心脏机械瓣膜置换术后华法林抗凝治疗效果及INR抗凝强度范围分析

目的探讨华法林抗凝在心脏机械瓣膜置换术后的治疗效果及抗凝强度的范围。方法选取行心脏机械瓣膜置换术患者72例,按随机数字表法分成对照组和观察组各36例。对照组华法林服用剂量按INR值范围2.0～3.0调整,观察组华法林服用剂量按INR值范围1.5～2.0调整。对比两组治疗后并发症发生率及各项心功能指标。结果治疗后,两组血栓栓塞事件发生率相比,差异无统计学意义(P>0.05);但观察组出血事件发生率低于对照组,差异有统计学意义(P<0.05);观察组PT、TT、APTT水平均高于对照组,FIB水平低于对照组,差异有统计学意义(P<0.05)。结论心脏机械瓣膜置换术后华法林INR抗凝强度的范围1.5-2.0更安全可靠,预后良好,可有效降低并发症发生率。     

华法林在心脏机械瓣膜置换术后抗凝治疗疗效观察

目的:研究心脏机械瓣膜置换术后华法林的应用.方法:随访观察2003年1月-2007年6月本院行机械瓣膜置换术患者98例,分析华法林的应用情况及其并发症.结果:术后97名患者长期应用华法林抗凝治疗,其中8例出现并发症.结论:机械瓣膜置换术后应用华法林抗凝治疗有效,但有引起致命性并发症危险.     

心脏机械瓣膜置换术后患者华法林抗凝并发症的发生率及其影响因素分析

目的探讨心脏机械瓣膜置换术后患者早期华法林抗凝相关并发症的发生率，并分析其影响因素。方法以门诊复诊和电话随访的方式，对115例心脏瓣膜置换术后早期应用华法林抗凝治疗的患者进行调查，记录患者抗凝认知、治疗依从性、社会支持情况及抗凝并发症发生情况。结果115例患者中，发生出血的患者为24例（占20．9％），发生栓塞的患者为11例（占9．5％），抗凝认知得分和社会支持得分是患者发生抗凝相关并发症的显著预测因子。结论华法林抗凝相关并发症发生率较高，医务人员应加强对患者及其照护者抗凝知识的指导，同时强调社会支持对患者术后抗凝治疗效果的重要性，降低华法林相关并发症的发生率。     

心脏机械瓣膜置换术后输尿管中下段结石的手术及围术期处理

探讨心脏机械瓣膜置换术后输尿管中下段结石的手术方法选择及围手术期抗凝药物的使用及其安全性。【方法】8例心脏机械瓣膜置换术后罹患输尿管中下段结石患者,长期口服华法林抗凝治疗,入院后停用华法林,改用普通肝素0．5 mg／kg ,q4 h 静脉注射,调整凝血酶原时间（PT ）至正常范围之内,于手术前24 h 停用抗凝药物。手术方式采用全麻下输尿管硬镜气压弹道碎石加 D‐J 管内置术,手术时间控制在30 min 之内,术后24～48 h 口服华法林并与肝素重叠使用,3 d 后停用肝素,单服华法林并维持国际标准化比率（INR）于治疗范围之内。【结果】8例患者均顺利渡过围术期,一次性碎石排石率100％。【结论】针对心脏机械瓣膜置换术后输尿管中下段结石患者,在合理调整抗凝药物种类、剂量及用法,掌握合适的抗凝强度,并注意术中操作及术后处理的前提条件下,输尿管镜碎石＋ D‐J 管内置术,其疗效确,安全可靠。     

心脏机械瓣膜置换术后华法林抗凝的调整策略

目的：研究心脏机械瓣膜置换术后华法林抗凝的调整策略及年龄、性别、体重与华法林抗凝剂量、疗效的关系。方法：回顾192例心脏机械瓣膜置换术后服用华法林抗凝患者的临床资料,总结华法林抗凝调整国际标准化比值（INR）的方法,分析年龄、性别、体重和华法林剂量、INR值的关系,观察其抗凝效果及主要不良反应。结果：1例患者因过量服用华法林出现颅内出血死亡,1例过量出现严重皮下出血及鼻出血,1例出现腔隙性脑梗死,2例单用华法林效果不佳,合用拜阿司匹林后INR可调整到目标范围,其余患者效果较好,无严重出血及血栓形成。结论：心脏机械瓣膜置换术后华法林抗凝维持剂量个体差异较大,与年龄、性别、体重无关;抗凝治疗维持INR在1.8-2.5间较为适宜,不增加出血及血栓风险。     

