220例早产原因及对母婴影响的分析

目的探讨早产发生的危险因素及对母儿的影响.方法回顾性分析220例早产的原因及对母儿的影响,并对不同孕龄组28～34周,34+～37周二组作分析比较.结果胎膜早破、臀位、双胎、妊娠高血压综合征(PIH)、妊娠合并肝内胆汁郁积症(ICP)占据早产病因前五位.不同孕周的二组早产对母亲影响无显著差别;在新生儿死亡、新生儿呼吸窘迫综合征(RDS)及低体重儿发生率有显著差别(P＜0.01).结论早产是新生儿发病和死亡的主要原因.胎龄越小、新生儿体重越轻其死亡比越高.提高早产的预防、诊断及治疗水平,对围产医学质量的提高,有着十分重要的意义.     

Outcome of very low-birth weight infants born at a perinatal center

One hundred six infants with birth weights less than or equal to 1,000 gm were born at a Perinatal Center in 1979 and 1980. Eighty-three (78%) were born to women transferred to the Center because of antenatal problems. The most common obstetric problem was premature labor with or without premature rupture of the membranes. Seventy-two infants (68%) survived. The following perinatal factors were associated with increased survival: increased birth weight and gestational age, intrauterine growth retardation, antenatal steroids, absence of hyaline membrane disease, and absence of seizures or clinical signs of intraventricular hemorrhage. Of the 72 survivors, two were lost to follow-up and one died (sudden infant death syndrome). The most common general health problem was recurrent middle ear infection. Growth was satisfactory. Significant neurological or developmental handicap was found in nine infants (13% of the 69 evaluated).     

Maternal and perinatal outcome of expectant management of premature rupture of membranes in the midtrimester

The purpose of this clinical investigation was to determine the maternal and perinatal results of continuing pregnancy in 118 consecutive patients with premature rupture of the membranes at 16 to 26 weeks. The mean gestational age at diagnosis of premature rupture of the membranes was 23.1 +/- 2.7 weeks, with a median of 23.5. The interval from rupture to delivery ranged from 1 to 152 days, with a mean of 13. There was no correlation between gestational age at the time of rupture and the latency period. Thirty-five patients received tocolytic agents and 24 received steroids. Forty-eight percent were delivered within 3 days, 67% within 1 week, and 83% within 2 weeks. There was one maternal death from sepsis; 46 (39%) had amnionitis, and 8 (6.8%) had abruptio placentae. The mean gestational age at the time of delivery was 24.7 +/- 3.6 weeks. The 118 pregnancies resulted in 124 births. There were 17 stillbirths and 67 neonatal deaths, for a total perinatal mortality of 67.7%. In patients with premature rupture of the membranes at less than or equal to 23 weeks the perinatal survival rate was 13.3%, while it was 50% in patients with premature rupture of the membranes at 24 to 26 weeks (p less than 0.0001). Information was charted at 3 to 36 months for 34 of 40 surviving infants. The intact survival rate in this group was 67%, and 33% had some form of developmental abnormality. Expectant management in such cases can be justified in only a limited number of patients (patients who understand and accept the risks and patients beyond 23 weeks of gestation).     

Outcome of premature infants delivered after prolonged premature rupture of membranes before 25 weeks of gestation

OBJECTIVE: To identify factors influencing the outcome of premature infants delivered after prolonged premature rupture of membranes before 25 weeks' gestation. DESIGN AND POPULATION: All premature infants with gestational age <34 weeks, either inborn or outborn, with history of rupture of membranes before 25 weeks' gestation, admitted to our NICU between January 1992 and July 1997, were eligible for this retrospective study. Collected information included birth weight, gestational age at rupture of membranes and at delivery, duration between rupture of membranes and delivery (latency period), severity of oligohydramnios, pre- and post-natal managements, and follow-up of survivors. RESULTS: A total of 28 neonates fulfilled the inclusion criteria. Despite new strategies of ventilation and optimal management, the overall mortality rate was 43% (12/28). Nonsurvivors were significantly less mature at rupture of membranes, and had severe oligohydramnios (anamnios). We also noted less antenatal corticosteroids and antibiotic therapy in this group. Nine of eleven infants (82%) following rupture of membranes before 22 weeks' gestation died shortly after birth. The two remaining infants developed severe bronchopulmonary dysplasia. Nine deaths occurred in thirteen cases (69%) of anamnios. The major death causes were refractory respiratory failure and neurologic complications. Half of all survivors (8/16) developed bronchopulmonary dysplasia. CONCLUSION: The outcome of premature infants following prolonged premature rupture of membranes before 25 weeks' gestation is influenced by gestational age at rupture, severity of oligohydramnios, and antenatal antibiotics and corticosteroids. Neonates with rupture of membranes before 22 weeks have a very low chance of survival at the present time.     

