居家孕妇远程胎心监护103例临床分析

目的:探讨居家孕妇远程胎心监护的临床实践及其应用价值。方法:选择2015年12月至2017年2月在浙江大学医学院附属妇产科医院产前检查的晚期妊娠103例孕妇,其中正常妊娠孕妇50例为正常组,具有高危因素及妊娠合并症或并发症的孕妇53例为高危组。两组孕妇在家进行远程胎心监护,由专业医师对启用孕周、归还/分娩孕周、使用时间、远程胎心监护上传时间和次数(分成≤3次、4~9次及≥10次)等进行分析,同时追踪监护结果及分娩结局。结果:(1)两组孕妇启用孕周比较差异无统计学意义(P0.05),高危组孕妇远程胎心监护的归还/分娩孕周及使用时间均短于正常组(P0.05)。(2)103例孕妇共上传654次,其中≤3次、4~9次及≥10次孕妇的比较中,文化程度(大专及以上)、启用孕周和使用时间上差异有统计学意义(P0.05),而年龄、产次、高危人数及归还/分娩孕周的比较,差异无统计学意义(P0.05)。(3)高危组胎心监护结果异常率(22.8%)高于正常组(5.1%),差异有统计学意义(P0.05)。而两组异常结果复查的比较,差异无统计学意义(14.3%vs 16.2%,P0.05)。(4)远程胎心监护结果异常孕妇中的脐带因素、胎儿窘迫、新生儿窒息、新生儿并发症入NICU的发生率明显高于结果正常孕妇(P0.05)。结论:孕妇远程胎心监护开启了家庭自我监护新途径,是胎儿安全的有力保障,尤其适合于高危妊娠;对伴有脐带因素的胎儿孕期管理具有很好的监测作用。     

无负荷试验与胎儿心电图联合监测251例分析

在胎儿监护中，无负荷试验（ＮＳＴ）和胎儿心电图（ＦＥＣＧ）的单项监测不能全面反映胎儿宫内情况。为此，我院１９９４年３～６月对２５１例足月和过期妊娠的产妇进行ＮＳＴ和ＦＥＣＧ联合监测，现报道如下。１　资料和方法１－１　一般资料　１９９４年３～６月为２７５例孕妇行ＮＳＴ和ＦＥＣＧ联合监护，其中２４例ＦＥＣＧ记录不满意而未能做临床分析。２５１例记录成功的孕妇年龄２０～３９岁，平均２５－７岁。初产妇２２１例，经产妇３０例。孕３７～４１＋６周２１９例，过期妊娠３２例。高危妊娠１１７例，正常妊娠１３４例。１…     

应用聚合酶链反应和酶联免疫吸附试验检测孕妇和胎儿巨细胞病毒感染的研究

目的探讨酶联免疫吸附试验（ＥＬＩＳＡ）和聚合酶链反应（ＰＣＲ）两种方法对孕妇和胎儿人巨细胞病毒（ｈｕｍａｎｃｙｔｏｍｅｇａｌｏｖｉｒｕｓ，ＨＣＭＶ）感染的临床诊断价值。方法１８８１例孕妇用ＥＬＩＳＡ检测血清ＨＣＭＶ－ＩｇＭ，其中６５６例同时用ＰＣＲ检测血ＨＣＭＶＤＮＡ。９９例感染孕妇和４７例非感染孕妇的胎儿同样应用ＥＬＩＳＡ和ＰＣＲ法检测。结果本组孕妇血清ＨＣＭＶ－ＩｇＭ阳性率为２．４％，血ＨＣＭＶＤＮＡ阳性率为１２．０％。感染孕妇的胎儿血ＨＣＭＶ－ＩｇＭ和（或）ＨＣＭＶＤＮＡ阳性率为１７．２％。ＨＣＭＶ－ＩｇＭ、ＨＣＭＶＤＮＡ单项阳性或合并阳性的孕妇宫内传播率分别为１８．５％、１４．８％、２７．３％。ＥＬＩＳＡ和ＰＣＲ同时检测６５６例孕妇和１４６例胎儿血，结果显示有相关性。ＰＣＲ检测阳性率显著高于ＥＬＩＳＡ检测阳性率。结论ＥＬＩＳＡ与ＰＣＲ同时检测可提高对孕妇和胎儿ＨＣＭＶ感染的诊断率。     

