传统剖宫产与新式剖宫产术后再次剖宫产289例临床分析

目的分析不同剖宫产手术方式对再次剖宫产的影响,了解瘢痕子宫再次剖宫产手术的风险．以提高手术的安全性。方法回顾性分析289例再次剖宫产患者。其中对照组157例,前次手术为传统的腹部纵切口子宫下段剖宫产术,研究组132例,前次手术为新式剖宫产术。比较两组患者一般情况,包括：前次剖宫产间隔时间、年龄、孕周、新生儿体重等方面;术中情况,包括：开腹时间、总手术时间、术中出血量、粘连状况;术后情况,包括：术后排气时间、产褥病率、切口感染、产后出血。结果两组间一般情况各项比较。差异均无统计学意义。术中情况比较,研究组手术开腹时间、总手术时间、无粘连例数和重度粘连例数均明显低于对照组．前者分别为（8．33±2．65）min、（43．79±3．65）min、57例、15例,后者分别为（11．25±4．03）rain、（51．95±4．55）min、47例、48例,差异有统计学意义（P〈0．05）。术后情况比较,术后排气时间差异有统计学意义（P〈0．01）。结论新式剖宫产再次手术因粘连发生率低、手术时间短、术后恢复快,有利于降低再次剖宫产的手术难度和并发症的发生,值得在临床加以推广。     

全身麻醉对剖宫产产妇与新生儿医疗结局影响的研究进展

目前椎管内麻醉仍是推荐的剖宫产首选麻醉方式,但随着气道管理设备的不断改良以及新型麻醉药物的广泛应用,全身麻醉在剖宫产中的安全性已大幅提高。但是全身麻醉会延长产妇的住院时间、增加ICU入住率及深静脉血栓等并发症发生率,对新生儿也会产生一定的负面影响。为进一步了解全身麻醉在剖宫产中的应用,现就全身麻醉对剖宫产产妇与新生儿医疗结局的影响进行如下综述。     

Case report and mini literature review: anesthetic management for severe peripartum cardiomyopathy complicated with preeclampsia using sufetanil in combined spinal epidural anesthesia

Peripartum cardiomyopathy (PPCM) is a rare entity, and anesthetic management for cesarean section of a patient with this condition can be challenging. We hereby present the anesthetic management of a patient with PPCM complicated with preeclampsia scheduled for cesarean section, along with a mini review of literature. A 24 year-old primigravida with twin gestation was admitted to our hospital with severe PPCM and preeclampsia for peripartum care, which finally required a cesarean section. Preoperative optimization was done according to the goal of managing left ventricular failure. Combined spinal epidural (CSE) anaesthesia with bupivacaine and sufentanil was used for cesarean section under optimal monitoring. The surgery was completed without event or complication. Postoperative pain relief was adequate and patient required only one epidural top up with sufentanil 6 hours after operation. To the best of our knowledge there is no report in literature of the use of sufentanil as a neuraxial opioid in the anesthetic management of cesarean section in a patient with PPCM. CSE with sufentanil may be a safer and more effective alternative in such cases.     

医用胶粘合剖宫产腹部切口效果观察

目的采用医用胶粘合剖宫产腹部切口的方法取代传统缝合皮肤切口。方法将剖宫产随机分成两组,研究组(应用康派特医用胶粘合皮肤切口)100例,对照组(应用4/0可吸收线连续缝合切口)100例。观察术后切口渗血渗液、线结反应红斑、硬结,观察术后切口瘢痕增生明显程度。结果两组切口甲级愈合率无显著差异(P>0.05)。研究组手术时间短,术后切口炎症轻,愈合快,疤痕小,外观好。结论应用康派特医用胶粘合剖宫产切口,省力、省时,避免了切口皮肤因缝合产生的线结反应红斑、硬结及瘢痕增生。     

Acute Shunt Malfunction after Cesarean Section Delivery: A Case Report

Shunt malfunctions that require surgical intervention during pregnancy and the postpartum period are rare. Furthermore, no study has reported on an acute shunt malfunction immediately after cesarean section. Here, we describe the case of a 32-yr-old woman who became drowsy 12 hr after cesarean section delivery of her second child. She had a ventriculoperitoneal shunt placed to treat hydrocephalus associated with meningitis at 26 yr of age. Marked ventriculomegaly was seen on brain computed tomography and her consciousness recovered temporarily after aspirating cerebrospinal fluid from the flushing device. At surgery, the distal catheter tip was plugged by a blood clot. We believe that the blood spilled over during the cesarean section. The clogged catheter end was simply cut off and the remaining catheter was repositioned in the peritoneal cavity. Her consciousness recovered fully.     