Prematurity and the obstetrician. A regional neonatal intensive care nursery is not enough

Modern-day perinatal care has resulted in dramatically improved outcomes of premature infants, particularly those weighing 750 to 1,500 gm or of 27 to 32 weeks' gestational age. Assuming that the birth is not traumatic, the infant asphyxiated, or made hypothermic at birth, the chances of the very small premature baby developing normally are great. The delivery of an infant of less than or equal to 32 weeks' gestational age or weighing less than 1,500 gm should occur at a perinatal center when possible.     

早产相关因素及早产儿结局临床分析

目的探讨早产发生的高危因素及早产对围生儿的影响。方法选取2001年1月1日-2007年6月30日在我院分娩的早产儿508例作为病例组，并随机选取同期足月分娩产妇508例作为对照组，比较两组产妇的相关情况，围产儿结局，分析早产的高危因素。结果早产儿窒息、RDS发生率及死亡率与足月儿相比差异显著；孕周越小，发病率及死亡率越高。胎膜早破、胎位异常、胎盘因素是造成早产的高危因素。应用地塞米松与未应用者相比，足量应用地塞米松与未足量应用者相比，新生儿并发症发生率、早产儿死亡率均明显降低。孕35周后早产患者，延长孕周并不能降低早产儿并发症发生率及死亡率。结论早产的发生是多种因素的结果。孕周越小，早产儿发病率及死亡率越高。应用糖皮质激素是改善早产儿结局的重要治疗措施。35～36^＋6周PPROM者建议在破膜48h内分娩，以减少早产儿并发症。     

Antibiotic therapy in preterm premature rupture of membranes: a randomized, prospective, double-blind trial

The use of antibiotics in the management of preterm, premature rupture of membranes remains controversial. By use of a prospective randomized double-blind design we investigated the maternal-fetal benefits associated with antibiotic therapy in 85 women with premature rupture of membranes at 34 weeks' estimated gestational age. In the treatment group 40 patients received intravenous mezlocillin for 48 hours followed by oral ampicillin until delivery. In the control group 45 patients received intravenous and oral placebo. Patients who received antibiotics had chorioamnionitis and endometritis less frequently than the control group (p less than 0.01 and p less than 0.05). Pathologic examination of the placentas showed a lower incidence of chorioamnionitis in the treatment group (p less than 0.05). The period from premature rupture of membranes to delivery (latency) was prolonged with antibiotics (p less than 0.05) and resulted in significant weight gain in the infants in the antibiotic group (p less than 0.0001). These infants also had higher 1- and 5-minute Apgar scores. Clinically suspected sepsis, respiratory distress syndrome, intraventricular hemorrhage, perinatal death rate, and prolonged hospitalization (greater than 30 days) were also increased in the control group.     

The corticosteroid therapy of premature rupture of the fetal membranes

Antenatal corticosteroids are now administered for the purpose of hastening maturation of the preterm infant's organs and tissues, thus reducing neonatal mortality and the incidence of respiratory distress syndrome (RDS). Our purpose was to determine the efficacy of maternal corticosteroid therapy on fetal maturation in cases with preterm premature rupture of the membranes. The rates of RDS and survival in low birth weight infants treated with corticosteroids is influenced by the duration of the premature rupture of the membranes and the duration of the corticosteroid therapy, as well as by the gestational age.     

Impact of infants born at the threshold of viability on the neonatal mortality rate in Colorado.

