延期妊娠终止妊娠时机及方式探讨

目的探讨延期妊娠终止妊娠时机,以确定适当的处理措施。方法回顾性分析我院产科2005年10月-2007年9月分娩的妊娠41-41州周且无妊娠合并症的初产妇278例的临床资料。结果延期妊娠组羊水过少、羊水Ⅲ度污染、胎儿窘迫、新生儿窒息、巨大儿和剖宫产率均较足月分娩组高（P〈0．05）;延期妊娠引产干预组羊水Ⅲ度污染、剖宫产率均较延期妊娠自然临产组高,而阴道自然分娩率低（P〈0．05）;用地诺前列酮做引产前预处理＋催产素引产较直接催产素静点引产组有较高的自然分娩率和较低的剖宫产率及引产失败率（P〈0．05）。结论延期妊娠属于高危妊娠,在综合监测提示胎盘功能良好状态下仍可继续妊娠,不适当的干预可增加难产率,引产前的预处理可增加自然分娩机会。     

未足月胎膜早破449例临床分析

目的探讨未足月胎膜早破（preterm premature rupture of membranes,pPROM）的发病规律,分析pPROM患者不同孕周对分娩方式及围产儿结局的影响。方法对2003年1月至2007年12月间郑州大学第三附属医院的449例pPROM患者的临床资料进行回顾性分析。结果胎膜早破的发生率为14．3％,而pPROM发生率为3．3％;pPROM相关因素的构成比中,流产、引产史最高41．0％,其次为不明原因23．8％o、多胎10．4％及感染史9．8％;在分娩的437例pPROM患者中,孕32-34^＋6周组的剖宫产率高于孕28-31^＋6周组和孕35-36^＋6周组（P=0．001）;而孕28-31^＋6周组与孕35-36^＋6周组比较,无统计学意义（P=0．78）;490例围生儿中,孕32-34^＋6周组不同分娩方式对围生儿结局比较,无统计学意义（P〉0．0166）,孕28～31^＋6周组、孕32-34^＋6周组的转PICU率、新生儿窒息率及低体重儿率均高于孕35-36^＋6周组,差异有统计学意义（P=0．001）。结论流产、引产史、感染及不明原因是pPROM发生的主要影响因素;剖宫产并不是降低围生儿不良结局的最佳分娩方式;围生儿结局与孕周密切相关。     

不同分娩方式对低危孕产妇分娩结局及卫生经济学指标的影响

目的探讨不同分娩方式对低危孕产妇分娩结局及卫生经济学指标的影响。方法对2002年9月至2007年4月北京协和医院分娩的3751例孕37-41周^＋6的低危孕产妇的资料进行回顾性分析,按分娩的干预方式不同分为3组：择期引产组（包括药物及手术引产）501例、择期剖宫产组1634例和自然临产组1616例,分别对3组孕产妇的一般情况及住院费用以及分娩结局（产后出血、产褥病率、尿潴留、输血情况、切口愈合情况、产时副损伤）、新生儿Apgar评分情况等进行统计比较。结果（1）一般情况分析：自然临产组孕产妇住院天数（4．8d）与择期引产组（6．3d）及择期剖宫产组（6．3d）比较,差异有统计学意义（P〈0．01）;择期剖宫产组孕产妇住院费用（3472元）明显高于择期引产组（3201元）及自然临产组（2293元）,分别比较,差异有统计学意义（P〈0．01）,尤其是择期引产组中的剖宫产患者住院费用明显高于择期剖宫产组及自然临产组中的剖宫产患者,分别比较,差异均有统计学意义（P〈0．01）。（2）产时及产后并发症总发生率：孕产妇产时及产后并发症总发生率分别是择期引产组为12．4％、择期剖宫产组为0．9％,自然临产组为6．8％。（3）产后出血（≥500ml）发生率：择期引产组、择期剖宫产组和自然临产组分别为3．0％（15／501）、0．6％（9／1634）和1．2％（19／1616）,3组分别比较,差异有统计学意义（P〈0．01）。（4）尿潴留发生率：择期引产组、择期剖宫产组和自然临产组分别为4．6％（23／501）、0和3．3％（54／1616）,择期剖宫产组尿潴留发生率低于择期引产组与自然临产组（P〈0．01）,择期引产组与自然临产组比较,差异无统计学意义（P〉0．01）。（5）有无分娩中或产后输血：择期引产组、择期剖宫产组和自然临产组率孕产妇有输血者分别为2．0％（10／501）、0．1％（1／1634）和0．4％（6／1616）,3组分别比较,差异有统计学意义（P〈0．01）。（6）产时副损伤：择期引产组、择期剖宫产组和自然临产组产时副损伤发生率分别为0．6％（3／501）、0和0．4％（7／1616）,3组分别比较,择期剖宫产组低于其他两组（P〈0．01）,择期引产组与自然临产组比较,差异无统计学意义（P〉0．01）。（7）切口延期愈合：择期引产组、择期剖宫产组和自然临产组分别为0．8％（4／501）、0和0．2％（4／1616）,3组分别比较,差异有统计学意义（P〈0．01）。（8）产褥病率：3组间相互比较,差别无统计学意义（P〉0．01）。（9）新生儿窒息发生率：择期引产组、择期剖宫产组和自然临产组分别为1．2％（6／501）、0．1％（1／1634）和1．0％（17／1616）,择期剖宫产组与其他两组分别比较,差异均有统计学意义（P〈0．01）,择期引产组与自然临产组比较,差异无统计学意义（P〉0．01）。结论择期引产会增加孕产妇产后出血、分娩中或产后输血的机会,且没有降低产妇尿潴留、新生儿窒息的发生率;择期剖宫产是相对安全的分娩方式,对孕产妇分娩并发症的发生没有不良影响,但会明显增加住院费用。     