机械瓣膜置换术后患者华法林服药信念与抗凝治疗依从性的相关性

目的评估机械瓣膜置换术患者华法林服药信念,并探讨其与抗凝治疗依从性的关系。方法采取方便抽样的方法电话回访2011年1—12月在山东大学齐鲁医院心脏外科行机械瓣膜置换术后出院患者130例,对其进行华法林服药信念问卷及抗凝治疗依从性问卷的调查。结果本组机械瓣膜置换术后患者华法林服药信念得分为（6．49±3．11）分,其中知觉受益维度得分为（16．18±1．76）分,高于知觉障碍维度得分[（9．68±1．96）分]（P〈0．01）;患者抗凝治疗依从性得分为（37．12±4．33）分,63．2％的患者抗凝治疗依从性良好;患者华法林服药信念与抗凝治疗依从性呈正相关（P〈0．01）。结论机械瓣膜置换术患者华法林服药信念与抗凝治疗依从性呈正相关,医护人员可通过评估患者的华法林服药信念,及时识别患者的不良认知并有效引导患者树立积极正确的华法林服药信念,从而提高患者的抗凝治疗依从性,保证治疗效果。     

心脏瓣膜置换术后患者华法林抗凝治疗依从性影响因素分析及对策

目的：探讨心脏瓣膜置换术后患者华法林抗凝治疗依从性的影响因素分析及对策。方法：选取2021年1月1日～2022年3月31日行心脏瓣膜置换术的209例患者作为研究对象，分为达标组(INR达标率≥80%)138例和未达标组(INR达标率<80%)71例，术后均给予华法林抗凝治疗，分析影响患者华法林抗凝治疗依从性的相关因素。结果：华法林抗凝知识认知程度调查结果显示，华法林的用法、华法林口服时间及华法林的效用认知正确率均高于80%。两组受教育程度、居住地、家庭收入、华法林抗凝知识认知程度比较差异有统计学意义(P<0.05)。多元Logistic回归分析结果显示，受教育程度、居住地、华法林抗凝知识认知程度为影响患者心脏瓣膜置换术后依从性的独立危险因素(P<0.05)。结论：心脏瓣膜置换术后患者华法林抗凝知识总体认知水平不高，且依从性较差，其中受教育程度低、居住地为农村、华法林抗凝知识认知程度差均为导致患者依从性差的独立危险因素，临床需加强对患者的干预，以提高术后治疗依从性。     

心脏机械瓣膜置换术后华法林抗凝治疗出血并发症的研究进展

心脏机械瓣膜置换术后需要终身抗凝治疗,抗凝相关出血并发症严重影响病人生存时间和生活质量。从出血类型、部位及出血评估工具、影响因素及减少出血并发症的策略方面综述心脏机械瓣膜置换术后华法林抗凝治疗出血并发症的研究进展,以期为心脏瓣膜置换术后抗凝治疗安全性提供参考。     

心脏机械瓣膜置换术后患者院外早期抗凝监测的依从性及其影响因素

目的调查心脏机械瓣膜置换术后患者院外早期抗凝监测的依从性现状,并探讨其影响因素,为制订有针对性的健康教育策略提供依据。方法采用自行设计的患者抗凝监测依从性问卷、华法林抗凝治疗认知情况调查表、焦虑自评量表、抑郁自评量表和社会支持评定量表,以门诊复诊和电话随访的方式对115例心脏机械瓣膜置换术后6个月口服华法林进行抗凝治疗的患者进行问卷调查。结果患者早期抗凝监测依从性得分为（2．73±0．84）分,63．5％的患者依从性好,36．5％的患者依从性差;监测依从性与华法林抗凝认知情况、文化程度、客观支持和就业情况呈正相关（P〈0．05）。结论患者抗凝监测依从性尚待提高,护理人员应加强对患者华法林抗凝相关知识的宣教,特别是文化程度较低、客观社会支持较差以及抗凝认知不足的在岗患者,以提高其对术后华法林抗凝监测的重视,降低抗凝相关并发症的发生率及再住院率。     

