLBW) preterm infants after histologic chorioamnionitis (HCA).

Methods: We performed a retrospective analysis of 5849 single infants (birth weight <1500?g) born at a gestational age between 22?+?0 and 33?+?6 weeks. Clinical data were obtained from the Neonatal Research Network Japan between 2003 and 2007. Multivariable logistic regression analyses were performed to assess the effect of HCA on short- and long-term outcome.

Results: According to logistic regression analysis, HCA was associated with lower incidence of respiratory distress syndrome (odds ratio [OR]?=?0.54; p?<?0.001), increased chronic lung disease (OR?=?1.68; p?<?0.001) and sepsis (OR?=?1.71; p?<?0.001) and as a short-term outcomes. There was no significant association with intraventricular hemorrhage (OR?=?1.11; p?=?0.33), periventricular leukomalacia (OR?=?1.07; p?=?.070) and death before discharge (OR?=?0.97; p?=?0.084). HCA was associated with increased home oxygen therapy (OR?=?3.09; p?<?0.001), but not with cerebral palsy (CP; OR?=?0.91; p?=?0.63), develop quotient?<?70 (OR?=?1.27; p?=?0.17), visual impairment (OR?=?1.08; p?=?0.77), severe hearing impairment (OR?=?1.28; p?=?0.62) and death (OR?=?0.98; p?=?0.91) before three years of age.

Conclusions: In this retrospective population-based study in Japan, HCA was not a risk factor for death, neurodevelopmental impairment and CP in VLBW three-year-old preterm infants.     

Delivery in the 'grey zone': collaborative approach to extremely preterm birth

During the recent New South Wales and Australian Capital Territory consensus workshop on Perinatal Care at the limits of viability, recommendations were made in the areas of education, counselling and management. Critically, there was a consensus that between 23 weeks and zero days and 25 weeks and six days of gestation, it was reasonable to offer the option of non-initiation of resuscitation and intensive care. Within this, obligation to treat increases as the gestation advances. Implications of the statement for obstetricians are discussed in this article.     

Oxygen administration at birth in preterm infants: a retrospective analysis

Objective: The aim of the study was to retrospectively investigate the association between initial oxygen concentration in delivery room and short-term outcomes in preterm infants.

Methods: Data from infants needing neonatal resuscitation, born at our department between January 2008 and December 2011, were analyzed. Patients were divided into three groups based on gestational age: between 32 and 36 weeks, between 31 and 28 weeks, and below 28 weeks.

Results: The administration of each additional unit of oxygen up to 50% showed an association with a 5% increased need for mechanical ventilation (MV) in the neonatal intensive care unit in infants between 32 and 36 weeks [adjusted odds ratio 1.1, 95% confidence interval (CI) 1.04–1.1] and infants between 28 and 31 weeks (adjusted odds ratio 1.12, 95% CI 1.08–1.44). On the contrary, in infants below 28 weeks, increasing initial concentration of supplementary oxygen did not show any association with MV.

Conclusions: Initial oxygen concentration seems to be associated with increased MV in the NICU. Our observations further stress the need for randomized controlled studies in order to obtain definitive recommendations for the optimal initial oxygen concentration during neonatal resuscitation of preterm infants.     

Effects of lutein supplementation on biological antioxidant status in preterm infants: a randomized clinical trial

Abstract

Objective: To test the hypothesis that lutein, compared to the placebo, would enhance the total antioxidant status (TAS) in the preterm infants.

Methods: Infants with gestational age (GA) ≤34 weeks were randomly assigned to receive a daily dose of lutein and zeaxanthin (0.5?mg?+?0.02?mg/kg/d) or placebo from the 7th day of life until 40th week of postmenstrual age or until discharge.

Results: Seventy-seven preterm infants were randomized (38 in the Lutein group and 39 in the Placebo group) with mean GA of 30.4 (±2.3) weeks and the mean birth weight of 1415 (±457) grams. The TAS did not result statistically different between the two groups during all the study period, but a significant linear correlation was evidenced between plasma lutein concentration and TAS (r?=?0.14, p?=?0.012) and between plasma zeaxanthin concentration and TAS (r?=?0.13, p?=?0.02).

Conclusions: Supplementation of preterm infants with orally lutein was ineffective in enhancing biological antioxidant capacity. Further studies need to better understand the bioavailability of lutein in the neonatal period in order to identify any best form of supplementation.

Trial registration number: UMIN000007041.     

