产后出血高危预警及防范

产后出血是我国孕产妇死亡的第一位因素,子宫收缩乏力、胎盘胎膜残留、软产道损伤、凝血功能异常是常见原因。孕妇分娩前体重指数（BMI） >25.9、贫血、宫高>34.5cm, 高龄,瘢痕子宫等均是发生产后出血的临床预警信息。对具备这些警示信息的孕产妇,应及时采取针对性防范措施,以降低产后出血的发生率。     

Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study.

OBJECTIVE: The study was aimed to identify obstetric risk factors for early postpartum hemorrhage (PPH) in singleton gestations and to evaluate pregnancy outcome. STUDY DESIGN: A comparison between consecutive singleton deliveries with and without early PPH was performed. Deliveries occurred during the years 1988-2002 in a tertiary medical center. A multivariate logistic regression model was constructed in order to define independent risk factors for PPH. RESULTS: Postpartum hemorrhage complicated 0.4% (n = 666) of all deliveries enrolled in the study (n = 154 311). Significant risk factors for PPH, identified using a multivariable analysis, were: retained placenta (OR 3.5, 95%CI 2.1-5.8), failure to progress during the second stage of labor (OR 3.4, 95%CI 2.4-4.7), placenta accreta (OR 3.3, 95%CI 1.7-6.4), lacerations (OR 2.4, 95%CI 2.0-2.8), instrumental delivery (OR 2.3, 95%CI 1.6-3.4), large for gestational age (LGA) newborn (OR 1.9, 95%CI 1.6-2.4), hypertensive disorders (OR 1.7, 95%CI 1.2-2.1), induction of labor (OR 1.4, 95%CI 1.1-1.7) and augmentation of labor with oxytocin (OR 1.4, 95%CI 1.2-1.7). Women were assigned into three different groups according to the assessed severity of PPH, assuming that the severe cases were handled by revision of the birth canal under anesthesia, and the most severe cases required in addition treatment with blood products. A significant linear association was found between the severity of bleeding and the following factors: vacuum extraction, oxytocin augmentation, hypertensive disorders as well as perinatal mortality, uterine rupture, peripartum hysterectomy and uterine or internal iliac artery ligation (p < 0.001 for all variables). CONCLUSION: Hypertensive disorder, failure to progress during the second stage of labor, oxytocin augmentation, vacuum extraction and LGA were found to be major risk factors for severe PPH. Special attention should be given after birth to hypertensive patients, and to patients who underwent induction of labor or instrumental delivery, as well as to those delivering LGA newborns.     

Matching risk and resources in high-risk pregnancies

Objective.?To evaluate the joint impact of pregnancy risk and the timing of referral of high-risk pregnancies from obstetricians to maternal fetal medicine (MFM) sub-specialists on gestational age (GA) at delivery.

Methods.?For the period 1992–2002, 2567 consecutive deliveries from pregnancies of at least 23 weeks gestational age (GA) from a community-level sub-specialty perinatal center were studied. A multiple regression model was developed specifying the impact of various risk factors and referral timing.

Results.?Prior pregnancy risk was inversely related to GA at birth. Referral timing, operationalized as a continuous variable, did not have a significant additive impact on GA at birth, but several dummy-variable interaction effects combining risk factors and referral before 20 weeks as a dichotomy were significant.

Conclusion.?There are identifiable risks that occur either before the pregnancy or early into it that should lead to early referral to a sub-specialist because of their impact on GA at birth. Early referral is an important tactic in a larger preterm prevention strategy, but it needs to be embedded in a broader maternal-fetal health initiative in which both generalists and sub-specialists play important roles.     

Psychological causative factors in postpartum depression amongst women with normal and high-risk pregnancies