心脏机械瓣膜置换术后患者采用华法林抗凝治疗相关并发症的发生情况及影响因素分析

目的对心脏机械瓣膜置换术后早期患者进行随访,分析华法林抗凝治疗相关并发症的发生情况及影响因素。方法对300例心脏瓣膜置换术后早期应用华法林进行抗凝治疗的患者进行问卷调查,记录一般资料、疾病资料、抗凝认知情况、抗凝治疗依从性、社会支持情况,以及抗凝相关并发症的发生情况。结果有效问卷260份。260例患者共发生并发症73例(28.1%),其中发生出血56例(21.5%),发生栓塞17例(6.5%)。单因素分析显示不同受教育程度患者发生并发症的差异无统计学意义(P>0.05),不同居住地域、抽烟史、嗜酒史、病程长短、治疗依从性、社会支持得分、认知水平得分患者并发症发生例数差异有统计学意义(P<0.05)。Logistic多因素回归分析结果显示,居住地域、抽烟史、嗜酒史、病程长短、治疗依从性、社会支持得分、认知水平得分是心脏机械瓣膜置换术后患者采用华法林抗凝治疗发生并发症的独立危险因素。结论华法林抗凝相关并发症发生率较高,医务人员应加强对患者及其照护者进行华法林抗凝知识的宣传教育,重视社会支持对患者术后抗凝治疗效果的重要性。     

Establishment of trimester-specific reference intervals of serum lipids and the associations with pregnancy complications and adverse perinatal outcomes: a population-based prospective study

BackgroundDisturbances in maternal lipid metabolism may increase the risk of developing pregnancy complications and adverse perinatal outcomes. However, there is no consensus as to what constitutes normal serum lipid ranges during pregnancy. Our study was aimed to establish trimester-specific serum lipid reference intervals (RIs) and investigate the associations between maternal dyslipidaemia and adverse outcomes in a population-based study.MethodsThe first- and third-trimester lipid profiles were derived from 16,489 singlet pregnant women for regular antenatal check-ups between 2017 and 2019. The serum samples were assayed for total cholesterol (TC), triglycerides (TG), high-density lipoprotein-cholesterol (HDL-C), and low-density lipoprotein-cholesterol (LDL-C) in the institutional clinical laboratory. The trimester-specific lipid RIs were estimated with both of the direct observational and the indirect Hoffmann methods. The associations between maternal lipid profiling and pregnancy complications and perinatal outcomes were assessed statistically.ResultsSerum levels of TC, TG, LDL-C and HDL-C were all increased significantly in the third trimester of pregnancy. There was no significant difference between the observed RIs established with healthy pregnant women and the calculated RIs derived from the Hoffmann method. A trend towards increased risks of gestational complications and adverse perinatal outcomes was observed in the subjects with elevated levels of TC, TG, and LDL-C or decreased level of HDL-C.ConclusionsIn pregnancy, increased serum levels of TC, TG and LDL-C, and a decreased level of HDL-C posed higher risks of developing pregnancy complications and adverse perinatal outcomes.

Key messages

• It is necessary to establish trimester-specific reference intervals for serum lipids including TC, TG, LDL-C and HDL-C that were found significantly increased as the gestational age went up. More importantly, around the upper reference limits of TC, TG and LDL-C (or the lower reference limit of HDL-C), the higher the serum lipid levels were (or the lower the HDL-C level was), the higher risks of developing pregnancy complications and adverse perinatal outcomes were observed.

