胎膜破裂前后羊水及脐血厌氧菌培养68例分析

对６８例胎膜早破、临产后破膜及胎膜未破的孕产妇，在剖宫产术中取羊水及脐血作厌氧菌培养。结果：普通培养（＋）１５例次，厌氧培养（＋）２０例次，阳性结果在胎膜早破组和临产破膜组比较无明显差异（Ｐ〉０．０５）；两破膜组与胎膜未破组比较有显著差异（Ｐ〈０．００１）；感染组与非感染组比较，前者破膜距手术时间较后者明显延长（Ｐ〈０．００１）。胎膜未破组也有阳性结果出现。认为：①产科感染中厌氧菌感染占半数以上；     

肿瘤坏死因子在妊高征发病中的作用

目的：探讨肿瘤坏死因子（ＴＮＦ）在妊高征发病中的作用及其对胎儿生长的影响。方法：应用放射免疫法对正常晚期妊娠妇女１６例（对照组）及妊高征患者４６例（妊高征组）的血浆、羊水和新生儿脐血中ＴＮＦ进行检测。结果：分娩前妊高征组血浆ＴＮＦ水平较对照组高，以中、重度妊高征者增高显著（Ｐ＜０．０５）；产后７２小时妊高征组血浆ＴＮＦ水平下降，与对照组差异无显著性。对照组及轻度妊高征者新生儿脐血ＴＮＦ水平与母血接近，羊水ＴＮＦ水平明显低于母血（Ｐ＜０．０５）；中、重度妊高征者脐血和羊水ＴＮＦ水平均较母血低（Ｐ＜０．０５；Ｐ＜０．０１）。新生儿脐血、羊水中ＴＮＦ水平在两组间差异无显著性。在中、重度妊高征者中，合并胎儿生长迟缓者其羊水和新生儿脐血ＴＮＦ水平明显高于未合并胎儿生长迟缓者。结论：ＴＮＦ可能作为母体对胎儿抗原的异常免疫反应的重要介质，在妊高征的发病中起一定作用。     

硬膜外麻醉剖宫产术中输注佳乐施对胎儿氧供的影响

目的：估计硬膜外剖宫产术中输佳乐施（血定安）对胎儿氧运输的效力，以增加胎儿氧供及母体循环稳定。方法：采用随机对照方法，对４８例择期剖宫产产妇分别输注佳乐施（Ｇ组，ｎ＝２４）和林格氏液（Ｒ组，ｎ＝２４）进行临床观察。结果：输注佳乐施后母体血液稀释，Ｐ＜０．０１；Ｈｃｔ由０．３５６±０．０５４下降至０２５９±０．０３９，Ｐ＜０．０１；动脉血氧含量（ＣａＯ２）降低Ｐ＜０．０５；胎儿脐静脉血ｐＨ、ＰｖＯ２、ＳｖＯ２、ＣｖＯ２、脐动脉血ＰａＯ２显著高于输林格氏液者（Ｐ值分别为＜０．０５，＜０．０５，＜０．０１，＜０．０１，＜０．０５）。结论：佳乐施组胎儿氧供、氧耗都增加，但氧供的增加超过氧耗的增加，胎儿无血液稀释作用。提示：硬膜外麻醉剖宫产术中输注佳乐施能改善胎儿体内代谢状态，并能增加氧储，提高胎儿对麻醉及手术期间缺氧的耐受力。     

足月胎膜早破的引产时机对妊娠结局的影响

目的：探讨足月胎膜早破孕妇引产时机对妊娠结局的影响。方法：选取青岛大学附属医院和临沂市中心医院2015年1月—2017年12月足月妊娠胎膜早破孕妇1 474例，根据宫颈评分及引产时间分为4组。A组，Bishop评分≥6分，破膜2 h未临产缩宫素引产；B组，Bishop评分≥6分，破膜12 h未临产缩宫素引产；C组，Bishop评分＜6分，破膜2 h未临产缩宫素引产；D组Bishop评分＜6分，破膜12 h未临产缩宫素引产。回顾性分析4组的妊娠结局。结果：A、B两组间阴道分娩率差异无统计学意义（P＞0.05）；而D组阴道分娩率高于C组，差异有统计学意义（P＜0.05）。A组的产褥期感染率、引产并发症总发生率明显低于B组（P＜0.05），而C组孕妇引产并发症总发生率、胎儿窘迫率、新生儿转科率高于D组（P＜0.05）。结论：足月胎膜早破孕妇，宫颈成熟者可破膜后2 h引产，宫颈不成熟者，可期待至破膜后12 h引产。     