OBJECTIVE: To determine the contribution of infants born at the threshold of viability (< 750 gm) on neonatal mortality in Colorado. STUDY DESIGN: For the period of January 1991 to December 1996, all Colorado live births who expired were evaluated for gestational age, birth weight, gender, hospital level of care, age at time of death, delivery room resuscitation, mechanical ventilation, medical and surgical complications, and serious malformations. RESULTS: Although infants weighing < 750 gm represent only 0.31% of all live births, they account for 46.3% of deaths. While those infants weighing < 500 gm and with a gestation of < 24 weeks almost always died (94.7%), the majority born in the 500- to 745-gm category (55.8%) survived. The vast majority (88.5%) of deaths occurred on the first day of life. A total of 38.4% of births in which the infant weighed < 750 gm occurred outside bona fide regional perinatal centers. CONCLUSION: Future attempts to reduce the Colorado neonatal mortality rate would best focus on the 500- to 750-gm weight group through the re-regionalization of high-risk perinatal care.     

Preterm premature rupture of the membranes: diagnosis and management

Preterm premature rupture of the membranes (preterm PROM) is a common and significant cause of preterm birth and perinatal morbidity and mortality. The obstetric caregiver has the opportunity significantly to alter pregnancy and perinatal outcome for women suffering from this complication. Although management is often predetermined by the presence of clinical infection, vaginal bleeding, labor, or nonreassuring fetal heart-rate pattern on admission, a gestational age-based approach to the management of the stable patient with preterm PROM offers the potential to reduce perinatal infectious and gestational age-dependent morbidity for patients who are amenable to conservative management.     

Chorioamnionitis and funiculitis in the placentas of 200 births weighing less than 2.5 kg.

Summary. A retrospective histopathological study of the placental and non-placental membranes and umbilical cords of 200 live and stillborn babies weighing <2·5 kg is reported. The pathological studies were specifically concerned with the presence of infection as evidenced by a polymorphonuclear leucocytie infiltrate at these sites. Inflammatory lesions were demonstrated in 48·5% of specimens. The incidence of inflammatory lesions was highest in those with prolonged rupture of the membranes, and in the placentas of the smallest and least mature infants of a size appropriate t o their gestational age. Puerperal pyrexia, neonatal sepsis and perinatal mortality were also more common in the infected group but none of the perinatal deaths was directly attributable to infection. The role of infection as a cause of premature rupture of the membranes, premature labour and subsequent perinantal outcome is still unclear though our data would suggest it is not unimportant.     

Increased risk in the elderly parturient

PURPOSE OF REVIEW: The steady increase in age in primiparous and multiparous women raises questions concerning increased obstetric risk and outcome in such pregnancies. This review highlights the effects of maternal age on obstetric and perinatal outcome. RECENT FINDINGS: Complications have been associated with increasing maternal age, including abnormal weight gain, obesity, gestational diabetes, chronic and pregnancy-induced hypertension, antepartum haemorrhage, placenta praevia, multiple gestation, prelabour rupture of membranes, and preterm labour. Intrapartum complications of malpresentation, fetopelvic disproportion, abnormal labour, increased use of oxytocin in labour, caesarean section, instrumental delivery, sphincter rupture, and postpartum haemorrhage are more frequent in older women. Advanced maternal age is associated with a higher risk of stillbirth throughout gestation, and the peak risk period is 37-41 weeks. Perinatal outcomes differ with maternal age concerning gestational age, birth weight, prematurity, low birth weight, incidence of small-for-gestational-age infants, fetal distress, and perinatal morbidity and mortality. The increased risk cannot be explained only by intercurrent illness or pregnancy complications. SUMMARY: Increasing maternal age is independently associated with specific adverse outcomes. Increasing age is a continuum rather than threshold effect. More information about obstetric consequences of delayed childbearing is needed both for obstetricians and fertile women.     

Perinatal survival with expectant management of midtrimester rupture of membranes

A retrospective study of 70 patients with preterm premature rupture of membranes before 26 weeks of gestation was performed. The purpose of this study was to examine the perinatal outcome and the potential maternal and neonatal morbidity associated with this obstetric condition. The mean gestational age at diagnosis of rupture of membranes was 23.7 weeks. The latency period ranged from 24 hours to 60 days with the mean being 12 days. There was no correlation between gestational age at rupture of membranes and latency period. Seventy-one infants were delivered. The perinatal survival was 63%. Sixty-eight percent of the survivors had normal neurological and physical development at 1-year follow-up. Amnionitis developed in 43% of patients. The incidence of respiratory distress syndrome in the neonates was 52%. Betamethasone did not appear to reduce this incidence. The perinatal survival in patients with midtrimester rupture of membranes appears to be improving with the advancements in neonatal care of the extremely premature infant.     