     

The role of adipocytokines in insulin resistance in normal pregnancy: visfatin concentrations in early pregnancy predict insulin sensitivity

BACKGROUND: Throughout pregnancy maternal adipose tissue is metabolically active, producing adipocytokines involved in the process of insulin resistance. We explored the role of serum adipocytokines, including the newly identified adipocytokine visfatin, in the process of insulin resistance in normal pregnancy. METHODS: We examined 80 pregnant nonobese, nondiabetic white women during the 3 trimesters of pregnancy. All study participants underwent anthropometric measurements, adipocytokine evaluation, and a 75-g oral glucose tolerance test. Homeostasis mathematical model assessment (HOMA-R), insulin sensitivity index (ISI), and indices of beta-cell secretion were calculated. RESULTS: Maternal weight, percentage total body fat, hip circumference, and indices of beta-cell secretion increased significantly during the 3 trimesters, and HOMA-R and ISI increased and decreased, respectively, in the 3rd trimester. During early pregnancy, insulin resistance, beta-cell secretion, and weight correlated positively with leptin. During the 1st trimester, visfatin correlated negatively with percentage body fat and was the best positive predictor of 2nd trimester ISI. In the 2nd trimester, serum visfatin was the best negative predictor of percentage body fat. CONCLUSIONS: During normal pregnancy of nonobese, nondiabetic women, adipose tissue increases, accompanied by a significant progressive increase of insulin resistance. Visfatin concentrations in the 1st trimester positively predict insulin sensitivity during the 2nd trimester. Body fat mass during 1st trimester of pregnancy is negatively associated with insulin sensitivity during the 2nd trimester and perhaps should be kept under control.     

Evaluation of adrenomedullin and endothelin-1: Are they factors in the adaptation of maternal vascular system in normotensive pregnancy

INTRODUCTION: The aim of our study was to analyse the role of adrenomedullin (AM) and endothelin-1 (ET-1) in the adaptation of the maternal vascular system in normotensive pregnancy. METHODS: Twenty-eight pregnant women, who were normotensive throughout the duration of their pregnancy, were recruited into the study. Plasma levels of AM and ET-1 at each trimester were measured and the AM/ET-1 ratio was calculated. RESULTS: Our experiment showed a significant decrease in plasma concentrations of AM in the first trimester for the study group (n=28) compared with the non-pregnant control group (n=16). There was also a significant decrease in plasma concentrations of ET-1 in all three trimesters (P<0.05) and a significant increase in the AM/ET-1 ratio in all three trimesters (P<0.05) for the study group compared with the control group. CONCLUSION: An alteration in vascular equilibrium between AM and ET-1, favouring AM, may be a reason why the physiological adaptation of the maternal vascular system to pregnancy occurs during normotensive pregnancy.     

CC5-02: A Descriptive Study of Vaccinations Occurring During Pregnancy, 2002-2006

Background/Aims Trivalent influenza vaccine (TIV) is the only vaccine recommended by the Advisory Committee on Immunization Practices (ACIP) for routine administration during pregnancy. The ACIP categorizes remaining vaccines as, "should be considered if indicated", "contraindicated", or with "special/conditional recommendation." The objective of this study was to describe rates of vaccination during pregnancy in seven Vaccine Safety Datalink (VSD) sites. Methods Using the VSD Pregnancy Algorithm, we identified all pregnancies ending in 2002-2006, including both live births and other birth outcomes (e.g., miscarriages, terminations). We then identified all vaccinations administered during pregnancies occurring in the study period. Results We identified 595,929 pregnancies and 68,839 vaccinations. The most commonly administered vaccine was TIV, with 58,683 doses and an incidence rate of 98.47 doses per 1,000 pregnancies. TIV was more likely to be administered during the 2nd or 3rd trimester (98.12 per 1,000 pregnancies), versus the 1st trimester (21.98 per 1,000). The total number of indicated vaccinations was 6,743 (11.32 per 1,000) and the most common vaccines in this category were tetanus-diphtheria and hepatitis B (6.65 and 4.31 per 1,000, respectively). Indicated vaccines were more likely to be given during the 1st trimester (7.42 per 1,000) than during the 2nd or 3rd trimesters combined (5.02 per 1,000). A total of 882 contraindicated vaccines were administered during the study period (1.48 per 1,000), and the majority of these were measles-mumps-rubella (MMR) (0.64 per 1,000), varicella (0.49 per 1,000) and live-attenuated influenza vaccine (LAIV) (0.19 per 1,000). The majority of contraindicated vaccines were administered during the 1st trimester (1.02 per 1,000) versus the 2nd or 3rd trimesters (0.58 per 1,000). Discussion TIV, which is recommended during pregnancy, was the most commonly administered vaccine in our study population. MMR, varicella, and LAIV were the most common contraindicated vaccines administered. With the exception of TIV, other vaccines were more likely to be administered during the 1st trimester of pregnancy, suggesting that vaccinations may occur during a period when either the woman and/or provider are unaware of the pregnancy. Given that some women were also vaccinated during later pregnancy, clearer recommendations and improved provider education may be needed.     