对妊娠大于38周孕妇实行计划分娩的临床应用

我院自１９８５年开始实行计划分娩，其孕周由过期妊娠、延期妊娠到近２年的妊娠大于３８周，使过期妊娠发生率逐渐下降。本文随机选择计划分娩２００例与同期自然分娩１００例相比较，结果计划分娩组总产程较自然分娩组平均缩短１小时余，无早产儿、新生儿呼吸窘迫综合征及足月低体重儿发生。孕３８￣３９周３日内引产成功率明显高于过期妊娠者引产成功率（Ｐ〈０．０１），宫颈成熟者３日内引产成功率明显高于宫颈未成熟者（Ｐ〈０     

米索前列醇阴道后穹窿给药用于足月妊娠引产90例临床分析

目的：探讨小剂量米索前列醇（米索）用于足月妊娠引产的有效性和完全性。方法：A组90例根据宫颈Bishop评分阴道后穹窿首次置米索25－50μg,观察宫缩情况，若无规律宫缩则每3小时置药一次（25μg），直至出现规律宫缩，总量不超过200μg；B组90例，静滴催产素引产作为对照组。结果：两组引产成功率分别为87．78％和80．00％（P＞0．05）。A组从开始用药至临产时间较B组明显缩短（P＜0．05）。初产妇宫颈评分≤5分者，A组引产成功率高于B组（P＜0．05），两组剖宫产率，产时出血量及新生儿窒息的发生率均无显著性。结论：小剂量重复阴道后穹窿给米索用于足月妊娠引产，是一种安全、有效的方法。     

服用米非司酮促足月妊娠妇女宫颈成熟和引产

为测定米非司酮埘健康的足月妊娠妇女促使宫颈成熟和引产的最佳剂量和评价母体、胎儿及新生儿对米非司酮耐受性．收集1992年5月-1995年11月法国8个研究中心的足月妊娠妇女．进行随机双盲安慰剂对照研究。选择的研究对象为单胎妊娠，头先露，孕龄37。41周加3d，宫颈不成熟，48h以内（胎儿或母体因素）有引产指征，年龄〉18岁，同意引产者。排除对象：有阴道分娩禁忌证，     

双胎输血综合征诊断处理和妊娠结局

目的 探讨双胎输血综合征的临床诊断、处理及妊娠结局。方法 回顾性分析十五年间18例双胎输血综合征（TTTS组）和620例非双胎输血综合征双胎（非TTTS组）的临床资料，比较两组的妊娠并发症、妊娠合并症和妊娠结局。结果 （1）双胎输血综合征占双胎妊娠总数的2．8％，占单绒毛膜双胎的8．1％；（2）明确分期14例，引产10例，要求保留胎儿7例（Ⅱ期1例、Ⅲ期5例、Ⅳ期1例）；3例经腹羊水减量，其中2例转为Ⅴ期后引产，1例胎儿镜下激光凝固胎盘血管交通支，获两活婴；（3）TTTS组辅助生育受孕明显低于非TTTS组（11．1％比40．0％，P〈0．05），胎盘早剥发生率明显高于非TTTS组（22．2％比1．3％，P〈0．05）；（4）TTTS组终止妊娠孕周、胎儿平均出生体重显著低于非TTTS组（P〈0．01）。TTTS组胎儿死亡、畸形和窒息的发生率分别为41．7％、16．7％和33．3％，显著高于非TTTS组的6．4％、1．9％和7．0％（P〈0．01）。结论 （1）双胎输血综合征严重影响胎儿预后；（2）明确双胎输血综合征的分期有助于临床处理和评估预后；（3）胎儿镜下激光凝固胎盘血管交通支术治疗双胎输血综合征有较好的应用前景。     