人乳头状瘤病毒母婴垂直传播的临床观察

应用聚合酶链反应（ＰＣＲ）方法，对３０例妊娠晚期妇女宫颈分泌物及其新生儿生后１２￣４８小时的咽部分泌物，１３例剖宫产术中留取的羊水进行人乳头状瘤病毒（ＨＰＶ）检测。结果：孕妇宫颈、新生儿咽部、羊水中的ＨＰＶ检出率分别为５３．３％（１６／３０）、４６．７％（１４／３０）、２３．１％（３／１３）。３例羊水阳性者中，１例伴有新生儿咽部分泌物阳性。提示：ＨＰＶ可经羊水传播给胎儿，剖宫产不能完全阻止母婴垂直     

胎膜早破孕妇血清和羊水白细胞介素6及肿瘤坏死因子水平的研究

目的探讨白细胞介素６（ＩＬ６）和肿瘤坏死因子α（ＴＮＦα）水平在胎膜早破孕妇和绒毛羊膜炎患者母血和羊水中的变化及其临床意义。方法采用放射免疫法和酶联免疫吸附试验,测定４６例胎膜早破孕妇（胎膜早破组）和２０例正常足月孕妇（对照组）母血和羊水中ＩＬ６、ＴＮＦα水平,同时进行胎膜病理检查。结果观察组母血中ＩＬ６和羊水中ＩＬ６、ＴＮＦα明显高于对照组,差异有极显著性（Ｐ＜０．０１）;破膜时间与母血中ＩＬ６,羊水中ＩＬ６、ＴＮＦα水平有明显关系,随着破膜时间延长其含量增高;１２例绒毛羊膜炎患者其母血和羊水中ＩＬ６、ＴＮＦα水平均明显高于非绒毛羊膜炎孕妇,差异有显著性（Ｐ＜０．０１～Ｐ＜０．０５）。结论母血和羊水中ＩＬ６、ＴＮＦα水平变化可作为绒毛羊膜炎的诊断指标之一。     

正常晚期妊娠胎儿脐动脉、大脑中动脉及腹主动脉血流速度波形与胎儿血气相关性探讨

目的探讨正常妊娠胎儿血流速度波形与胎儿血气的相关性。方法应用彩色多普勒超声对４５例正常晚期妊娠初孕妇女于剖宫产术前２４小时内进行胎儿脐动脉（ＵＡ）、大脑中动脉（ＭＣＡ）及腹主动脉（ＡｂＡｏ）的血流速度波形（ＦＶＷｓ）检查，计算搏动指数（ＰＩ）、阻力指数（ＲＩ）及收缩期最大血流速度（Ｓ）与舒张末期血流速度（Ｄ）的比值（Ｓ／Ｄ），同时对剖宫产分娩的新生儿立即进行脐动脉血气ｐＨ、二氧化碳分压（ＰＣＯ２）、氧分压（ＰＯ２）测定。结果ＵＡＲＩ与血ｐＨ、ＰＯ２呈明显负相关（Ｐ＜０．０１，Ｐ＜０．０５），与ＰＣＯ２呈正相关（Ｐ＜０．０５），ＭＣＡＲＩ与血ｐＨ、ＰＯ２呈明显正相关（Ｐ＜０．０１，Ｐ＜０．０５），与ＰＣＯ２呈负相关（Ｐ＜０．０５）。结论产前监测ＵＡ及ＭＣＡ的血流速度波形，可间接了解胎儿血气情况，及时判断胎儿宫内安危的状况。     

胎膜早破的诊断

胎膜早破的诊断天津医科大学总医院（３０００５２）陈韻仙胎膜早破（ＰＲＯＭ）指临产前胎膜全层（绒毛膜和羊膜）发生自然破裂，破膜后一小时内未发动临产者。ＰＲＯＭ的发生与某些病理因素相关，而破膜后可能更使母儿并发症增加，甚至死亡。破膜至临产发动的时间称为潜...     