Pregnancy outcome following women's participation in a randomised controlled trial of acupuncture to treat nausea and vomiting in early pregnancy

OBJECTIVES: Recent studies have concluded that acupuncture is safe in the hands of a qualified practitioner. This study assessed the risk of adverse effects of acupuncture administered during pregnancy. METHODS: 593 women with nausea and vomiting in early pregnancy volunteered to participate in a randomised controlled trial, conducted at the Women's and Children's Hospital, in South Australia. Patients were given either traditional acupuncture, formula acupuncture, sham acupuncture or no acupuncture. OUTCOME MEASURES: Data were collected on perinatal outcome, congenital abnormalities, pregnancy complications and the newborn. RESULTS: No differences were found between study groups in the incidence of perinatal outcome, congenital abnormalities, pregnancy complications and other infant outcomes. CONCLUSION: Our findings suggest that no serious adverse effects arise from acupuncture administered in early pregnancy.     

孕产妇产前抑郁与妊娠期体重增加的关系

目的 分析孕妇产前抑郁状态的发生情况,探讨各孕期抑郁以及整个孕期抑郁的变化与孕妇妊娠期体重增加的关系。方法 对2011-2013年期间在浙江省某妇幼保健院进行围产期保健的孕妇,分别在孕8~12周、孕22~26周、孕32周后进行基线和随访调查,收集孕妇社会人口学信息、生殖婚育史和各孕期身体状况、生活行为信息等资料,采用抑郁自评量表（SDS）评估抑郁状态。结果 孕早、中、晚期抑郁状态的发生率分别为48.8%、35.0%和34.9%,且各孕期SDS得分均高于中国常模。孕早期SDS与孕早期BMI增加呈负相关（=-0.01,P=0.0184）。未观察到孕期抑郁与孕期体重改变的相关性。结论 孕期妇女抑郁状态发生率较高,应加强妊娠期的精神保健,促进母婴健康。     

Unfractionated heparin for second trimester placental insufficiency: a pilot randomized trial

Summary. Objective: To conduct a pilot randomized controlled trial of unfractionated heparin (UFH) in women considered at high risk of placental insufficiency in the second trimester. Methods: Women with either false‐positive first trimester (pregnancy‐associated placental protein‐A [PAPP‐A] < 0.35 MoM) or second trimester (alpha‐fetoprotein [AFP] > 2.0 MoM, inhibin > 3.0 MoM, human chorionic gonadotropin > 4.0 MoM) serum screening tests or medical/obstetric risk factors were screened for placental insufficiency by sonographic evaluation of the placenta and uterine artery Doppler between 18 and 22 weeks. Thrombophilia screen‐negative women with two or three abnormal test categories were randomized by 23+6 weeks to self‐administration of subcutaneous unfractionated heparin (UFH) 7500 IU twice daily until birth or 34 weeks, or to standard care. Maternal anxiety and other maternal‐infant outcomes were determined. Results: Thirty‐two out of 41 eligible women consented, with 16 women randomized to UFH and 16 to standard care. There was no statistically significant difference identified between the two treatment groups (standard care vs. UFH) for the following: maternal anxiety score (mean [standard deviation]), 14.2 [± 1.6] vs. 14.0 [± 1.8]; birth weight (median [range]), 1795 [470–3295]g vs. 1860 [730–3050]g; perinatal death, 3 vs. 0; severe preeclampsia, 2 vs. 6; placental weight < 10th percentile, 7 vs. 4; or placental infarction, 4 vs. 3. Conclusion: Our study design identified women at high risk of adverse maternal‐infant outcomes attributable to placental insufficiency. Women with evidence of placental insufficiency were willing to undergo randomization and self‐administration of UFH without increased maternal anxiety.     