两种术式剖宫产再次开腹时粘连情况比较

目的通过再次手术时对比两种不同剖宫产术后腹壁瘢痕及腹腔粘连情况,探讨新式剖宫产不缝合腹膜的可行性及其优越性。方法通过回顾性分析方法,对有剖宫产手术史156例再次开腹手术腹腔粘连程度、粘连部位进行观察分析。其中新式剖宫产96例,子宫下段剖宫产60例。结果腹壁瘢痕愈合情况、大网膜、腹膜、膀胱反折腹膜粘连情况,在新式剖宫产组明显优于传统子宫下段剖宫产组,不缝合腹膜与缝合腹膜,粘连发生有显著性差异。结论新式剖宫产术在腹壁切口愈合及腹腔粘连方面优于子宫下段剖宫产,不缝合腹膜可减少粘连。新式剖宫产有诸多优越性,值得临床推广应用。     

金属夹板外固定与可吸收骨锚系统治疗早期闭合性锤状指

背景：可吸收骨锚治疗锤状指是一种新型的内固定方法。 目的：比较金属夹板外固定与可吸收骨锚系统治疗早期闭合性锤状指病例的临床效果。 方法：早期闭合性锤状指病例40例,其中采用金属夹板外固定治疗24例,采用可吸收骨锚内固定治疗16例,受伤至给予治疗时间均为1周以内。对两组患者临床资料及手术结果进行回顾性分析,并对两组的优良率进行统计学分析。 结果与结论：所有病例均获得随访4个月以上,最长随访时间14个月。参照国际手外科学会推荐的TAM系统评定法,金属夹板外固定组优良率66.7%;可吸收骨锚内固定组优良率93.8%,两组间差异有显著性意义(P < 0.05),金属夹板固定组有2例分别于治疗后4个月,6个月出现复发;骨锚组有1例功能锻炼时出现局部肿痛、皮肤发红,经物理治疗后好转,表明可吸收骨锚内固定组的疗效显著优于金属夹板外固定组。可吸收骨锚系统治疗过程简单,效果肯定,是治疗早期闭合性锤状指的首选治疗方法,但其价格昂贵,未能广泛开展;金属夹板虽然操作简单,但是治疗过程中管理困难,复发率发高。     

Clinical analysis of 16 patients with acute pancreatitis in the third trimester of pregnancy

Aim: Acute pancreatitis (AP), in particular, severe acute pancreatitis (SAP), is a rare but challenging complication during pregnancy in terms of diagnosis and management. The objective of this paper is to investigate the causes and therapeutic strategies of AP in patients during the third trimester of pregnancy. Methods: We performed a retrospective analysis of the clinical features, laboratory data, and outcomes in 16 patients with acute pancreatitis during the third trimester of pregnancy. Results: Information was collected on admission, management, and outcome. A total 16 patients were diagnosed with acute pancreatitis during pregnancy. In 7 of 9 patients with mild AP, pregnancy was terminated by cesarean section and all 9 cases were cured. In 4 out of 7 patients with SAP, pregnancy was terminated by cesarean section in conjunction with peritoneal irrigation and drainage, and the mothers and infants survived. In the remaining 3 patients with SAP, there was one case of intrauterine death in which Induced labor was performed and 2 patients died of multiple organ failure. Conclusion: A high-fat diet and cholelithiasis are the triggers of AP in pregnancy. Conservative treatment is the preferred therapeutic method; in particular, for mild AP. Endoscopic surgery and peritoneal drainage are effective for acute biliary pancreatitis. Patients with hyperlipidemic pancreatitis should undergo lipid-lowering therapy, and hemofiltration should be done as soon as it becomes necessary. For patients with SAP, termination of pregnancy should be carried out as early as possible.     

