米非司酮配伍米索前列醇在早中孕引产的应用

目的 观察米非司酮配伍米索前列醇用于妊娠10～16周早中孕引产的效果.方法 对46例妊娠10～16周,自愿要求终止妊娠的健康妇女作为研究组,对研究组采用米非司酮配伍米索前列醇方法引产,胎儿自然排除后即行清宫术;选用同期同样条件46例宫颈插管后行钳刮术为对照组,对两组人工流产痛、术中情况进行统计学比较.结果 研究组引产成功率为96%,其疼痛较对照组轻微减轻(P＜0.05);术中情况有显著性差异P＜0.05.结论 米非司酮配伍米索前列醇有胃肠道反应轻,手术时间短、出血少、疼痛轻、组织残留率降低,并发症少、成功率高等特点,是一种简便、有效、安全的终止早中妊娠的方法,值得临床推广应用.     

A short-scheme protocol of gemeprost for midtrimester termination of pregnancy with uterine scar

OBJECTIVE: The purpose of this study is to investigate the safety and effectiveness of a short-scheme protocol of gemeprost for second trimester induction of abortion in women with previous uterine surgery. STUDY DESIGN: Retrospective review of women who underwent second trimester medical termination of pregnancy (TOP) at our hospital in a 5-year period. A short regimen of gemeprost was used: over a 24-h period, 1 mg vaginal gemeprost was given every 3 h up to three doses after which, if abortion did not occur, another course at the same dosage schedule was administered up to 4 days. Induction failure was defined as women undelivered by 96 h. A homogeneous population was identified. Statistical analysis was performed with the chi(2) test or Fisher's Exact Test for categorical data and t test for continuous variables. RESULTS: Four hundred seventeen women underwent medical midtrimester TOP in the 5-year study period. Two hundred five patients were selected for this review, comparing 63 patients with scarred uterus to 142 women without uterine scars. There were no differences between the two groups in induction-to-abortion interval and number of pessaries given. The overall failure of induction rate was 1.5% and need for blood transfusion was 0.5%. No uterine rupture was reported. CONCLUSION: The regimen of gemeprost proposed seems to be as safe and effective in patients with uterine scars as in women with unscarred uteri with a very low incidence of complications.     

米非司酮配伍米索前列醇联合依沙吖啶羊膜腔注射引产的临床效果观察

目的:探讨米非司酮配伍米索前列醇联合依沙吖啶羊膜腔内注射引产的临床效果。方法:孕15~26周中期妊娠引产受术者120例,按知情选择的原则分为观察组和对照组各60例。对照组予依沙吖啶100mg羊膜腔内注射引产。观察组予依沙吖啶100mg羊膜腔内注射同时顿服米非司酮150mg,24h后予米索前列醇200μg,阴道后穹隆置药。结果:观察组在宫缩发动时间、总产程时间、出血量方面均明显少于对照组(P0.05)。观察组与对照组分别有2例和3例软产道损伤,无统计学差异(P0.05)。两组均未发生子宫破裂、大出血及严重的药物过敏反应等。结论:米非司酮配伍米索前列醇联合依沙吖啶羊膜腔内注射终止中期妊娠,明显缩短了引产时间,无严重不良反应。     

米非司酮、米索终止13～20周妊娠的随机对照研究

目的:以利凡诺为参比制剂,观察米非司酮、米索用于终止13-20周妊娠的临床效果及可接受性.方法:采用开放性随机对照原则,按研究方案接纳怀孕13～20周要求终止妊娠的妇女100例,随机分配到实验组(n=50)和对照组(n=50).实验组采用米非司酮 米索引产,口服米索后4～6小时内清宫;对照组采用利凡诺羊膜腔内穿刺法引产,视胎盘胎膜残留情况酌情清宫.用药后观察两组对象的疗效、宫腔内容物排出时间、产时产后出血量等.结果:采用t检验和x2检验,两组在引产成功率、宫腔内容物排出时间、产时产后出血量方面无显著差异.结论:米非司酮、米索在用于终止13～20周内妊娠的效果与利凡诺羊膜腔内穿刺是等同的.     