OBJECTIVES: The study presented in the following article was based on the assumption a state of mind of a mother-to-be directly influences her state of mind after giving birth. The aim of the study was to determine whether a case of a high-risk pregnancy, and the related stress, can be significant causative factors in postpartum depression, in case of pregnancies with a normal course, as well as whether incidences of postpartum depression among women with normal and high-risk pregnancies are correlated with the level of stress and depression experienced during pregnancy. MATERIALS AND METHODS: 70 women were examined in the study: 35 women with normal pregnancies represented the control group and 35 women with high-risk pregnancies represented the study group. The following methods were used to find answers to the posed research questions: a demographic survey, Perceived Stress Scale, the Beck Depression Scale and the Edinburgh Postnatal Depression Scale. RESULTS: Women with high-risk pregnancies demonstrated a significantly much higher level of stress and related negative emotions; also they handled the stress and emotions worse than women with normal pregnancies. Also, higher intensity of depression symptoms during pregnancy were observed in the study group of women with high-risk pregnancies. In both groups, higher intensity of symptoms of post-childbirth depression was correlated with higher level of stress and more severe depression during pregnancy. CONCLUSIONS: Pregnancy--especially high-risk pregnancy, which is associated with health difficulties and complications, and consequently, higher stress level, feelings of uncertainty and depression--is an additional risk factor of postpartum depression. There exists a necessity to create therapeutic programs aimed at psychological support for suffering women.     

Matching risk and resources in high-risk pregnancies.

OBJECTIVE: To evaluate the joint impact of pregnancy risk and the timing of referral of high-risk pregnancies from obstetricians to maternal fetal medicine (MFM) sub-specialists on gestational age (GA) at delivery. METHODS: For the period 1992-2002, 2567 consecutive deliveries from pregnancies of at least 23 weeks gestational age (GA) from a community-level sub-specialty perinatal center were studied. A multiple regression model was developed specifying the impact of various risk factors and referral timing. RESULTS: Prior pregnancy risk was inversely related to GA at birth. Referral timing, operationalized as a continuous variable, did not have a significant additive impact on GA at birth, but several dummy-variable interaction effects combining risk factors and referral before 20 weeks as a dichotomy were significant. CONCLUSION: There are identifiable risks that occur either before the pregnancy or early into it that should lead to early referral to a sub-specialist because of their impact on GA at birth. Early referral is an important tactic in a larger preterm prevention strategy, but it needs to be embedded in a broader maternal-fetal health initiative in which both generalists and sub-specialists play important roles.     

Analysis of premature twin pregnancies and deliveries

Preterm labor is the most frequent complication of twin gestation. Between 1988-1998, 123 twin pregnancies complicated by preterm labor were observed. Complications during pregnancy, mode of delivery, neonatal outcomes, mortality and morbidity were presented. We compared our outcomes to data from current literature.     

Women with endometriosis at first pregnancy have an increased risk of adverse obstetric outcome

Objective: To evaluate pregnancy, delivery and neonatal outcome in singleton primiparous versus multiparous women with/without endometriosis.

Methods: Multicentric, observational and cohort study on a group of Caucasian pregnant women (n?=?2239) interviewed during their hospitalization for delivery in five Italian Gynecologic and Obstetric Units (Siena, Rome, Padua, Varese and Florence).

Results: Primiparous women with endometriosis (n?=?219) showed significantly higher risk of small for gestational age fetuses (OR: 2.72, 95% CI 1.46–5.06), gestational diabetes (OR: 2.13, 95% CI 1.32–3.44), preterm premature rupture of membranes (OR: 2.93, 95% CI 1.24–6.87) and preterm birth (OR: 2.24, 95% CI 1.46–3.44), and were hospitalized for a longer period of time (p?n?=?1331). Multiparous women with endometriosis (n?=?97) delivered significantly more often small for gestational age fetuses (OR: 2.93, 95% CI 1.28–6.67) than control group (n?=?592). Newborns of primiparous women with endometriosis needed more frequently intensive care (p?=?0.05) and were hospitalized for a longer period of time (p?Conclusions: Women with endometriosis at first pregnancy have an increased risk of impaired obstetric outcome, while a reduced number of complications occur in the successive gestation. Therefore, it is worthy for obstetricians to increase the surveillance in nulliparous women with endometriosis during pregnancy.     

Maternal serum soluble CD30 is increased in pregnancies complicated with acute pyelonephritis

Objectives. Normal pregnancy is characterized by activation of the innate immunity and suppression of the adaptive limb of the immune response. However, pregnant women are more susceptible to the effects of infection and microbial products than non-pregnant women. CD30 is a member of the tumor necrosis factor receptor superfamily and is preferentially expressed by activated T cells producing Th2-type cytokines. Its soluble form (sCD30) is proposed to be an index of Th2 immune response. High serum concentrations of sCD30 have been found in the acute phase of viral infections, such as HIV-1 and hepatitis B. There is, however, conflicting evidence about serum sCD30 concentration in patients with bacterial infections. The objective of this study was to determine whether there are changes in the serum concentration of sCD30 in pregnant women with pyelonephritis.