不同类型早产所致围生儿存活及发病情况研究

目的:探讨不同类型早产是否与围生儿的存活及发病情况有关。方法:回顾分析489例活胎妊娠孕妇(孕28~36+6周)及其分娩的550例新生儿(活产儿539个,死产儿11个),按早产类型将其分为自发性早产(SPB)、胎膜早破性早产(PPROM)、医源性早产(IPD)3组。对3组孕妇和新生儿的临床特征,围产儿的存活和发病情况进行了比较分析。结果:(1)IPD单胎围生儿存活率低于SPB和PPROM(P<0.01)。多胎围生儿存活率无统计学差异;(2)围生儿主要并发症的发病率在3组早产中无统计学差异(P>0.05)。(3)非条件Logistic回归多因素分析结果显示:Apgar 5m in评分,孕周,剖宫产与围生儿的存活成正相关。医源性早产,小于胎龄儿与围生儿存活成负相关。Apgar 5m in评分,孕周与围生儿的发病成负相关。结论:IPD与围生儿的存活呈负相关,IPD单胎围生儿存活率低于SPB和PPROM(P<0.01)。     

Effect of delivery method on outcomes in the very low-birth weight breech infant: is the improved survival related to cesarean section or other perinatal care maneuvers?

The perinatal mortality rate among very low-birth weight infants has been decreased by 20% during the last 4 years of the 1973 to 1980 period here reported. The concurrent increase in the cesarean section rate from 11.9% to 49.1% during the same time frames has been assumed to be responsible for the improved outcome. The changes were most marked in the extremely low-birth weight group (less than 1,000 gm). The survival rates and cesarean section rates were examined among infants of similar birth weight and gestational age in the vertex presentation, in the same time frames. A similar or greater reduction in mortality rate (from 85% to 45%) was noted in the very low-birth weight vertex infants, whereas the cesarean section rate remained minimally and not significantly increased (14.2% to 22.2%). The interpretation of this finding is by no means clear but must include the hypothesis that the increased cesarean section rate may be incidental and in no way related to the improved outcome. The most statistically significant determinants of outcome remain birth weight and gestational age strata, with no significant difference in outcomes when the extremely low-birth weight group is analyzed separately from the entire very low-birth weight group. As yet unidentified perinatal care practices, other than cesarean section, may be more likely to affect outcome in this high-risk group.     

Infants' length at birth: an independent effect on perinatal mortality

AIM: To investigate whether variations in birth length (crown-heel-length) were associated with perinatal mortality rate independent of birth weight. MATERIAL: The study population was singleton live- and stillbirths from 16 weeks of gestation compiled in the Medical Birth Registry of Norway from 1967 to 1997, totaling 1,705,652 births. METHOD: The total population was analyzed using z-scores for length at birth, birth weight and gestational age. Variation in perinatal mortality by length at birth was studied within birth weight strata (250 g) by logistic regression. RESULTS: Perinatal mortality varied more by birth length than by birth weight or gestational age, especially for values above the population means. Within birth weight strata, the association between perinatal mortality and length was similar in all 250 g birth weight categories above 1,500 grams: mortality was lowest at birth lengths 0-2 cm below average, with mortality rates increasing exponentially in either direction. CONCLUSION: Within all birth weight strata, and adjusted for gestational age, long infants had the higher risk of perinatal death, suggesting that length at birth may be a valuable predictor when assessing the risk of perinatal mortality.     

Diabetes and pregnancy - a clinical and statistical analysis of 1800 pregnancies and deliveries in the years 1952 - 1971. 3. Birth weights percent values of newborn infants of diabetic mothers and further studies on the birth weight]

Newborn babies of diabetic mothers have a higher birth weight in comparison with newborns of nondiabetic mothers in the same gestational age (35. to 39. week). Body weight percentiles were estimated for new borns of diabetics (excluding stillborn babies), it was to be shown that birth weight lower than 2750 gm in the 38. to 39. gestational week (less than 10. percentile) characterizes "small for gestational age babies". Not any influence of maternal blood glucose values during the second part of pregnancy was to be seen. Severe toxaemias and vascular-renal complications (WHITE-class F) were statistically significant correlated with underweight in newborns. The lowest perinatal mortality was found in the weight class 3500 to 3999 gm.     