Comparative study of the effect of intravaginal misoprostol at 50 and 100 micrograms in cervical ripening and labor induction

The objective of this work was to compare the efficacy of 50 and 100 microg of misoprostol administered intravaginally for cervical ripening and labor induction. Ninety-five patients were randomly assigned to receive 50 microg (n=48) or 100 microg (n=47) of misoprostol. The primary measures in this study were cesarean section rate, time from induction to delivery, need for oxytocin use, rate of uterine hyperstimulation and tachysystoles, proportion of fetal distress and neonatal Apgar score. The interval from first dose of prostaglandin to delivery was significantly shorter in the 100 ,g-group (p < 0.05). The use of oxytocin augmentation was significantly higher in the 50 microg-group (64.6% vs. 31.9%). There were 9 cases (18.8%) of tachysystole in the 50-microg group and 12 cases (25.5%) in the 100 microg-group (p NS). The cesarean section rate was double in the 100 microg-group and the difference was statically significant (p < 0.05). There was no report of uterine rupture. It can be concluded that 50 microg of misoprostol applied in the posterior vaginal fornix every 4 hours is an effective dosage for labor induction and has less adverse effects and complications than the 100 microg dose.     

Cesarean-associated complications: the importance of a scarcely justified use

Undoubtedly, cesarean section is one of the most important surgical procedures for solving obstetrical problems. However, the steady increase in its use might be reflecting a non-medically justified utilization. This work reviews the main complications associated to cesarean section and their effect on the health of mothers and their children. An additional objective is to highlight the importance of establishing clinical protocols aimed at identifying those cases in which a cesarean section should be practiced. The implementation of these guidelines might help to reduce the effect that factors such as preferences of medical personnel or women's demand exert upon the increase of cesarean section use.     

Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians

Guidelines for medical practice can contribute to improved care only if they succeed in moving actual practice closer to the behaviors the guidelines recommend. To assess the effect of such guidelines, we surveyed hospitals and obstetricians in Ontario before and after the release of a widely distributed and nationally endorsed consensus statement recommending decreases in the use of cesarean sections. These surveys, along with discharge data from hospitals reflecting actual practice, revealed that most obstetricians (87 to 94 percent) were aware of the guidelines and that most (82.5 to 85 percent) agreed with them. Attitudes toward the use of cesarean section were congruent with the recommendations even before their release. One third of the hospitals and obstetricians reported changing their practice as a consequence of the guidelines, and obstetricians reported rates of cesarean section in women with a previous cesarean section that were significantly reduced, in keeping with the recommendations (from 72.2 percent to 61.1 percent; P less than 0.01). The surveys also showed, however, that knowledge of the content of the recommendations was poor (67 percent correct responses). Furthermore, data on actual practice after the publication of the guidelines showed that the rates of cesarean section were 15 to 49 percent higher than the rates reported by obstetricians, and they showed only a slight change from the previous upward trend. We conclude that guidelines for practice may predispose physicians to consider changing their behavior, but that unless there are other incentives or the removal of disincentives, guidelines may be unlikely to effect rapid change in actual practice. We believe that incentives should operate at the local level, although they may include system-wide economic changes.     

小剂量舒芬太尼在剖宫产术麻醉中预防寒战及 牵拉痛的疗效评价

目的 小剂量舒芬太尼在剖宫产术麻醉时用于预防寒战及牵拉痛两方面具体的疗效。方法 选取2016年10月~2017年10月在佳木斯市妇幼保健计划生育指导中心行剖宫产术的120例产妇为研究对象,使用随机数字表法将120例研究对象分为麻醉组和对照组各60例,对照组使用常规麻醉药物罗哌卡因葡萄糖注射液,麻醉组在对照组基础上施加小剂量舒芬太尼,比较两组患者寒战和牵拉痛的发生情况以及手术时间、术后恢复时间和住院时间。结果 麻醉组寒战发生率6.67%和牵拉痛发生率8.33%低于对照组31.67%和35.00%,两组差异有统计学意义（P<0.05）;麻醉组产妇术后恢复时间（20.31±1.57）min和住院时间（5.14±1.60）d短于对照组的（28.94±2.58）min和（7.51±1.45）d,两组差异有统计学意义（P<0.05）。结论 小剂量舒芬太尼用于剖宫产术麻醉中预防寒战及牵拉痛的作用突出,可有效降低产妇在剖宫产术中寒战和牵拉痛的发生率,同时缩短患者术后恢复时间和住院时间,有利于产妇的术后恢复,值得推广。     

剖宫产术切口两种缝合法的对比分析

目的 改进剖宫产切口的缝合技术。方法 将100例产妇随机分为两组，其中50例采用快薇乔可吸收线皮内连续缝合手术切口(观察组)，50例采用三针间断褥式缝合手术切口(对照组)。比较两组住院时间及术后伤口愈合情况。结果 切口缝合时间观察组与对照组相比明显延长，但平均住院时间明显短于对照组，观察组甲级愈合率明显高于对照组，且愈合后皮肤较对照组平整，呈一条淡红色细线状瘢痕，皮下无硬结。结论 快薇乔可吸收线皮内连续缝合较三针间断褥式缝合效果好，值得推广。     