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。     

双胎妊娠合并贫血与妊娠结局的分析

目的：探讨双胎妊娠合并贫血对妊娠结局的影响，方法：将496例双胎妊娠分为两组，妊娠合并贫血者（贫血组）共321例，其余175例为对照组，对两组病的妊高征，产前出血，产后出血，早产，胎膜早破发生率与平均孕周，平均出生体重分别进行对照分析。结果：贫血组妊高征，产后出血，早产，胎膜早破发生率显著高于对照组（P＜0．05），且贫血严重程度与妊高征，产后出血发生率呈正相关（P＜0．05），与平均孕周呈负相关（P＜0．05）。两组新生儿平均出生体重无显著差异（P＞0．05），但重度贫血病例的新生儿平均出生体重与对照组比较，有显著性差异（P＜0．05）。结论：双胎妊娠合并贫血时各种并发症发生率成倍增加，特别是重度贫血对孕产妇和围生儿有严重的威胁。     

米非司酮用于足月妊娠促宫颈成熟的临床观察

为防止延期妊娠和过期妊娠，降低围产儿窒息率及病死率，对妊娠合并某些疾病以及孕周超过４０周的孕妇给予适时引产是产科常见的治疗措施，而宫颈条件则是引产成功的关键。引产成功率与宫颈成熟有关，宫颈不成熟者，引产失败率高达５０％［１］。我们通过随机对照研究，观...     

Fetal size as a determinant of obstetrical outcome of post-term pregnancy

HYPOTHESIS: We hypothesized that there might be differences in the outcomes of post-term pregnancy according to fetal size. METHODS: A retrospective analysis of 143 women with uncomplicated pregnancy that persisted beyond 42 weeks was conducted. Ultrasound dating was performed between 8 and 14 weeks in all cases. The obstetrical outcomes were compared between the cases in which neonatal birth weight was <3,600 g (non-large group) and >/= 3,600 g (large group). RESULTS: In primiparous women, there was no significant difference between the non-large and large groups in terms of the rate of cesarean section, but the rate of cesarean section for fetal distress in the non-large group was significantly higher than that found in the large group. In addition, the non-large group showed a significantly higher incidence of low pH (<7.20) compared with the large group (14/58 vs. 0/22, p < 0.01). In contrast, the rate of prolonged labor (>24 h) and induction failure in the non-large group were significantly lower than that in the large group. In multiparous women, there was no significant difference in obstetrical outcomes between the non-large and large groups. CONCLUSIONS: Primiparous women who were delivered of fetuses weighing not less than 3,600 g at post-term periods were at lower risk of fetal distress on the one hand and at higher risk of induction failure associated with infavorable cervix on the other. This study suggests that post-term pregnancy should be dealt with differently based on fetal weight.     

Comparative study of induction of labor in nulliparous women with premature rupture of membranes at term compared to those with intact membranes: duration of labor and mode of delivery

AIM: To evaluate the effect of premature rupture of membranes (PROM) at term on the duration of labor and mode of delivery in comparison with intact membranes in nulliparous women with an unfavorable cervix whose labor was induced. METHODS: This retrospective cohort study included all term nulliparous women with an unfavorable cervix requiring labor induction over a 2-year period. Prostaglandin E(2) (dinoprostone) and oxytocin were used for labor induction. Criteria for enrolment included (i) singleton pregnancy; (ii) term nulliparous women; or (iii) Bishop score below 6. Statistics were analyzed with Student's t-test, chi(2)-test, Fisher's exact test, and multiple logistic regression. RESULTS: Our study subjects were 82 women whose labor was induced for PROM and 219 women with intact membranes whose labor was induced for social or fetal reasons. The mean durations of active phase of labor were not significantly different between women with PROM and those with intact membranes. However, the women with PROM had a significantly longer mean duration of second stage and a higher rate of cesarean delivery for failure to progress than those with intact membranes. Multiple logistic regression demonstrated that only PROM and fetal macrosomia were significantly associated with an increased risk of cesarean delivery for failure to progress after other confounding variables were adjusted. CONCLUSIONS: Labor induction for PROM at term in nulliparous women with an unfavorable cervix is associated with longer duration of the second stage and a higher risk of cesarean delivery for failure to progress in comparison to those with intact membranes.     