Methods. This cross-sectional study included normal pregnant women (N = 89) and pregnant women with pyelonephritis (N = 41). Maternal serum concentration of sCD30 was measured by a specific and sensitive enzyme-linked immunoassay. Non-parametric tests were used for comparisons. A p value <0.05 was considered statistically significant.

Results. (1) Pregnant women with pyelonephritis had a significantly higher median serum concentration of sCD30 than those with a normal pregnancy (median 44.3 U/mL, range 16–352.5 vs. median 29.7 U/mL, range 12.2–313.2, respectively; p < 0.001), and (2) No significant differences were found in the median maternal serum concentration of sCD30 between pregnant women with pyelonephritis who had a positive blood culture compared to those with a negative blood culture (median 47.7 U/mL, range 17.1–118.8 vs. median 42.6 U/mL, range 16–352.5, respectively; p = 0.86).

Conclusions. Acute pyelonephritis during pregnancy is associated with a higher maternal serum concentration of sCD30 than normal pregnancy. This finding is novel and suggests that pregnant women with pyelonephritis may have a complex immune state in which there is activation of some components of what is considered a Th2 immune response.     

Fetal polycythemia and thrombocytopenia in pregnancies complicated by maternal diabetes mellitus.

In 40 pregnancies complicated by maternal diabetes mellitus umbilical venous blood was obtained by cordocentesis within 24 hours of elective delivery at 36 to 40 weeks' gestation. The mean fetal hematocrit was significantly higher and the mean platelet count significantly lower than the corresponding values of our reference ranges. Furthermore, blood gas analysis demonstrated these fetuses to be normoxemic but acidemic. The degree of fetal acidemia was significantly associated with both maternal and fetal blood glucose concentrations. The fetal hematologic indices were significantly related to the maternal glycosylated hemoglobin percentage but not to the degree of fetal acidemia or to the maternal or fetal blood glucose concentration at the time of cordocentesis. Fetal acidemia, polycythemia, and thrombocytopenia may contribute to the increased incidence of late unexplained intrauterine deaths in pregnancies complicated by maternal diabetes mellitus.     

Young maternal age associated with increased risk of postneonatal death

OBJECTIVE: To determine whether full-term, healthy infants born to early adolescent mothers (15 years old and younger) are at higher risk of postneonatal death compared with infants of adult mothers. METHODS: We combined the comprehensive 1996 and 1997 United States birth cohorts to compare postneonatal mortality rates among maternal age groups. With postneonatal death as our main outcome measure, we used multivariable logistic regression to model adjusted odds ratios. RESULTS: The postneonatal mortality rate for infants born to mothers 15 years old and younger was substantially higher (3.2 per 1000) than that of infants born to mothers 23-29 years old (0.8 per 1000) and remained substantially higher after adjusting for maternal race or ethnicity. Even after adjusting for maternal race or ethnicity, prenatal care utilization, and marital status, infants born to early adolescent mothers had a three-fold higher risk (odds ratio 3.0, 95% confidence interval 2.5, 3.6) of postneonatal death compared with adult mothers. CONCLUSION: Healthy infants born to early adolescent mothers are at increased risk of postneonatal death. Many of these deaths are potentially preventable; therefore, developing targeted postnatal support services specifically designed to address the needs of healthy infants born to adolescent mothers might have a positive effect on the lives of these children.     

Dilemma of increased obstetric risk in pregnancies following IVF-ET

Purpose : To determine the rates of pregnancy complications following in vitro fertilization in comparison with those in a matched control group. Methods : A total of 13,543 deliveries at the Department of Obstetrics and Gynecology, University of Szeged, between January 1, 1995 and February 28, 2002 were subjected to retrospective analysis. The 230 (1.7%) pregnancies following IVF-ET were evaluated and matched with spontaneous pregnancies concerning age, parity, gravidity, and previous obstetric outcome. Demographic and selected maternal characteristics, pregnancy and labor complications, and neonatal outcome were compared in the two groups. Results : The pregnancy complication rate was partly significantly higher among the singleton IVF-ET pregnancies. The obstetric risk was elevated, though not significantly concerning twin pregnancies. Conclusions : IVF-ET presents an additional obstetric risk. The neonatal outcome displays a significant difference only concerning an increased premature birth rate of singleton pregnancies. Triplet IVF-ET pregnancies involve a much higher risk of both pregnancy complications and neonatal outcome.     