羊水内皮素-1与围产儿缺氧的关系

目的　探讨羊水内皮素１（ＥＴ１） 与围产儿缺氧的关系。方法　采用放射免疫法对１６１例孕（ 产）妇进行羊水ＥＴ１ 水平检测。将其分为正常妊娠组１１０ 例,对其中足月妊娠３０ 例同时进行母血和脐血ＥＴ１ 水平检测;宫内缺氧组５１ 例。结果　（１） 羊水ＥＴ１ 水平在正常妊娠组孕１４ ～２７ 周时为（７．７４０±２ ．１３３）ｎｇ／Ｌ,至妊娠晚期时为（１８．６４０ ±１ ．９６８）ｎｇ／Ｌ,随孕周增加呈上升趋势（ Ｐ＜ ０．０１） 。（２） 脐血ＥＴ１ 水平明显高于母血ＥＴ１ 水平,但较羊水为低（Ｐ＜０．０１） 。羊水与脐血ＥＴ１ 水平存在正相关关系（ｒ＝０．９５２,Ｐ＜０．０１）,而母血与脐血无相关关系（ｒ＝ ０．３３８,Ｐ＞ ０ ．０５） 。（３） 宫内缺氧组中,出现胎儿窘迫者羊水ＥＴ１ 水平为（３０．６５４ ±５．８３２）ｎｇ／Ｌ,较正常妊娠组明显升高（ Ｐ＜０．０１） ;出现重度新生儿窒息死亡者羊水ＥＴ１ 水平为（９６０ ．６５０ ±２３６ ．６９８）ｎｇ／Ｌ,为正常晚期妊娠的６０ 倍左右（ Ｐ＜０ ．００１） 。结论　正常妊娠羊水中存在ＥＴ１ ,且随妊娠进展而增加。胎儿缺氧时羊水ＥＴ１ 水平升高,并随缺氧程度加重而显著上     

经腹羊膜腔输液治疗小于34孕周羊水过少的疗效观察

目的：探讨产前经腹羊膜腔输液在临床应用的可行性。方法：以３２ 例（早破膜及未破膜者）＜ ３４ 孕周羊水过少的患者作为研究对象，在Ｂ超引导下，经腹壁行羊膜腔穿刺，留置导管，向羊膜腔内输３７℃复方氯化钠溶液３００～５００ｍ ｌ／ｄ，滴速２ｍ ｌ／ｍ ｉｎ，羊水指数＞ ８ｃｍ 为停止输液指标。辅以抑制宫缩及促胎肺成熟、防治感染等综合治疗，观察延长孕龄的时间及母婴预后。取３２例未开展本研究之前孕周相同的羊水过少患者作为对照。结果：研究组孕龄延长最短３ｄ，最长３８ｄ。剖宫产率、产后出血率及产褥病率均无明显增加。研究组早产儿Ａｐｇａｒ评分１、５ｍ ｉｎ 均高于对照组（Ｐ＜ ０．０５，Ｐ＜ ０．０１），研究组围产儿存活率明显高于对照组（Ｐ＜ ０．０１）。结论：产前经腹羊膜腔内输液是治疗＜ ３４孕周羊水过少的简便、有效措施之一。     

Value of placental microbial evaluation in diagnosing intra-amniotic infection

OBJECTIVE: To evaluate the ability of microbiologic and pathologic examination of the placenta to accurately diagnose intraamniotic infection and inflammation. METHODS: One hundred eighty-three women with a clinically indicated amniocentesis were enrolled prospectively. We applied our analysis to 56 women with evidence of preterm labor or preterm premature rupture of membranes who delivered within 48 hours of amniotic fluid testing results. Twenty-three patients, assessed for fetal lung maturity in the third trimester, served as controls. Amniotic fluid was cultured for aerobic, anaerobic, Ureaplasma, and Mycoplasma species. We used mass spectrometry to assess the degree of intraamniotic inflammation (Mass Restricted scoring). After delivery, microbiologic and histologic studies of the placenta were performed. These results were interpreted in comparison with the direct microbiologic and inflammatory analysis of the amniotic fluid. A sample size of 45 patients was required to show a test accuracy of 80% or more. RESULTS: Ninety-two percent of women with positive amniotic fluid cultures tested with at least one positive placenta culture. Eighty percent of women who had negative amniotic fluid cultures also tested with a positive placenta culture. The accuracy of placental cultures in predicting amniotic fluid infection varied from 44% to 57%. Placental pathology showed an accuracy of only 58% in diagnosing intraamniotic inflammation. CONCLUSION: Placental microbiologic and histologic studies poorly reflect the infectious and inflammatory status of the amniotic fluid. Results of such studies should be interpreted with caution in the management and future counseling of women with preterm labor or preterm premature rupture of membranes. LEVEL OF EVIDENCE: II.     