Success rates with low dose misoprostol before induction of labor for nulliparas with severe preeclampsia at various gestational ages.

OBJECTIVE: To assess the efficiency of labor induction using low dose misoprostol for cervical ripening among nulliparous patients with severe preeclampsia. METHODS: This retrospective investigation involved cases gathered from our perinatal database for nulliparous women with severe preeclampsia delivering singleton gestations between January 2002 and May 2006. After a review of 229 hospital records, we selected only those cases (N = 145) that were eligible for a trial of labor and were administered intravaginal misoprostol (25 mcg every 3 to 6 h) for an unfavorable cervix. Primary outcomes related to the success and timing of vaginal deliveries. Secondary outcomes involved maternal and neonatal morbidity rates. Statistical evaluations included Chi-square testing and regression analysis. RESULTS: Vaginal delivery was successful in 95 cases (65.5%). This rate increased from 55.1% in cases at <34 weeks to 68.9% in cases at between 34 and 36 weeks, and to 72.5% in those at >or=37 weeks. Most of those who delivered vaginally did so within 24 h (82 of 95 cases, 86.3%), regardless of gestational age. Vaginal delivery was associated with a shorter postpartum stay (2.5 vs. 3.2 days; p = 0.001) and with less neonatal respiratory distress (4.2% vs. 26.0%; p < 0.001). CONCLUSIONS: Vaginal delivery within 24 h was common, with less morbidity than cesarean delivery, in this nulliparous group presenting with severe preeclampsia and an unfavorable cervix.     

Postdate fetal surveillance: is 41 weeks too early?

During an 18-month period, 293 patients had a nonstress test and ultrasonographic evaluation of amniotic fluid volume twice weekly beginning at 41 weeks' gestation. Patients were admitted for induction of labor for either an abnormal nonstress test result or oligohydramnios. A control population consisted of 59 low-risk patients who were delivered between 39 and 41 weeks' gestation and had antepartum testing within 4 days of delivery. Study patients who were delivered between 41 and 42 weeks' gestation had a significantly increased incidence of abnormal nonstress tests, oligohydramnios, cesarean sections for fetal distress, and admissions to the neonatal intensive care unit compared with control patients. The abnormal fetal testing and adverse perinatal outcome associated with pregnancies over 42 weeks were also found in pregnancies between 41 and 42 weeks' gestation. These data support the concept that postdate fetal testing should begin at 41 weeks of gestation.     

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。     

Prediction of adverse outcome associated with vaginal misoprostol for labor induction

Objective: To identify predictors of adverse outcome in pregnant women at term receiving 50 μg of intravaginal misoprostol for labor induction. Study design: A prospective observational study was conducted of 720 pregnant women at term with an unfavorable cervix and a medical or obstetric indication for labor induction. All patients received 50 μg of intravaginal misoprostol every 4 h up to three doses. The primary outcome measure was “adverse outcome” defined as: neonatal death, fetal acidemia and emergent cesarean delivery performed for non-reassuring fetal heart rate tracings. A stepwise logistic regression analysis was used to identify predictors of adverse outcome. Results: Tachysystole (frequent uterine contractions) (odds ratio (OR), 3.7; 95% confidence interval (CI), 1.2–10.8) and fetal tachycardia (OR, 4.8; 95% CI, 1.4–16.2) were determined as significant predictors of adverse outcome. The specificity of the model was 94.2%, whereas the sensitivity was 20.4%. Conclusion: In the absence of tachysystole and fetal tachycardia, an uneventful delivery might be expected for women receiving 50 μg of intravaginal misoprostol.     

Success rates with low dose misoprostol before induction of labor for nulliparas with severe preeclampsia at various gestational ages

Objective. To assess the efficiency of labor induction using low dose misoprostol for cervical ripening among nulliparous patients with severe preeclampsia.

Methods. This retrospective investigation involved cases gathered from our perinatal database for nulliparous women with severe preeclampsia delivering singleton gestations between January 2002 and May 2006. After a review of 229 hospital records, we selected only those cases (N = 145) that were eligible for a trial of labor and were administered intravaginal misoprostol (25 mcg every 3 to 6 h) for an unfavorable cervix. Primary outcomes related to the success and timing of vaginal deliveries. Secondary outcomes involved maternal and neonatal morbidity rates. Statistical evaluations included Chi-square testing and regression analysis.