产前B族链球菌感染对母儿的影响

目的　了解孕妇的Ｂ族链球菌（ＧＢＳ）带菌情况及对新生儿的影响。　方法　对１２０ 例产妇产前取阴道后穹窿分泌物,分娩后取胎盘子面分泌物及新生儿胃液分别检测ＧＢＳ,留脐血检测Ｃ反应蛋白、ＩｇＭ、ＩｇＧ 抗体,产后观察母婴情况并随访６ 周。　结果　产前母体ＧＢＳ带菌率１５－８％ ,胎盘带菌率１０ ％ ,新生儿带菌率３－３ ％ ,患病率０－８３ ％ 。ＧＢＳ阳性孕妇既往流产史多,胎膜早破、早产发生率较阴性者高（Ｐ＜ ０．０５） 。产时胎儿窘迫、羊水混浊及新生儿低体重、新生儿肺炎发生率虽比阴性者高,但无统计学意义。脐血Ｃ反应蛋白、ＩｇＭ、ＩｇＧ 无明显升高。　结论　为降低ＧＢＳ感染对围产期母儿的患病率,应对孕妇常规行ＧＢＳ筛检,阳性孕妇应给予预防性治疗并于产前复查,产时应对ＧＢＳ阳性孕妇及新生儿给予适当治疗以避免发生并发症。     

产间声振胎动监护效果分析

分析１５８例产妇产间声振胎动试验预测胎儿预后的效果。结果 有胎动组１１５例，无胎动组４３例；新生儿窒息率，有胎动组为１．７４％（２／１１５），无胎动组为１１．６３％（５／４３），两组比较具有显著差异（Ｐ〈０．０５）。产间声振胎动预测胎儿酸中毒及新生儿窒息的各项预测率依次分别为阳性预测率２３．３％，１１．６％；阴性预测率８６．９％，９８．３％；敏感性４０．０％，７１．４％；特异性７５．２％，７４．８     

延期妊娠对羊水过少患者妊娠结局的影响

目的:探讨延期妊娠对羊水过少患者妊娠结局的影响.方法:选取我院2002年6月至2012年6月因羊水过少晚期妊娠的孕妇183例作为研究组(孕40+1～41+6周为研究组1,孕37～40周为研究组2),对应选取不同孕周羊水量正常孕妇183例为对照组(孕40+1～41+6周为对照组1,孕37 ～40周为对照组2),应用回顾性对照研究的方法分析各组孕产妇的临床资料,比较各组孕产妇在产前胎儿窘迫及胎盘功能、分娩方式方面的差异.结果:胎儿窘迫、胎盘钙化、剖宫产发生率比较:研究组1均高于对照组1与研究组2(P＜0.05);研究组2与对照组2以上指标比较,差异均无统计学意义(P＞0.05).所有病例均未出现新生儿窒息.结论:在延期妊娠的羊水过少孕妇中,胎儿窘迫、胎盘钙化发生率明显增高,应积极引产,出现胎儿窘迫应以剖宫产为宜.     

对妊娠肝内胆汁淤积症孕妇进行胎儿监护的临床意义

目的 探讨对妊娠肝内胆汁淤积症（ＩＣＰ）孕妇进行胎儿监护的监床价值。方法 对２０６例ＩＣＰ孕妇进行无负荷试验（ＮＳＴ）和声振刺激试验（ＶＡＳ－Ｔ）,对其中５１例进行宫缩和试验（ＣＳＴ）或产素激惹试验（ＯＣＴ）,１５７例进行超声脐动脉血流分析,１２７例进行胎儿心电图检查,结果 ＯＣＴ和超声脐血流分析结果异常者的围产儿预后不良的发生率分别为７３．３％和５０．０％,明显高于下沉者的２７．８;％和３３．０     