Infection and labor. VI. Prevalence, microbiology, and clinical significance of intraamniotic infection in twin gestations with preterm labor

The purpose of this study was to establish the prevalence, microbiology, and outcome of microbial invasion of the amniotic cavity in twin gestation presenting with preterm labor and intact membranes. Amniocenteses were performed on both sacs of 46 women with twin gestations, preterm labor, and intact membranes. Indigo carmine was injected to ensure sampling of both amniotic sacs. Amniotic fluid was cultured for aerobic and anaerobic bacteria, Mycoplasma hominis, and Ureaplasma urealyticum. A positive amniotic fluid culture of at least one sac was noted in 10.8% (5/46) of patients admitted in preterm labor and in 11.9% (5/42) of women delivered of preterm neonates. Of the five patients with microbial invasion of the amniotic cavity, three had microorganisms isolated from both sacs. The presenting sac was involved in all cases, supporting an ascending route for microbial invasion of the amniotic cavity in twin gestation. Polymicrobial infection was found in three of the eight amniotic sacs with positive cultures. In two cases different organisms were isolated from each sac. All patients with positive amniotic fluid cultures were delivered of preterm infants within 48 hours of amniocentesis. Patients with positive amniotic fluid cultures presented with preterm labor at an earlier gestational age and with more advanced cervical dilatation than did women with negative amniotic fluid cultures. Clinical evidence of chorioamnionitis subsequently developed in two of five women with positive amniotic fluid cultures. The interval between amniocentesis and delivery was shorter in women with positive amniotic fluid cultures than in women with negative amniotic fluid cultures (median: 3.5 vs 168 hours, p less than 0.0001). Infants born to women with microbial invasion of the amniotic cavity had a lower median birth weight and a higher incidence of respiratory distress syndrome than those born to women with negative amniotic fluid cultures (birth weight: 1085 vs 1975 gm, p = 0.024; respiratory distress syndrome: 37.5% vs 8.3%, p = 0.04).     

Correlation of quantitative amniotic fluid cultures with endometritis after cesarean section

At the time of cesarean section, amniotic fluid was collected transabdominally from 60 patients, and quantitative cultures were performed on the amniotic fluid. A culture was defined as positive if ≥10² colony-forming units per milliliter of a high-virulence organism were isolated. Any other result was defined as negative. In 24 patients with no labor or rupture of the membranes, no positive cultures were found, but there was a 25% incidence of endometritis. Among 36 patients with labor or rupture of the membranes, or both, 13 (36%) had a positive culture. Twelve of the 13 (92%) developed endometritis, whereas nine of the 23 (39%) patients with a negative culture had endometritis (p < 0.002). The usual clinical risk factors for endometritis were not different between the positive and negative culture groups. However, the patients with positive cultures had a significantly shorter time interval from cesarean section to endometritis than did the patients with negative cultures (p < 0.02). There was an excellent correlation between a positive amniotic fluid culture and endometritis after cesarean section.     

Natural transmission of group B Streptococcus during delivery

This is a study of group B Streptococcus during labor of 121 patients in whom group B Streptococcus was isolated in the vagina and/or rectum before delivery. The intrapartum vaginal culture was positive in 55.2% of the antepartum carriers (32/58). When the vaginal culture during delivery was positive, the group B Streptococcus was isolated in the amniotic fluid 2 h after the rupture of membranes in 81% of the cases. The newborns of antepartum carriers, when the labor developed naturally, were colonized by group B Streptococcus in 69.2% of cases when the intrapartum vaginal and/or amniotic fluid cultures were positive (9/13), while only 5.6% of the newborns of antepartum carriers but with negative cultures during delivery were colonized by group B Streptococcus (1/18). The most frequent positive neonatal culture was in the umbilicus (83.3%) followed by the external ear (62.5%).     