The physician factor in cesarean birth rates

To investigate the influence of physicians' practice styles on the rate of deliveries by cesarean section, we studied 1533 affluent women at low risk of obstetrical complications who were cared for by 11 obstetricians in a single community hospital. The mean rate of delivery by cesarean section was 26.9 percent, but the rate ranged from 19.1 to 42.3 percent, according to the physician. The mean rate of primary cesarean section (i.e., the rate for women without previous cesarean deliveries) was 17.2, with a range of 9.6 to 31.8 percent. A stepwise logistic-regression model of the determinants of primary cesarean section, including the individual physician, parity, birth weight, and maternal age and excluding specific medical indications, showed that only nulliparity (P less than 0.0001) was more important than the identity of the physician (P less than 0.001) in its influence on the rate of cesarean section. Variation in cesarean-section rates among physicians was not attributable to the practice setting, the patient population, the degree of obstetrical risk, or the physician's recent medicolegal experience, and it was not accompanied by corresponding differences in neonatal outcome. We conclude that individual practice style may be an important determinant of the wide variations in the rates of cesarean delivery among obstetricians. Our data do not permit us to say with certainty whether the procedure is overused by some obstetricians or underused by others, but we found no obvious differences in neonatal outcome associated with differences in the cesarean-section rate.     

妊高征剖宫产术后并发大量腹水临床分析及预防措施

目的 探讨妊高征剖宫产术后并发大量腹水临床特点及预防.方法 回顾分析5例妊高征剖宫产术后大量腹水（腹水组）和21例妊高征剖宫术后无腹水病例（对照组）.结果 腹水组总蛋白、白蛋白、血色素水平明显低于对照组（P＜0.05）术前腹水明显多于对照组（P＜0.01）.术后白细胞及中性粒细胞明显高于对照组（P＜0.05）.结论 妊高征剖宫产术后大量腹水与患者术前病情（术前大量腹水、低蛋白血症、贫血）、潜在感染及术中清除大量腹水加重低蛋白血症有关.因此,补充白蛋白、控制感染、孕期纠正贫血十分重要.     

Cesarean section before the onset of labor and subsequent motor function in infants with meningomyelocele diagnosed antenatally

Background. Meningomyelocele can now be detected before birth. Few data are available on its natural history, however, and optimal management at the time of delivery is controversial, although it has been suggested that labor and vaginal delivery may cause pressure on exposed nerve roots, resulting in additional loss of neural function. Methods. To assess the effect of labor and the type of delivery on the level of motor function in fetuses with uncomplicated meningomyelocele, we identified 200 cases of this disorder, accounting for 95 percent of the cases that occurred in the state of Washington during our 10-year study period. We compared the outcomes of 47 infants delivered by cesarean section before labor began, 35 delivered by cesarean section after a period of labor, and 78 who were delivered vaginally (another 40 were ineligible for the study). In cases of meningomyelocele detected prenatally, cesarean section was performed before the onset of labor if isolated meningomyelocele without severe hydrocephalus was present. The infants delivered in this manner were compared with those who were delivered either vaginally or by cesarean section after labor began. Results. At two years of age, the infants who had been exposed to labor were 2.2 times more likely to have severe paralysis than those delivered by cesarean section without labor (95 percent confidence interval, 1.7 to 2.8). Infants delivered by cesarean section before the beginning of labor had a mean (+/- SD) level of paralysis 3.3 +/- 3.0 segments below the anatomical level of the spinal lesion at two years of age, as compared with 1.1 +/- 2.3 for infants delivered vaginally and 0.9 +/- 4.1 for infants delivered by cesarean section after the beginning of labor (P less than 0.001 for both comparisons). Exposure to labor did not affect the frequency of neonatal complications or later intellectual performance. Conclusions. For the fetus with uncomplicated meningomyelocele, delivery by cesarean section before the onset of labor may result in better subsequent motor function than vaginal delivery or delivery by cesarean section after a period of labor.     