Risk factors for prematurity and premature rupture of membranes: A prospective study of the vaginal flora in pregnancy

Prematurity remains a major cause of perinatal mortality in the United States. Some research has indicated that infectious agents play a role in either initiating preterm labor, causing premature rupture of the membranes, or preventing tocolysis. This study attempted to determine if the presence of various vaginal pathogens in early pregnancy was associated with the subsequent development of premature rupture of membranes or preterm labor. We found that among 233 evaluable patients those with Trichomonas vaninalis were significantly more likely to have premature rupture of the membranes (p < 0.03), and those with Bacteroides sp. were more likely to be delivered of their infants before 37 weeks (p < 0.03) and to have infants weighing less than 2500 gm (p < 0.05). Those with Ureaplasma urealyticum more frequently began preterm labor (p < 0.05). Preterm premature rupture of the membranes was found significantly more often among patients with Bacteroides sp. Stepwise multiple logistic regression analysis indicated that those associations were not related to the number of previous abortions, deliveries, or preterm deliveries or to maternal age. We conclude that microbiologic screening in early pregnancy may aid in the assessment of patient risk for preterm delivery.     

Repeat surfactant therapy for postsurfactant slump.

OBJECTIVE: To evaluate repeat surfactant therapy for the treatment of respiratory failure associated with postsurfactant slump in extremely low birth weight infants (ELBW) by characterizing the population of premature infants who develop postsurfactant slump and measuring their response to a secondary course of surfactant therapy. STUDY DESIGN: A retrospective analysis of a cohort of all patients admitted over a 3-year period with birth weights <1000 g (ELBW infants). Information was collected by chart review and the patients were categorized into three distinct groups for analysis. Initial surfactant only, patients who received surfactant replacement therapy only for respiratory distress syndrome (RDS); repeat surfactant, patients who received both initial surfactant replacement for RDS and repeat surfactant therapy for postsurfactant slump (defined as respiratory failure after 6 days of age), and no surfactant, patients in whom no surfactant was ever administered. A respiratory severity score (RSS) was used to measure the severity of lung disease and response to surfactant therapy. RESULTS: Over 3 years, there were 165 ELBW infants who could develop postsurfactant slump and be eligible for repeat surfactant therapy. There were 39 infants who never received any surfactant therapy estimated gestational age (EGA) 27.7 +/- 1.7, birth weight 856 +/- 109 g) either at birth or after 6 days of life. There were 126 patients treated for RDS with initial surfactant replacement therapy (EGA 25.6 +/- 1.9 weeks, birth weight 713 +/- 179 g). Out of these RDS patients, 101 improved with an initial course of surfactant therapy (EGA 26 +/- 1.8, birth weight 751 +/- 143 g), but 25 (20% of the patients with RDS) developed postsurfactant slump and received a repeat course of surfactant therapy (EGA 24.7 +/- 1.2, birth weight 647 +/- 120 g). The repeat surfactant group (postsurfactant slump) was significantly more premature and had significantly lower birth weights compared to both the initial surfactant only group and the no surfactant ever group. Logistic regression analysis revealed that lack of antenatal steroids, earlier gestational age, and the receiving of 2 or more doses of surfactant to treat the initial RDS were significantly associated with receiving repeat surfactant therapy for postsurfactant slump. Of the 25 patients treated with a repeat course of surfactant therapy more than 70% of patients (n = 18) had an improvement in their lung disease with a 15% reduction in their RSS. This improvement was significant at all time points evaluated (12, 24, and 48 h). CONCLUSION: We found that a repeat course of surfactant therapy, after day of life 6, led to a significant improvement in hypoxemic respiratory failure in premature infants with postsurfactant slump. Infants who received repeat surfactant therapy were born at a significantly earlier gestational age, had significantly smaller birth weight and had significantly worse lung disease. They were significantly less likely to have received antenatal steroids and were significantly more likely to have received multiple doses of surfactant to treat their initial RDS. A repeat course of surfactant therapy for patients with postsurfactant slump appeared beneficial in the short-term. These initial findings would support performing randomized control trials of repeat surfactant therapy for postsurfactant slump.