Amniocentesis in the identification of inapparent infection in preterm patients with premature rupture of the membranes

Twenty-nine preterm patients with premature rupture of the membranes who were not in labor and who did not have clinical chorioamnionitis underwent successful amniocenteses. Nine fluids were positive for bacteria. Subsequent clinical chorioamnionitis and shorter latency periods were more common in these 9 patients than in the 20 with sterile amniotic fluid. Positive fluids were more likely to be obtained from patients tapped within 48 hours of membrane rupture. In most patients with heavy bacterial growth, clinically apparent infection and/or labor soon supervened.     

Tumor necrosis factor in preterm and term labor.

OBJECTIVE: Our objective was to determine if labor (term and preterm) and microbial invasion of the amniotic cavity were associated with changes in amniotic fluid concentrations of tumor necrosis factor. STUDY DESIGN: Amniotic fluid was retrieved by transabdominal amniocentesis from 269 women in the following groups: midtrimester (n = 38), preterm labor with intact membranes (n = 52), preterm premature rupture of membranes (n = 74), term in active labor (n = 84), and term not in labor (n = 21). Fluid was cultured for aerobic and anaerobic bacteria and for Mycoplasma species. Tumor necrosis factor was measured with a commercially available enzyme-linked immunosorbent assay validated for amniotic fluid (sensitivity 60 pg/ml). RESULTS: Amniotic fluid from pregnant women in the second and third trimesters who were not in labor did not contain tumor necrosis factor. Among women in preterm labor, 92.3% (12/13) of patients with a positive amniotic fluid culture had detectable tumor necrosis factor in the amniotic fluid (median 820 pg/ml, range less than 60 to 2340 pg/ml). In contrast, only 10.2% (4/39) of women with a negative amniotic fluid culture had detectable tumor necrosis factor. Histopathologic chorioamnionitis was found in all patients who had a positive amniotic fluid culture, and tumor necrosis factor was detectable in the amniotic fluid of all but one of these patients. Among women in active labor at term, 25% (21/84) had detectable tumor necrosis factor in the amniotic fluid. Tumor necrosis factor was detected more frequently in the amniotic fluid of patients with a positive amniotic fluid culture than in patients with a negative culture (46.6% [7/15] vs 20.2% [14/69], p = 0.047). Amniotic fluid concentrations of tumor necrosis factor were significantly higher in patients with preterm premature rupture of membranes, labor, and a positive amniotic fluid culture than in the other subgroups of patients with preterm premature rupture of membranes. CONCLUSION: Parturition in the setting of microbial invasion of the amniotic cavity is associated with activation of the cytokine network as demonstrated by the detection of tumor necrosis factor in human amniotic fluid.     

The relationship between oligohydramnios and the onset of preterm labor in preterm premature rupture of membranes

OBJECTIVE: The objective of this study was to determine whether a reduced amniotic fluid volume was associated with the onset of preterm parturition in patients with preterm premature rupture of membranes. STUDY DESIGN: An amniotic fluid index was determined before transabdominal amniocentesis in 129 patients with preterm premature rupture of membranes (gestational age < or = 35 weeks). Amniotic fluid was cultured for aerobic and anaerobic bacteria, as well as for mycoplasmas. Survival techniques were used for analysis. RESULTS: Amniotic fluid index was < or = 5 cm in 29% of patients (38/129). Patients with an amniotic fluid index of < or = 5 cm had a significantly higher rate of positive amniotic fluid culture than those with an amniotic fluid index of >5 cm (42% [16/38] vs 18% [16/91]; P<.01). Spontaneous preterm delivery within 24 hours and 48 hours was more frequent among patients with an amniotic fluid index of < or = 5 cm than those with an amniotic fluid index of >5 cm (for 24 hours, 29% vs 12%; for 48 hours, 42% vs 21%; P<.05 for each). The amniocentesis-to-delivery interval was significantly shorter in patients with an amniotic fluid index of < or = 5 cm than in patients with an amniotic fluid index of >5 cm (median, 38 hours; range, 0.2-1310 hours; vs median, 100 hours; range 0.1-2917 hours; P<.01). Moreover, Cox proportional hazards model analysis indicated that an amniotic fluid index of < or = 5 cm was a significant predictor of the duration of the pregnancy after adjustment for gestational age and the results of amniotic fluid culture (odds ratio, 2.4; 95% confidence interval, 1.4-3.9; P<.001). CONCLUSION: Patients with preterm premature rupture of membranes and an amniotic fluid index of < or = 5 cm are at increased risk for a shorter interval to delivery.     