依沙吖啶羊膜腔注射中期引产术的安全性及有效性临床研究回顾性再评价

目的:评估依沙吖啶羊膜腔注射中期引产的安全性及有效性。方法:回顾性分析全国10家医院依沙吖啶羊膜腔注射中期引产的临床资料。结果:本研究纳入10家医院1893例依沙吖啶羊膜腔注射中期引产妇女,注射与引产间隔中位时间41.5(43.7±14.6)h。3d内成功分娩1798例(95.0%),5d内成功分娩1886例(99.6%)。孕周越大(OR=1.28,P0.001)、产次越多(OR=1.13,P=0.007)、依沙吖啶使用剂量越大(OR=1.02,P=0.012),规律宫缩发动越早(OR=0.94,P0.001),则引产间隔时间越短。278例有剖宫产史妇女无子宫破裂发生。结论:依沙吖啶羊膜腔注射中期引产具有较高的安全性及有效性,不增加瘢痕子宫妇女引产风险。     

364例中期妊娠引产相关原因调查与分析

目的了解育龄妇女中期妊娠引产原因,提出减少中期妊娠引产的预防对策,减少非意愿妊娠发生。方法选择2007～2010年在宜昌市夷陵区计划生育服务站进行中期妊娠引产的364例育龄妇女为研究对象,回顾性分析病历资料及当初的问卷调查,将研究对象的临床资料进行搜集整理。结果 364例怀孕妇女中未婚93例(25.5%),初婚256例(70.3%),再婚15例(4.1%)。避孕措施失败236例(64.8%),未采取避孕措施128例(35.2%),其中含政策内怀孕医学原因终止妊娠11例。导致中期引产的主要原因为:相关知识缺乏和认识误区,生育意愿和生育政策相悖,特殊原因错过早期人工流产时机。结论加强对育龄妇女及未婚女性避孕节育知识的宣传教育,使她们充分认识到避孕节育知情选择的重要性和必要性,自愿选择合适自己的有效避孕方法,减少非意愿性妊娠。加强对意外妊娠早发现早终止的知识教育,减少中期妊娠引产,保护育龄妇女的身体健康。     

药流后加桂枝茯苓胶囊缩短阴道出血时间观察

目的 探讨加服桂枝茯苓胶囊对缩短药物流产后阴道出血时间的作用.方法 将180例早孕妇女分为两组,观察组于排出孕囊后加服桂枝茯苓胶囊3天,对照组排出孕囊后未服用,以观察流产效果.结果 完全流产率,观察组为97.77%,对照组为90.00%(P＜0.01),有显著性差异.完全流产者观察组平均阴道出血时间为11.81±4.55天,对照组为15.92±4.13天(P＜0.01),有显著性差异.结论 桂枝茯苓胶囊有缩短药物流产后阴道出血时间的作用.     

晚期妊娠死胎引产方法及综合方式引产效果分析

目的探讨晚期妊娠死胎引产方法及运用综合方式引产的效果。方法回顾性分析2017年1月1日至12月31日湖北省妇幼保健院收治的140例晚期妊娠引产病例,将引产时死胎设为观察组(42例),胎儿存活设为对照组(98例)。比较两组病例的一般情况、引产时间及并发症,并分析综合方式引产与单一方式引产的并发症差异。结果观察组与对照组孕妇的产次(Z=-2.258)、妊娠期糖尿病患病率(χ^2=4.444)、分娩时身体质量指数(BMI)(t=0.138)、住院天数(t=6.848)比较差异均有统计学意义(均P<0.05)。观察组仅需使用催产素引产率显著高于对照组(χ^2=5.051),引产时间显著短于对照组(t=4.546),差异均有统计学意义(均P<0.05)。综合方式引产的引产时间(t=7.984)、产后出血量(t=3.284)、产后出血率(χ^2=10.256)、产后输血率(χ^2=13.453)、产褥病率(χ^2=10.256)均高于单一方式引产,差异均有统计学意义(均P<0.05)。结论晚期妊娠死胎使用米非司酮配伍利凡诺或COOK球囊安全、有效,综合方式引产的应用可减少引产过程中的中转剖宫取胎的几率,但需要警惕产后出血、产褥感染等并发症。     