Purification and properties of peritoneal eosinophils from pediatric dialysis patients

Peritoneal eosinophilia frequently occurs in patients undergoing peritoneal dialysis. We have devised a method for isolating large numbers of these peritoneal eosinophils from pediatric patients on continuous peritoneal dialysis. Patients were selected on the basis of previous high peritoneal eosinophil counts and had an age range of 1.5-11 years. The unfractionated peritoneal fluid contained 7.9 +/- 3.7% neutrophils, 3.8 +/- 1.0% lymphocytes, 11.0 +/- 3.7% monocytes/macrophages, and 77.3 +/- 6.3% eosinophils (based on Wright stain) and up to 2 x 10(9) cells could be recovered from 1 liter of peritoneal dialysate. The cells were concentrated by centrifugation and the cell suspension then layered over a discontinuous Percoll gradient consisting of layers of 45%, 55%, 65%, and 75% Percoll. The gradients were centrifuged resulting in the formation of bands of cells at the interfaces of the layers. The densest band of cells (above 75% Percoll) contained 94.7 +/- 1.8% eosinophils (mean with median of 98%) and 4.3 +/- 16% neutrophils. The eosinophil counts were 72.2 +/- 7.1% above the 65% layer, 57.1 +/- 8.7 above 55%, and 40.9 +/- 10.9% above 45%. The monocyte/macrophage count increased from 0.1% above the 75% layer to 42.9% above the 45%. The denser eosinophils (above 75% and 65%) had the appearance of normal blood eosinophils and comparable function to blood eosinophils in cytotoxic and oxidative assays. This method provides a means of obtaining large numbers of very pure eosinophils for study of eosinophil function, eosinophil subpopulations, or eosinophil granule constituents.     

Method of Delivery and Parent-Newborn Interaction

Concern over the increased rate ofcesarean section deliveryhas led to a number of investigations that have focused on theeffects of surgical delivery. The purpose of the present investigationwas to determine if method of delivery was related to neonatalbehavior, parental behavior, parental perceptions, or mother-newborninteraction. The investigation employed 20 full-term healthyinfants in each of the following four groups: Firstborn vaginaldelivery, later-born vaginal delivery, firstborn emergency cesarean,and later-born repeat cesarean section. Measures were takenon the second day after delivery and included the Neonatal PerceptionInventory (NPI), a mother-infant feeding observation, the BrazeltonNeonatal Behavioral Assessment Scale (BNBAS), and the State-TraitInventory. Multivariate analyses performed on the method ofdelivery by sex of infant by birth order design indicated nosignificant differences for infant behavior, parental perceptionsof infant behavior, or mother-infant interaction. There wasa significant main effect for birth order and State scores,with mothers of firstborn infants exhibiting less optimal transitoryanxiety scores. These findings suggest that the current concernover cesarean deliveries and their impact on parents and infantsmay be partially unfounded.     

探讨使用仿生助产仪对剖宫产率的影响

目的：探讨使用仿生助产仪对剖宫产率的影响.方法：采用KCB-Ⅰ型全自动仿生助产仪,200例产妇行宫颈及阴道扩张术为观察组,并分别与自然经历产程的200例产妇做对照.比较两组产程的长短、难产发生率及其剖宫产率.结果：观察组产程时间、阴道分娩率、剖宫产率均明显低于对照组（P＜0.01）.结论：仿生助产仪可明显缩短产程、降,有效降低剖宫产率.     

可吸收固位钉治疗多发性肋骨骨折

背景：介绍可吸收材料的种类及优点,可吸收肋骨钉治疗多发性肋骨骨折适应证及禁忌证。对比观察采用可吸收固位钉和保守方法治疗多发性肋骨骨折的疗效。 方法：以“肋骨骨折,可吸收固位钉,内固定”为检索词,检索2002/2010 PubMed数据库、维普数据库与可吸收固位钉与多发性肋骨骨折相关文献,重点探讨了可吸收材料的种类及优点,以及可吸收肋骨钉治疗多发性肋骨骨折适应证及禁忌证。并进行了临床验证,对120例多发性肋骨骨折的患者采用可吸收钉进行内固定,同时以行保守治疗的多发肋骨骨折患者80例做对照。 结果：可吸收肋骨固定钉具有良好的组织相容性;抗弯曲强度略高于人体骨皮质;无毒副作用;3~5年可完全降解,避免二次手术。临床验证表明采用可吸收钉固定的患者恢复肋骨连续性,胸骨疼痛持续时间,住院时间较保守治疗者明显缩短(P < 0.01);同时可吸收钉固定患者的肺不张例数,胸廓畸形例数,胸腔积液例数,胸膜粘连例数比保守治疗者减少(P < 0.01)。 结论：对胸外伤引起多根多段肋骨骨折,用可吸收肋骨钉进行固位方法简易,并发症少,疗效可靠。