Temporal Trends in Preterm Birth,Neonatal Mortality,and Neonatal Morbidity Following Spontaneous and Clinician-Initiated Delivery in Canada, 2009-2016

ObjectiveClinician-initiated deliveries at 34 to 36 weeks gestation have increased in Canada since 2006, but the impacts of clinician-initiated deliveries on the overall preterm birth (PTB) rate and concomitant changes in neonatal outcomes are unknown. This study examined gestational age–specific trends in spontaneous and clinician-initiated PTB and associated neonatal mortality and morbidity.MethodsThis population-based study included 1 880 444 singleton live births in Canada (excluding Québec) in 2009-2016, using hospitalization data from the Canadian Institute for Health Information. The primary outcomes were neonatal mortality and a composite outcome mortality and/or severe neonatal morbidity identified by International Statistical Classification of Diseases and Related Health Problems, 10th revision, Canada codes. Outcomes were stratified by spontaneous and clinician-initiated deliveries and gestational age categories. Logistic regression yielded adjusted odds ratios (aORs) per 1-year change and 95% confidence intervals (CIs) (Canadian Task Force Classification II-2).ResultsThe PTB rate remained stable (6.2%) and the proportion of clinician-initiated PTBs increased from 31.0% to 37.9% (P < 0.001). Although overall neonatal mortality remained stable (1.1%), mortality declined among infants born spontaneously at 28 to 33 weeks gestation (aOR 0.92; 95% CI 0.87–0.97). The composite mortality and/or severe morbidity declined from 12.7% to 12.2% (aOR 0.98; 95% CI 0.97–0.99). Declines were observed in the rates of sepsis (aOR 0.96; 95% CI 0.95–0.98) and respiratory distress syndrome requiring ventilation (aOR 0.97; 95% CI 0.96–0.98), whereas rates of intraventricular hemorrhage increased (aOR 1.03; 95% CI 1.01–1.05).ConclusionWith the increase in clinician-initiated deliveries, the stable rates of PTB and neonatal mortality and the decline in composite mortality and/or severe morbidity are encouraging findings. This study adds to clinical understanding of carefully timed and medically justified early interventions.     

Galanin in the amniotic fluid and neonatal birth weight: a prospective observational study

Abstract

Objective: The aim of the present study was to examine whether an association is present between amniotic fluid (AF) galanin and neonatal birth weight (NBW).

Design: Prospective observational study.

Setting: Fetal maternal unit in a tertiary teaching hospital.

Population: Fifty women of singleton pregnancy who underwent amniocentesis during the second trimester and delivered after the 37th week of gestation.

Methods: Amniocentesis 18th–19th gestational week for genetic indication with the use of a 22G needle under real-time sonographic guidance and measurement of galanin concentration in the AF.

Main outcome measures: Association between concentration of AF galanin and NBW at term.

Results: Galanin was isolated in all samples of AF (median concentration 19.95?pg/mL; range: 19.0–21.7). A strong linear correlation between AF galanin and NBW was detected (τ?=?0.928; p?<?0.001). Non-parametric linear regression analysis revealed that galanin concentration could explain 72.1% of the variance in the NBW, when controlling for gestational week at birth and mother’s body mass index at delivery.

Conclusions: AF galanin during the second trimester seems to have a strong linear correlation with NBW of term deliveries in singleton pregnancies, even when controlling for important confounders.     

Neonatal mortality in Sri Lanka: Timing,causes and distribution

Abstract

Objective.?To evaluate the timing, causes and distribution of neonatal deaths in Sri Lanka, to provide information for policy makers, to undertake appropriate measures to achieve the Millennium Development Goals.

Methods.?All neonatal deaths, reported to the Registrar General's Office, Sri Lanka, from 1997 to 2001, were included in the analysis.

Results.?During this 5-year period, 17,946 neonatal deaths have occurred, of them 90.5% have occurred during the first week of life. The leading causes were preterm deliveries (33.2%), infections (19.8%) and cardiac anomalies (17.4%). The neonatal mortality rates (NMR) were higher in districts with specialised neonatal care facilities and high concentration of estates.

Conclusions.?Approximately 3600 neonates die in Sri Lanka annually, even though it has a lower NMR compared to rest of the South Asia. Neonatal deaths were higher in the major cities and in the estate sector. The majority of neonatal deaths were due to complications of preterm birth, neonatal sepsis and cardiac anomalies.