《2020 ACOG实践简报:孕龄≤70 d药物流产(No.225)》解读

药物流产(MA)是早孕期避孕失败的补救措施,主要药物为米非司酮和米索前列醇,二者联合使用,可使早孕期孕妇完全终止妊娠率达到90%。但是,MA导致的患者阴道流血时间长、量多,甚至阴道大流血,而需采取急诊刮宫术治疗等,尚未被彻底解决。如何安全、有效终止早孕期妊娠,保护女性生殖健康是目前国内外该领域的研究重点。美国妇产科医师学学会(ACOG)发布的《2020 ACOG实践简报:孕龄≤70 d药物流产(No.225)》对早孕期孕妇终止妊娠,具有重要指导作用。笔者拟就该简报对MA用于孕龄≤70 d孕妇的临床效果评估,MA用药方案、禁忌证、适应证,MA前咨询和检查,MA疼痛管理,MA后观察、预防性抗菌药物使用、随访管理、避孕措施9个方面基于循证医学推荐进行解读。     

晚孕期腹腔镜手术4例报告及文献复习

目的探讨妊娠晚期妇科腹腔镜手术的可行性。方法回顾性分析2009~2015年北京大学第一医院妇产科收治的4例晚孕期因附件包块住院、行腹腔镜手术治疗患者的临床资料,并随访其妊娠结局和新生儿情况。结果 4例患者的孕周为28+2~31+5周,临床表现均为急腹症,疑诊附件包块扭转而行腹腔镜手术,病理诊断为3例输卵管系膜囊肿扭转坏死,1例为增大坏死的卵巢。术后出现宫缩予硫酸镁、吲哚美辛等保胎治疗成功,未发生手术相关合并症。4例患者均足月分娩,3例因产科因素行剖宫产,1例阴道顺产,新生儿无窒息。随访6周~6年,患者月经正常、肿物无复发,小儿发育良好。结论晚孕期腹腔镜手术风险相对较大,对于因附件包块而致急腹症的患者,在有条件的医疗机构,由有经验的内镜医生施术,不失为一种治疗方法。     

Poor quality of life and health in young to middle aged Bosnian female war refugees: a population-based study

Objective: To evaluate whether female Bosnian refugees have a poorer quality of life than Swedish women.Design: A cross-sectional study of quality of life using a slightly modified ‘Göteborg Quality of Life’ instrument. The women rated their global well-being (19 items) on a 7-degree scale ranging from ‘very bad’ (1) ‘to excellent, could not be better’. The second part of the questionnaire consisted of 29 yes/no items about somatic and psychological symptoms which should take less than 5 min to complete. Factor analysis was performed in order to reduce the number of variables. Differences between mean ranks were tested by the Kruskal–Wallis test. Differences in distributions of the yes/no-questions in the different groups were tested with a likelihood ratio χ² test.Setting: Malmö and Lund, two cities in Southern Sweden.Subjects: A simple random sample of 120 women aged 18–59, born in Bosnia-Hercegovina with accepted refugee status, and registered in Lund and Malmö, was interviewed. The control group for this was 292 Swedish women of the same age, registered in Dalby (Lund). The response rate for Bosnian women was 74% and for Swedish women 75%.Main outcome measures: The factor analysis resulted in one factor, ‘global health’, to which all the well-being variables were related.Results: 38% of the Bosnian and 23% of the Swedes had bad global health. Bosnian women with bad global health had lower mean rankings than Swedish women, namely low quality of life in ‘appetite’, ‘memory’, ‘leisure time’, and aspects of mental well-being such as ‘energy’, ‘patience’, ‘sleep’, ‘mood’, and ‘health’. They also had larger proportions of symptoms than Swedish women.Conclusions: Bosnian women irrespective of health status had a poorer quality of life in most variables and more symptoms than Swedish women with good global health.     

Diagnosis of a severe congenital anomaly: A qualitative analysis of parental decision making and the implications for healthcare encounters

Objective

To explore parental decision making following diagnosis of a severe congenital anomaly, and implications for healthcare encounters.

Design

Qualitative semi‐structured interviews with 38 parents‐to‐be were collated and triangulated with data generated from consultation recordings.

Analysis

Data were analysed using a constant comparative‐based approach.

Setting

Recruitment was undertaken across four fetal medicine sites in two tertiary referral trusts.

Participants

Parents‐to‐be whose pregnancy was suspected or diagnosed as being affected by a severe congenital anomaly. This sample was purposive to include known factors affecting the decision to terminate or continue the affected pregnancy.