Maternal serum soluble CD30 is increased in pregnancies complicated with acute pyelonephritis.

OBJECTIVES: Normal pregnancy is characterized by activation of the innate immunity and suppression of the adaptive limb of the immune response. However, pregnant women are more susceptible to the effects of infection and microbial products than non-pregnant women. CD30 is a member of the tumor necrosis factor receptor superfamily and is preferentially expressed by activated T cells producing Th2-type cytokines. Its soluble form (sCD30) is proposed to be an index of Th2 immune response. High serum concentrations of sCD30 have been found in the acute phase of viral infections, such as HIV-1 and hepatitis B. There is, however, conflicting evidence about serum sCD30 concentration in patients with bacterial infections. The objective of this study was to determine whether there are changes in the serum concentration of sCD30 in pregnant women with pyelonephritis. METHODS: This cross-sectional study included normal pregnant women (N = 89) and pregnant women with pyelonephritis (N = 41). Maternal serum concentration of sCD30 was measured by a specific and sensitive enzyme-linked immunoassay. Non-parametric tests were used for comparisons. A p value <0.05 was considered statistically significant. RESULTS: (1) Pregnant women with pyelonephritis had a significantly higher median serum concentration of sCD30 than those with a normal pregnancy (median 44.3 U/mL, range 16-352.5 vs. median 29.7 U/mL, range 12.2-313.2, respectively; p < 0.001), and (2) No significant differences were found in the median maternal serum concentration of sCD30 between pregnant women with pyelonephritis who had a positive blood culture compared to those with a negative blood culture (median 47.7 U/mL, range 17.1-118.8 vs. median 42.6 U/mL, range 16-352.5, respectively; p = 0.86). CONCLUSIONS: Acute pyelonephritis during pregnancy is associated with a higher maternal serum concentration of sCD30 than normal pregnancy. This finding is novel and suggests that pregnant women with pyelonephritis may have a complex immune state in which there is activation of some components of what is considered a Th2 immune response.     

Increased incidence of spontaneous abortion in pregnancies complicated by maternal diabetes mellitus

A retrospective sample of 164 pregnancies in the years 1956 to 1975 of 78 insulin-dependent diabetic women was examined to assess the extent of the risk of clinically recognizable spontaneous abortion relative to the expected risk in a comparable population. This study was done before the implementation of the policy to establish good control of maternal diabetes before conception was attempted. After control of data for pregnancy number, maternal age, and epoch, the risk of spontaneous abortion among the diabetic women was almost double the estimate of the expected risk (p less than 0.001).     

The utility of an obesity-specific small for gestational age standard for pregnancies complicated by maternal obesity*

Introduction: An obesity-specific standard for small for gestational age (SGA) pregnancies may help identify additional at risk pregnancies.

Methods: This was a retrospective cohort study of all non-anomalous singleton neonates born in Texas from 2006–2011. Analysis was limited to births between 34 and 42?weeks gestation. Two SGA birth weight standards (birth weight ≤10th centile) were generated, one using the entire population (SGA_pop) and another using obese pregnancies (SGA_cust). The outcomes of interest included: risks of stillbirth, neonatal death, 5-minute Apgar score below 7, NICU admission, and assisted ventilation?>6?h.

Results: Using the population standard, the prevalence of SGA complicated by obesity was 8.1%, compared with 10.3% using the obesity-specific standard. 10,457 additional pregnancies were identified as SGA. Compared to obese AGA pregnancies, the aHR for stillbirth was 5.45 [4.28, 6.94] for SGA_pop, and 1.21 [0.54, 2.74] for SGA_cust-pop. The risks for the following neonatal complications were slightly higher for SGA_cust-pop group compared to AGA group: neonatal death aOR 1.40 [1.05, 1.87], low 5-minute Apgar 1.31 [1.09, 1.57], and NICU admission 1.13 [1.03, 1.25]. These risks were lower than SGA_pop.

Conclusions: Using an obesity-specific SGA standard, a subgroup of pregnancies with marginally increased risk for neonatal complications was identified.