三城市孕妇人巨细胞病毒感染及其母婴传播的流行病学调查

目的：分析武汉、上海及沈阳三城市孕妇人巨细胞病毒（ＨＣＭＶ）感染及其母婴垂直传播状况。探讨早期诊断胎儿ＨＣＭＶ宫内感染的方法。方法：应用酶联免疫吸附法（ＥＬＩＳＡ）筛查５０１５例孕妇ＨＣＭＶ的特异性抗体（ＩｇＧ及ＩｇＭ），同时应用聚合酶链反应技术（ＰＣＲ）检测其中３０１例具有活动性ＨＣＭＶ感染者的胎儿附属物，新生儿血、尿及母乳的ＨＣＭＶＤＮＡ。结果：三城市孕妇ＨＣＭＶ感染率为８８．９３％；沈阳、上海分别为９６．７４％和９１．４２％，明显高于武汉（７９．５３％）；孕妇活动性感染率为５．４２％，武汉与沈阳分别为１１．２３％和１０．９８％，明显高于上海。有异常妊娠史孕妇的活动性感染率为１４．５９％；孕早期绒毛和孕中期羊水的ＨＣＭＶＤＮＡ阳性率分别为１６．００％和３５．３３％；羊水的ＨＣＭＶＤＮＡ阳性率与分娩期脐血、胎盘、新生儿血相比较，差异无显著性（Ｐ＞０．０５）。结论：我国城市孕妇ＨＣＭＶ感染有地区差异，三城市孕妇多数于孕前早已感染ＨＣＭＶ；孕妇于活动性感染时易传播胎儿，ＥＬＩＳＡ结合ＰＣＲ方法是当前诊断宫内ＨＣＭＶ感染的有效手段     

妊娠妇女及围产儿巨细胞病毒感染的研究

应用酶联免疫法（ＥＬＩＳＡ），对不同孕周孕妇２５６例及其中８４例巨细胞病毒ＩｇＭ抗体（ＨＣＭＶ－ＩｇＭ）阳性的妊娠晚期孕妇所分娩新生儿的脐血，进行ＨＣＭＶ－ＩｇＭ检测。结果：妊娠早期、中期妇女的４２份血清标本中，ＨＣＭＶ－ＩｇＭ阳性１７例，感染率为４０．４８％。妊娠晚期２１４份标本中，ＨＣＭＶ－ＩｇＭ阳性８４例，感染率为３９．２５％。ＨＣＭＶ－ＩｇＭ阳性者围产儿死亡率、新生儿窒息抢救率、胎儿畸形及有异常妊娠病史的妊娠妇女的比例均增加（Ｐ＜０．０１）。提示：ＨＣＭＶ－ＩｇＭ阳性表明妊娠妇女近期有巨细胞病毒（ＨＣＭＶ）感染，或既往有隐性的ＨＣＭＶ感染，在妊娠期复发（活动性感染）。     

443例妊娠期肝内胆汁郁积症临床分析

１９８７年１月至１９９３年９月我院分娩孕妇１２７１６例，其中妊娠期肝内胆汁郁积症（ＩＣＰ）４４３例，发生率３．４８％。ＩＣＰ主要表现为皮肤瘙痒、黄症及ＳＧＰＴ升高，４４３例中发生早产８５例，发生率为１９．２％。死胎１３例，死产８例，新生儿早期死亡３例，围产儿病死率为５４．２％。新生儿Ａｐｇａｒ评分≤７分者４８例，占１０．８％。新生儿平均体重３０８２ｇ。本文认为，早期诊断，孕期加强监护，产时严密观察     

远程胎儿监护在脐带绕颈孕妇产前自我保健中的作用

目的　探讨远程胎儿监护对提高脐带绕颈孕妇产前保健质量的作用。方法　根据家庭自我监护方式的不同 ,将脐带绕颈的孕妇分为试验组和对照组 ,试验组 (896例 )为远程胎儿监护和胎动计数者 ;对照组 (1914例 )为单纯胎动计数者。分别统计两组无负荷试验 (NST)、胎儿宫内窘迫、新生儿窒息、医院内外死胎、死产的资料。结果　试验组远程NST为反应型、无反应型和变异减速频繁发生的百分率 (分别为 2 5 6 %、16 1%、5 9 1% )与试验组常规NST(分别为 33 7%、11 5 %、33 4 % )和对照组常规NST(分别为 30 8%、12 1%、31 8% )比较 ,差异均有显著性 (P <0 0 5 ) ;试验组和对照组常规NST比较 ,差异无显著性 (P >0 0 5 )。试验组胎儿宫内窘迫检出率 (35 0 % )较对照组 (30 9% )明显升高 (P <0 0 5 ) ;试验组新生儿窒息的发生率 (3 5 % )较对照组 (5 6 % )明显降低 (P <0 0 5 )。医院外试验组死胎发生率 (0 1% )较对照组 (0 8% )明显降低 (P <0 0 1) ;两组医院内死胎发生率比较 ,差异无显著性 (P >0 0 5 ) ;两组间分娩方式比较 ,差异无显著性 (P >0 0 5 )。结论　远程胎儿监护可降低脐带绕颈孕妇新生儿窒息的发生率 ,减少医院外死胎的发生率 ;对手术产率无明显影响。远程胎儿监护为脐带绕颈孕妇家庭自     