Findings

In trying to make a decision about how to proceed with their pregnancy, parents‐to‐be typically had to work hard to negotiate multiple uncertainties around the diagnosis and prognosis of the suspected anomaly. This was influenced by parents’ capacity to cope with uncertainty and the way in which uncertainty was managed by the clinical team. This negotiation of uncertainty was enacted within a fluid, nonlinear three‐phase process: “information seeking,” reflecting the way parents‐to‐be face the uncertainty associated with a fetal diagnosis and associated prognosis; “implications,” where consideration is given to future consequences of the decision; and “decision making,” which reflects the way in which the decision is made (head‐ or heart‐led). Spectrums of responses were apparent within each phase.

Conclusions

This study provides important insights into how parents‐to‐be make decisions following diagnosis or suspicion of a severe congenital anomaly. The impact of these on healthcare encounters is discussed, alongside recommendations for clinical practice.     

Late Pregnancy Ultrasound to Screen for and Manage Potential Birth Complications in Nulliparous Women: A Cost-Effectiveness and Value of Information Analysis

BackgroundFetal growth restriction is a major risk factor for stillbirth. A routine late-pregnancy ultrasound scan could help detect this, allowing intervention to reduce the risk of stillbirth. Such a scan could also detect fetal presentation and predict macrosomia. A trial powered to detect stillbirth differences would be extremely large and expensive.ObjectivesIt is therefore critical to know whether this would be a good investment of public research funds. The aim of this study is to estimate the cost-effectiveness of various late-pregnancy screening and management strategies based on current information and predict the return on investment from further research.MethodsSynthesis of current evidence structured into a decision model reporting expected costs, quality-adjusted life-years, and net benefit over 20 years and value-of-information analysis reporting predicted return on investment from future clinical trials.ResultsGiven a willingness to pay of £20 000 per quality-adjusted life-year gained, the most cost-effective strategy is a routine presentation-only scan for all women. Universal ultrasound screening for fetal size is unlikely to be cost-effective. Research exploring the cost implications of induction of labor has the greatest predicted return on investment. A randomized, controlled trial with an endpoint of stillbirth is extremely unlikely to be a value for money investment.ConclusionGiven current value-for-money thresholds in the United Kingdom, the most cost-effective strategy is to offer all pregnant women a presentation-only scan in late pregnancy. A randomized, controlled trial of screening and intervention to reduce the risk of stillbirth following universal ultrasound to detect macrosomia or fetal growth restriction is unlikely to represent a value for money investment.     

中孕期使用子宫颈托对双胎妊娠孕妇早产预防的系统评价

目的系统评价双胎孕妇中孕期使用子宫颈托预防双胎妊娠发生早产的有效性。 方法计算机检索相关文献数据库中,关于双胎孕妇中孕期使用子宫颈托预防双胎妊娠发生早产的相关文献。其中,英文数据库包括：Embase、PubMed、Cochrane Central Register of Controlled Trials (CCRT)、Cochrane Database of Systematic Reviews、Ovid-Medline及American College of Physicians (ACP)等;中文数据库包括：中国生物医学文献数据库(CBM)、中国期刊全文数据库(CNKI)、维普(VIP)和万方数据库。此外,手工检索相关会议资料、论文集及学位论文汇编等。检索时间设定为自数据库建库至2018年1月,检索内容为双胎孕妇中孕期使用子宫颈托预防双胎妊娠发生早产的随机对照试验(RCT)。采用Cochrane系统评价法,对检索文献进行质量评价和Meta分析,参照系统综述和Meta分析优先报告的条目(PRISMA)报告规范进行报告。各研究间的异质性采用I²检验,若I²≤50%,则采用固定效应模型Meta分析;若I²>50%,则采用随机效应模型Meta分析。采用Mantel-Haenszel法评估RR值及其95%CI。 结果①通过相关文献检索,共计5篇RCT文献符合本研究纳入标准与排除标准,涉及2 465例双胎妊娠孕妇,其中宫颈长度(CL)缩短双胎妊娠孕妇为827例。②对纳入文献的方法学质量评价结果显示,纳入文献质量为中等质量文献。③对纳入的双胎孕妇中孕期使用子宫颈托的双胎妊娠预防早产主要/次要指标的Meta分析结果示,中孕期使用子宫颈托,可明显降低中孕期双胎妊娠者分娩新生儿的新生儿重症监护病房(NICU)治疗率(RR＝0.73,95%CI：0.53～1.00,P＝0.05),但是增加了双胎孕妇的阴道排液发生率(RR＝3.07,95%CI：1.29～7.30,P＝0.01)和早产儿视网膜病变(ROP)发生率(RR＝3.85,95%CI：1.19～12.45,P＝0.02)。对中孕期双胎妊娠合并CL缩短孕妇的亚组Meta分析结果显示,中孕期CL<38 mm双胎妊娠孕妇使用子宫颈托,可显著降低孕龄<37孕周前早产发生率(RR＝0.81,95%CI：0.69～0.94,P＝0.007),新生儿败血症发生率(RR＝0.50,95%CI：0.30～0.86,P＝0.01)与新生儿坏死性小肠结肠炎(NCE)发生率(RR＝0.43,95%CI：0.20～0.95,P＝0.04);中孕期CL≤25 mm双胎妊娠孕妇使用子宫颈托,不能显著改善双胎妊娠的胎儿/新生儿围生期结局。 结论双胎妊娠孕妇中孕期预防性使用子宫颈托,并不能有效预防早产发生,但是可明显降低CL<38 mm双胎妊娠孕妇孕龄≤37孕周前早产发生率。     