糖尿病患者妊娠时机的选择及对妊娠结局的影响

目的:探讨糖尿病患者适宜的妊娠时机及对妊娠结局的影响。方法:选择2002-2008年间于温州医学院附属第一医院就诊分娩的显性糖尿病合并妊娠患者共36例作为研究对象。按照妊娠时糖尿病病情控制情况分为计划妊娠组(15例)和非计划妊娠组(21例),对两组患者的母儿结局进行比较。结果:(1)孕妇结局,非计划妊娠组血糖控制相对困难,胰岛素用量大,孕妇并发症发生率明显高于计划妊娠组,分别为71.4%、33.3%,计划妊娠组以早产发生率最高,为26.7%,非计划妊娠组以妊娠期高血压疾病发生率最高,为52.4%。妊娠期高血压疾病发生率两组比较差异有显著性(P<0.05)。(2)围产儿结局,新生儿窒息发生率非计划妊娠组明显高于计划妊娠组(P<0.05),围产儿死亡3例均发生在非计划妊娠组。非计划妊娠组围产儿不良结局发生率明显高于计划妊娠组(P<0.01)。结论:孕前糖尿病患者病情控制良好情况下妊娠将显著提高妊娠安全性,有助于改善妊娠结局。     

Oxidative stress and inflammation in pregnancy

Pregnancy is a period when increased oxidative stress can be expected. We have focused especially on oxidative stress and inflammation in the period of pregnancy, when prenatal screening is usually performed. We determined advanced oxidation protein products (AOPPs), C-reactive protein (CRP) and anticardiolipin antibodies (ACA) IgG and IgM levels in the serum of 86 pregnant women in the 1st trimester and 102 pregnant women in the 2nd trimester. AOPP levels in the maternal serum of pregnant women were significantly higher in the 1st and 2nd trimesters than they were in that of non-pregnant women (p<0.0001, p<0.001, respectively). Maternal serum CRP levels, too, were increased compared with those in non-pregnant women (1st and 2nd trimester versus non-pregnant women p<0.05, p<0.005, respectively). Just as with AOPPs and CRP, the ACA IgG levels in pregnant women were significantly higher in both trimesters than they were in non-pregnant women (1st and 2nd trimesters versus non-pregnant women p<0.05, p<0.001, respectively). Maternal serum CRP levels correlated positively with AOPPs in the 2nd trimester (r = 0.504, p<0.05). The increased levels of AOPPs, CRP and ACA IgG in the 1st and 2nd trimesters may reflect a maternal response to inflammatory and oxidative stress in pregnant women.     

妊娠期间亚临床甲状腺功能减退的诊断与治疗

妊娠期亚临床甲状腺功能减退(SCH)是指妊娠期间血清促甲状腺激素(TSH)高于妊娠特异性参考值上限,而血清游离甲状腺素(FT4)在妊娠特异性参考值范围内。妊娠SCH特别是合并甲状腺自身抗体阳性者可以增加妊娠不良结局和围产期并发症的风险,并可能影响后代的智力和运动发育。建议对妊娠早期妇女开展SCH的筛查,筛查最佳时间是妊娠8周之内,筛查内容包括FT4、TSH和甲状腺过氧化物酶抗体(TPOAb)。建议孕前或妊娠期出现的SCH患者使用左旋甲状腺素(L-T4)治疗,治疗目标是将TSH恢复到妊娠特异参考值范围内。妊娠期间需碘量增加约50%,需适量补碘,建议每天额外补碘150 μg,以碘化钾最佳。