Results. Vaginal delivery was successful in 95 cases (65.5%). This rate increased from 55.1% in cases at <34 weeks to 68.9% in cases at between 34 and 36 weeks, and to 72.5% in those at ≥37 weeks. Most of those who delivered vaginally did so within 24 h (82 of 95 cases, 86.3%), regardless of gestational age. Vaginal delivery was associated with a shorter postpartum stay (2.5 vs. 3.2 days; p = 0.001) and with less neonatal respiratory distress (4.2% vs. 26.0%; p < 0.001).

Conclusions. Vaginal delivery within 24 h was common, with less morbidity than cesarean delivery, in this nulliparous group presenting with severe preeclampsia and an unfavorable cervix.     

Labor progression and risk of cesarean delivery in electively induced nulliparas

OBJECTIVE: To describe the pattern of labor progression and risk of cesarean delivery in women whose labor was electively induced. METHODS: We analyzed data on all low-risk, nulliparous women with an elective induction or spontaneous onset of labor between 37 + 0 and 40 + 6 weeks from January 2002 to March 2004 at a single institution. The median duration of labor by each centimeter of cervical dilation and the risk of cesarean delivery were computed for 143 women with preinduction cervical ripening and oxytocin induction, 286 women with oxytocin induction, and 1,771 women with a spontaneous onset of labor. An intracervical Foley catheter was used to ripen the cervix. RESULTS: Electively induced labor with cervical ripening had substantially slower latent and early active phases. After controlling for potential confounders, women who had an elective induction with cervical ripening had 3.5 times the risk of cesarean delivery during the first stage of labor (95% confidence interval 2.7-4.5), compared with those admitted in spontaneous labor. Elective induction without cervical ripening, on the other hand, was associated with a faster labor progression from 4 to 10 cm (266 compared with 358 minutes, P < .01) and did not increase the risk of cesarean delivery, compared with those in spontaneous labor. CONCLUSION: The pattern of labor progression differs substantially for women with an electively induced labor compared with those with spontaneous onset of labor. Furthermore, elective induction in nulliparous women with an unfavorable cervix has a high rate of labor arrest and a substantially increased risk of cesarean delivery. LEVEL OF EVIDENCE: II-2.     

脐带螺旋指数与脐动脉血流S/D比值及妊娠结局关系的研究

目的:探讨脐带螺旋指数(umbilical coiling index,UCI)与脐动脉血流收缩期最大血流速度(S)/舒张期末血流速度(D)比值(S/D比值)及妊娠结局之间的关系。方法:选择在我院住院分娩妊娠37~40周的孕产妇720例,计算UCI值,分析UCI与脐动脉血流S/D比值及胎儿窘迫、新生儿体重、新生儿窒息、围产儿死亡、羊水指数、产后出血及剖宫产率之间的关系。结果:UCI正常组与UCI不足组之间脐动脉血流S/D比值及羊水指数、产后出血、剖宫产率无显著差异,UCI不足组胎儿窘迫、新生儿窒息、围产儿死亡发生率显著高于UCI正常组。UCI过高组的脐动脉血流S/D比值、羊水过少发生率及剖宫产率明显高于UCI不足组,两组间胎儿窘迫、新生儿窒息、围产儿死亡发生率无显著差异。UCI过高组脐动脉血流S/D比值、胎儿窘迫、新生儿窒息、围产儿死亡、羊水过少发生率及剖宫产率明显高于UCI正常组,两组差异有统计学意义。结论:UCI异常可能与脐动脉血流S/D比值及妊娠结局相关。     

Vacuum application through a nonfully dilated cervix: a viable option

The aim of this cross-sectional study was to assess the feasibility of vacuum delivery through a nonfully dilated cervix. The study group consisted of 39 women with vacuum deliveries through a nonfully dilated cervix larger than 9 cm and station of the head at S or more +2 cm. These were compared to a control group of 215 vacuum deliveries at a fully dilated cervix and 46 women who underwent cesarean section at a nonfully dilated cervix larger than 9 cm. The main indication for vacuum extraction in the study group was fetal distress and in the control groups prolonged 2nd stage, dysfunctional labor and fetal distress. Maternal and neonatal morbidity was low and not different between the groups. Neonatal well being, evaluated by cord pH and 5-min Apgar score, was not different. Based on predefined criteria, vacuum extraction through a nonfully dilated cervix is a viable alternative to emergency cesarean section and is apparently not associated with higher maternal or infant morbidity.