Cohort study of Silastic obstetric vacuum cup deliveries: II. Unsuccessful vacuum extraction

In a cohort analysis of Silastic vacuum extractor deliveries, 65% were completed with the vacuum extractor alone, 24% with outlet forceps, 3% with midforceps, and 7% with cesarean section (vacuum extractor-cesarean). Control groups were formed by using the next sequential forceps delivery, spontaneous vaginal delivery, and every second cesarean section after a trial of labor. The infants were examined using a neurobehavioral scale, an encephalopathy assessment, cranial ultrasound, and indirect ophthalmoscopy. In the combined vacuum extractor and forceps delivery subgroup (vacuum extractor-forceps), all but 3% were converted from a high mid-forceps delivery to outlet forceps by the initial vacuum extractor procedure, thus eliminating many difficult midforceps deliveries. The study yielded no significant difference in maternal morbidity between vacuum extractor-forceps and forceps delivery, no difference in vaginal trauma for vacuum extractor-cesarean versus vacuum extractor delivery, and no greater hospital stay, infection rate, or need for transfusion for either vacuum extractor-forceps versus forceps delivery or vacuum extractor-cesarean versus cesarean delivery. Neonatal morbidity did not differ between successful and unsuccessful trial of vacuum extractor, except for an increased frequency of retinal hemorrhage. The frequency of scalp trauma, including cephalohematoma, did not differ between vacuum extractor-forceps and forceps delivery, or between vacuum extractor-cesarean and vacuum extractor delivery. For vacuum extractor-forceps versus forceps delivery and vacuum extractor-cesarean versus cesarean section, there were no significant differences in neurobehavioral or encephalopathy scores, or in the frequency of neonatal jaundice, facial palsy, anemia, fractures, or mortality.(ABSTRACT TRUNCATED AT 250 WORDS)     

Are Routine Interventions Necessary in Normal Birth?

Routine interventions during labor and birth, such as perineal shaving and enemas before vaginal delivery, continuous intrapartum electronic fetal monitoring (EFM), and episiotomy are prevalent in Taiwan, but they may not always be necessary. Numerous studies investigating these interventions have failed to find absolute benefits for women with uncomplicated and low-risk pregnancies. No evidence-based benefits support routine perineal shaving or enemas during labor for reducing the risk of perineal wound infection or neonatal infection. The use of EFM is associated with an increased rate of operative interventions (vacuum, forceps, cesarean delivery) but does not result in a significant decrease in the incidence of perinatal death or cerebral palsy. Routine episiotomy does not have demonstrable advantages over restrictive episiotomy in the frequency or severity of perineal damage or pelvic relaxation.     

METHODS OF FETAL HEART RATE MONITORING DURING LABOR

A review of the history of fetal heart rate monitoring is followed by detailed analysis of eight randomized, controlled trials and of a recent prospective study of electronic fetal monitoring compared with intermittent auscultation. No significant differences between the methods were reported in perinatal mortality rates, neonatal infection rates, and Apgar scores. Mixed results were reported for length of labor, maternal analgesic use during labor, maternal genital tract infection rates, umbilical cord pH values, and admissions to neonatal intensive care units. Auscultation was associated in two trials with a significantly increased rate of neonatal seizures. Electronic fetal monitoring was correlated with a significantly increased cesarean delivery rate in the first four trials, and with a significantly increased rate of operative delivery (forceps plus cesarean delivery) in three later trials. A decision tree is presented to assist the clinician in selecting the appropriate fetal monitoring method for a given client.     

What to do after a failed attempt of vacuum delivery?