TAT、PIC、TM、tPAI-C预测孕中晚期孕妇深静脉血栓价值

目的:探讨血浆中凝血酶抗凝酶复合物(TAT)、纤溶酶-抗纤溶酶复合物(PIC)、血栓调节蛋白(TM)、组织型纤溶酶原激活抑制复合物(tPAI-C)检测对孕中晚期深静脉血栓(DVT)的预测价值。方法:选择2019年1月-2019年9月于本院产科建立完整产前检查档案并计划分娩的孕中晚期DVT孕妇48例(DVT组)和健康孕妇54例(对照组),比较两组基线资料、实验室指标(TAT、PIC、TM、tPAI-C),多因素回归分析发生DVT独立影响因素;绘制受试者ROC曲线,确定最佳截断点和预测效能。结果:DVT组孕晚期PLT低于孕中期,FIB、PT、TAT、PIC、TM、tPAI-C值高于孕中期(P<0.05),对照组孕中期和孕晚期上述各指标无差异(P>0.05);DVT组孕晚期、孕中期FIB、PT低于对照组,TAT、PIC、TM、tPAI-C值高于对照组(均P<0.05)。TAT、PIC、TM、tPAI-C值是孕中晚期孕妇发生DVT独立影响因素(P<0.05)。PIC、TM、tPAI-C联合检测对孕中晚期孕妇发生DVT的预测价值最高(P<0.05)。结论:TAT、PIC、TM、tPAI-C为影响孕中晚期DVT发生的独立预测因子,联合检测可为临床早期诊治提供参考。     

Dual method use at last sexual encounter: a nationally representative,episode-level analysis of US men and women : Prepared for resubmission to Contraception

Objectives

Male condom use in conjunction with other contraceptives increases protection against pregnancy and sexually transmitted infections. However, few analyses contextualize dual method use within the sexual episode, include reports from men or explore gendered patterns in reporting.

Study design

We analyzed dual method use patterns using a nationally representative dataset of 18–44 years old in the US (N=404 men, 416 women). Respondents indicated contraceptive methods used at last penile–vaginal intercourse, condom practices and relationship and sexual information about that particular partner.

Results

More than one-in-three penile–vaginal intercourse episodes (40%) involved male condom use: 28% condom only and 12% condom plus a highly effective method. Dual method reporting did not differ significantly by gender. Among dual method users, only 59% reported condom use during the entire intercourse episode, while 35% began intercourse without one and 6% removed the condom during intercourse. A greater proportion of men than women reported incorrect use of condoms (49% versus 35%), though this difference was not statistically significant. Only 50% of dual method users reported condom use in all of their last 10 intercourse episodes.

Conclusions

Many people classified as “dual users” in previous studies may not be using dual methods consistently or correctly. Researchers and practitioners should inquire how and how often condoms are used when assessing and addressing dual method use. Furthermore, though men have rarely been surveyed about dual method use, they can provide consistent contraceptive estimates and may be more likely to report condom practices such as late application or early removal.

Implications statement

Many US women and men reporting dual method use also reported late application and early removal of condoms, as well as multiple condom-less prior sexual acts with that partner. Clinicians may wish to inquire how and how often clients use condoms; they may also wish to provide condom instruction and/or tips on better integrating condoms into the sexual experience with one's partner.