Amniotic fluid glucose concentration: a marker for infection in preterm labor and preterm premature rupture of membranes

Amniotic fluid Gram stain and culture have been utilized as laboratory tests of microbial invasion of the amniotic cavity. The Gram stain of amniotic fluid has a low sensitivity in the detection of clinical infection or microbial invasion of the amniotic cavity, and amniotic fluid culture results are not immediately available for management decisions. Glucose concentration is used to diagnose infection in other sites such as cerebrospinal fluid.Objective: The purpose of this study was to evaluate the usefulness of amniotic fluid glucose concentration in detecting microbial invasion of the amniotic cavity associated with preterm labor and preterm premature rupture of membranes.Methods: Amniocentesis was performed in 60 women with preterm labor and/or preterm premature rupture of membranes. Gram stain and culture for Mycoplasma hominis, Ureaplasma urealyticum, aerobic, and anaerobic bacteria were performed. Subjects were studied prospectively for the development of positive amniotic fluid cultures and the development of clinical chorioamnionitis.Results: The diagnosis of clinical chorioamnionitis was made in 25% (15/60) of women entered into the study. Low amniotic fluid glucose concentration Was considered < 15 mg/dl. The sensitivity, specificity, and positive predictive value of low amniotic, fluid glucose concentration to predict clinical chorioamnionitis were 73.3%, 88.1%, and 68.8% respectively, while positive amniotic fluid culture, hada sensitivity of 43.8%, specificity of 79.5%, and positive predictive value of 43.8%.Conclusions: Amniotic fluid glucose concentration was more sensitive in predicting chorioamnionitis than either Gram stain or culture. Amniotic fluid glucose concentration was better in predicting clinical chorioamnionitis than predicting positive amniotic fluid culture results. Gestational age-dependent normal ranges and pathologic conditions that may alter amniotic fluid glucose concentrations should be considered when interpreting amniotic fluid glucose values to diagnose microbial invasion of the amniotic cavity.     

Intraamniotic infection with fusobacteria

Summary A literature search produced ten studies in which Fusobacterium was cultured from amniotic fluid in women with preterm labor and intact membranes or with preterm premature rupture of membranes (PROM). Fusobacterium was isolated in 9.9% (9/91) of positive amniotic fluid cultures in women with preterm PROM and in 28.3% (17/60) of positive amniotic fluid cultures in women presenting with preterm labor and intact membranes. Fusobacterium plays a previously unrecognized role in the pathogenesis of premature labor and delivery. Amniotic fluid culture for anaerobs, specifically Fusobacterium, is suggested for all women who present with premature labor and intact membranes and do not respond to tocolytic drugs.     

Intraamniotic infection and the onset of labor in preterm premature rupture of the membranes

The purpose of this study was to examine the relationship between intraamniotic infection and the onset of labor in patients with preterm premature rupture of the membranes. Two hundred and thirty consecutive patients were admitted with premature rupture of the membranes to Yale-New Haven Hospital from January 1985 to July 1987. Amniotic fluid was retrieved by amniocentesis from 96% (221/230). Sixty-one patients were in labor on admission (27.6%, 61/221) and 39% of them (24/61) had a positive amniotic fluid culture. Patients in labor on admission were more likely to have a positive amniotic fluid culture than those who were not in labor on admission (24/61 versus 41/160, p = 0.049). Of the 160-patients who were not in labor on admission, 81 subsequently went into spontaneous labor; microbiologic information at the time of labor was known in 48 of these patients (59.2%). Seventy-five percent (36/48) of these patients had a positive amniotic fluid culture. The incidence of intraamniotic infection in quiescent women who subsequently went into labor was higher than that of patients admitted in active labor (75% versus 39%, p = 0.0004). These results provide a basis for the clinical impression that the onset of labor in women with preterm premature rupture of the membranes is associated with a subclinical intraamniotic infection. The mechanisms responsible for the onset of labor in women without an intraamniotic infection may be associated with an extraamniotic infection (e.g., deciduitis) or a noninfectious process.