OBJECTIVES: To determine whether there is a difference in maternal and neonatal outcomes if a sequential operative vaginal or cesarean delivery follows failed vacuum delivery. STUDY DESIGN: A cross sectional study. We have analyzed maternal and neonatal outcomes of 215 vacuum extractions (group 1), 106 forceps assisted deliveries (group 2), 28 deliveries in which failed vacuum extraction were followed by forceps delivery (group 3) and 22 deliveries in which failed vacuum extraction were followed by cesarean delivery (group 4). RESULTS: Compared to other groups, patients in group 4 had significantly more post partum anemia, meconium stained amniotic fluid and hospital stay (both maternal and neonatal) as well as lower pH. Apgar scores were similar in groups 3 and 4. Incidence of respiratory distress syndrome, cephalhematoma and jaundice were similar in neonates of all groups. CONCLUSIONS: If an attempted vacuum delivery has failed, the risk of adverse neonatal outcome is increased with either subsequent forceps or cesarean delivery. It should remain in the judgment of the attending obstetrician to choose the method most suitable under the given circumstances.     

Choosing between bad,worse and worst: what is the preferred mode of delivery for failure of the second stage of labor?*

Objective: To determine the preferred mode of delivery (vacuum, forceps or cesarean delivery) for second-stage dystocia.

Methods: Retrospective cohort study of women delivered by forceps, vacuum or cesarean delivery due to abnormalities of the second stage of labor. Primary outcome included neonatal and maternal composite adverse effects.

Results: A total of 547 women were included: 150 (27.4%) had forceps delivery, 200 (36.5%) had vacuum extraction, and 197 (36.1%) had cesarean section. The rate of neonatal composite outcome was significantly increased in vacuum extraction (27%) compared to forceps delivery (14.7%) or cesarean section (9.7%) (p?p?=?0.004).

Conclusion: Operative vaginal delivery was associated with reduced postpartum infection compared to cesarean section. Forceps delivery was associated with reduced risk for adverse neonatal outcome compared to vacuum extraction, with no increase in the risk of composite maternal complications.     

蛛网膜下腔-硬膜外联合阻滞麻醉用于分娩镇痛206例分析

目的　探讨分娩镇痛的效果及对产程、母婴状况的影响。方法　采用蛛网膜下腔 -硬膜外联合阻滞(CSEA)用于分娩镇痛的产妇 2 0 6例作为观察组 ,将未采用任何分娩镇痛药物而进入产程的产妇 2 0 6例作为对照组 ,分别观察产程时间、分娩方式、产后出血、胎儿窘迫及新生儿窒息情况。结果　两组产程活跃期比较 ,有极显著性差异 (P <0 0 1) ;两组分娩方式比较有显著性差异 (P <0 0 5 ) ;两组胎儿窘迫、新生儿窒息及产后出血发生率比较 ,无显著性差异 (P >0 0 5 )。结论　CSEA用于分娩镇痛 ,疼痛阻滞完善 ,加速了产程活跃期及第二产程的进展 ,降低了剖宫产及阴道难产率 ,对母婴均无不良影响     

A multicenter controlled trial of fetal pulse oximetry in the intrapartum management of nonreassuring fetal heart rate patterns

OBJECTIVE: Recent developments permit the use of pulse oximetry to evaluate fetal oxygenation in labor. We tested the hypothesis that the addition of fetal pulse oximetry in the evaluation of abnormal fetal heart rate patterns in labor improves the accuracy of fetal assessment and allows safe reduction of cesarean deliveries performed because of nonreassuring fetal status. STUDY DESIGN: A randomized, controlled trial was conducted concurrently in 9 centers. The patients had term pregnancies and were in active labor when abnormal fetal heart rate patterns developed. The patients were randomized to electronic fetal heart rate monitoring alone (control group) or to the combination of electronic fetal monitoring and continuous fetal pulse oximetry (study group). The primary outcome was a reduction in cesarean deliveries for nonreassuring fetal status as a measure of improved accuracy of assessment of fetal oxygenation. RESULTS: A total of 1010 patients were randomized, 502 to the control group and 508 to the study group. There was a reduction of >50% in the number of cesarean deliveries performed because of nonreassuring fetal status in the study group (study, 4. 5%; vs. control, 10.2%; P =.007). However, there was no net difference in overall cesarean delivery rates (study, n = 147 [29%]; vs. control, 130 [26%]; P = .49) because of an increase in cesarean deliveries performed because of dystocia in the study group. In a blinded partogram analysis 89% of the study patients and 91% of the control patients who had a cesarean delivery because of dystocia met defined criteria for actual dystocia. There was no difference between the 2 groups in adverse maternal or neonatal outcomes. In terms of the operative intervention for nonreassuring fetal status, there was an improvement in both the sensitivity and the specificity for the study group compared with the control group for the end points of metabolic acidosis and need for resuscitation. CONCLUSION: The study confirmed its primary hypothesis of a safe reduction in cesarean deliveries performed because of nonreassuring fetal status. However, the addition of fetal pulse oximetry did not result in an overall reduction in cesarean deliveries. The increase in cesarean deliveries because of dystocia in the study group did appear to result from a well-documented arrest of labor. Fetal pulse oximetry improved the obstetrician's ability to more appropriately intervene by cesarean or operative vaginal delivery for fetuses who were actually depressed and acidotic. The unexpected increase in operative delivery for dystocia in the study group is of concern and remains to be explained.     

妊娠晚期缺铁性贫血对妊娠结局的影响

目的：探讨妊娠晚期缺铁性贫血对产妇和新生儿的影响,提出相应预防措施。方法：按照2013年《妇产科学》第8版对妊娠期缺铁性贫血诊断的最新分类,回顾性分析421例妊娠晚期缺铁性贫血患者（其中轻度贫血组368例,重度贫血组53例）和同期入院的正常产妇（对照组500例）。对比分析3组研究对象的产后出血率、剖宫产率、产钳助产率、羊水过少发生率、羊水污染率、胎儿窘迫率、新生儿窒息率、低体质量儿出生率。结果：重度贫血组产后出血率、剖宫产率、羊水污染率、胎儿窘迫率、新生儿窒息发生率,低体质量儿出生率高于轻度贫血组和对照组（均P＜0.05）。轻度贫血组羊水污染发生率,胎儿窘迫率,低体质量儿出生率高于对照组（均P＜0.05）。3组患者产钳助产率和羊水过少发生率差异无统计学意义（均P＞0.05）。结论：妊娠期缺铁性贫血对产科妊娠结局有不良影响,应加强妊娠期贫血的防治。     

Early and late intraventricular hemorrhage: the role of obstetric factors.

OBJECTIVE: To evaluate the influence of active phase labor and other obstetric factors on the development of periventricular-intraventricular hemorrhage in the neonate. METHODS: A total of 230 infants were studied. Antenatal enrollment was carried out when estimated fetal weight was 1750 g or less. Serial head ultrasound scans were performed to screen for periventricular-intraventricular hemorrhage, with the initial scan performed within minutes of birth. Scan findings and obstetric and neonatal variables collected prospectively at scheduled intervals were analyzed to determine the significant factors that predispose to intraventricular hemorrhage. RESULTS: In 47 infants (20%), intraventricular hemorrhage was detected within 1 hour of birth (early) and in another 49 (21%) at a later age (late). The overall incidence of hemorrhage was similar between vaginal and cesarean deliveries (41 and 44%, respectively). Early hemorrhage was more frequent in vaginal (28%) than cesarean deliveries (11%), whereas late hemorrhage was more frequent in cesarean deliveries. When the role of delivery mode and labor was analyzed by stepwise logistic regression, the odds ratios for development of early intraventricular hemorrhage increased in the following order: cesarean delivery with no labor, cesarean delivery with latent phase labor, vaginal delivery with forceps use, cesarean delivery with active phase labor, and vaginal delivery without forceps use. For late hemorrhage, the odds ratios increased in the following order: vaginal delivery with forceps, vaginal delivery without forceps, cesarean delivery with no labor, cesarean delivery with latent phase labor, and cesarean delivery with active phase labor. CONCLUSIONS: Active phase labor may predispose to early periventricular-intraventricular hemorrhage, but its influence may be attenuated by use of forceps or by abdominal delivery. The protective effect of forceps remains for late periventricular-intraventricular hemorrhage, but abdominal delivery does not seem to protect against late hemorrhage.