孕妇血浆中胎儿DNA含量与早产关系的研究

目的:研究早产和先兆早产孕妇血浆胎儿DNA的含量以及临床意义.方法:选择孕满28周至不足37周出现自发性规律宫缩的孕妇(单男胎)51例,其中23例孕周<37周分娩为早产组;28例出现有威胁的早产宫缩但经抑制宫缩治疗后足月产为先兆早产组,另选择正常妊娠的孕妇25例为正常对照组.采用实时荧光定量PER方法测定孕妇血浆中总DNA和胎儿DNA的量,非参数统计方法进行数据分析.结果:①早产组孕妇血浆总DNA量中位数7639.0拷贝/ml高于正常对照组6931.8拷贝/ml,差异有统计学意义(P<0.05);②早产组孕妇血浆胎儿DNA中位数为386.6拷贝/ml,先兆早产组为312.9拷贝/ml,均高于正常对照组230.5拷贝/ml,差异均有统计学意义(P<0.05);③以正常对照组孕妇血浆胎儿DNA量的第90百分位作为阳性预测值,早产组的阳性预测率为82.6%,先兆早产组为46.4%,差异有统计学意义(P<0.05).结论:早产孕妇血浆中胎儿DNA水平升高,观察孕妇血浆中胎儿DNA变化可有助于发现存在早产的可能,便于及时干预和处理.     

早发型重度子痫前期合并胎儿生长受限期待治疗的妊娠结局探讨

目的:探讨期待治疗中早发型重度子痫前期合并胎儿生长受限(FGR)的母儿结局,为临床处理提供依据。方法:回顾性分析2002年1月至2012年12月厦门大学附属第一医院产科收治的早发型重度子痫前期患者143例的临床资料,其中合并FGR 48例(合并FGR组),未合并FGR 95例(未合并FGR组)。比较两组一般情况、孕产妇并发症、分娩情况和新生儿情况及143例患者不同分娩孕周(孕30周、孕30~31+6周、≥孕32周)围生儿结局。结果:1两组一般情况、期待治疗平均延长孕周和孕产妇并发症(HELLP综合征、子痫、胎盘早剥、心衰等)的发生率比较,差异均无统计学意义(P0.05)。2合并FGR组分娩孕周晚于未合并FGR组(P0.05),但其新生儿出生体重小于未合并FGR组(P0.05)。合并FGR组围生儿死亡率高于未合并FGR组(P0.05)。3新生儿并发症中,合并FGR组心脏发育不全的发生率高于未合并FGR组(P0.05)。4随着分娩孕周增加,早发型重度子痫前期患者的围生儿死亡率和新生儿肺透明膜病的发生率逐渐降低,差异均有统计学意义(P0.05)。合并FGR围生儿死亡率和总体心脏发育不全的发生率在分娩孕周≥32周后也明显降低(P0.05)。结论:对于早发型重度子痫前期合并FGR的患者,期待治疗并不增加孕产妇并发症。合并FGR的患儿心脏发育不全发生率及围生儿死亡率明显增加,但期待治疗后通过延长孕周可改善其围生儿结局。     

Neonatal and Maternal Complications after Administration of Indomethacin for Preterm Labour between 24 and 30 Weeks Gestation

Introduction: the safety of Indomethacin tocolysis in early gestation has not been established as conflicting results of undesirable neonatal side effects have been reported.Materials and methods: a matched retrospective case control study of 107 mothers who received Indomethacin for preterm labour and their neonates who were delivered between 24 and 30 weeks gestation.Results: there were no significant differences in the incidence of maternal and neonatal complications between the Indomethacin-treated and control groups.Conclusion: in contrast with previous reports, our findings indicate that the short term use of Indomethacin as a tocolytic agent is safe.     

Maternal Perception of Preterm Labor

The objective of this study was to determine the reliability of maternal perception of uterine contractions and the influence of gestational age and maternal training on the perception level. Three hundred fifty patients at high risk for preterm delivery were followed from 20 to 35 weeks of gestation. The average maternal perception (79%) of contractions did not significantly vary as a function of gestational age. Four groups of women were identified according to the perception index (PI) defined as the ratio of contractions felt by the mother and the contractions documented by tocodynamometer. Within each group, the PI did not significantly vary during consecutive monitoring sessions, as the women become more familiar with self detection of uterine contractions (R <. 65, P >. 95). Twenty-one percent (±5%) of all preterm uterine contractions were not perceived by the pregnant women from 21 to 35 weeks. Thirty-two patients (9.1%) fail to perceive most or all uterine contractions while 189 (54%) detect most or all at any time during the study period.     

Complications of Beta-Mimetic Therapy in Preterm Labour

Selective beta-mimetic drugs are the most frequently used agents for arresting preterm labour. For this purpose these drugs have to be given in high doses for several hours and since they act on several organ systems, side-effects, some of which are potentially dangerous, appear. These hazards, which involve chiefly the cardiovascular and metabolic areas, have been examined in the light of available experience with these drugs. This review considers the possible mechanisms for the side-effects and offers suggestions on how the dangers in the use of beta-mimetic drugs in preterm labour might be avoided.     

Meta-analysis of Nifedipine versus Beta-sympathomimetic Agents for Tocolysis during Preterm Labour

Objective: successful tocolysis during preterm labour enables the clinician to gain time in order to administer corticosteroids to the labouring woman in an effort to promote fetal lung maturation and reduce neonatal morbidity and mortality. Our current meta-analysis compared the effectiveness of nifedipine and beta-sympathomimetic agents in achieving tocolysis at 48 hours. In addition a comparison of maternal side effects was made.Data Sources: studies were identified through Ovid MEDLINE (1966 to December 1996). The following MEDLINE search terms were included, using both major MeSH headings and textwords: “tocolysic agents,” “nifedipine,” “calcium channel blocker(s)” and “dihydropyridines.” All Abstracts, review articles and letters were read, and their bibliographies searched for relevant additional articles.Methods of Study Selection: prospective studies were selected if they included more than 20 subjects, provided a formal definition of preterm labour, compared nifedipine with another sympathomimetic agent, randomly allocated subjects to treatment and examined rates for successful tocolysis at 48 hours. Nine randomized clinical trials were identified, of which seven were eligible for our meta-analysis.Tabulation, Integration and Results: data were extracted by a single, non-blinded reviewer for study design, interventions, rates of successful tocolysis at 48 hours, number of extra days achieved with each agent and any significant drug side effects. Both a fixed-effects and random-effects model were used for the meta-analysis. The mean gestational age among the 217 women randomized to receive nifedipine was 31.2 weeks (range 22 to 35 weeks), compared to the 207 women receiving beta-agonists (30.9 weeks; range 22 to 35 weeks). Six trials used intravenous ritodrine in the beta-mimetic arm, while another initiated therapy with magnesium sulphate, thereafter switching to oral terbutaline. Based on an intention-to-treat analysis, short-term tocolysis was favoured slightly with the use of nifedipine (pooled odds ratio [OR] 1.34, 95% CI 0.83 to 2.15). An on-treatment analysis also favoured nifedipine (pooled OR 1.27, 95% CI 0.83 to 1.95). Due to the presence of a significant degree of heterogeneity across these studies, the data were also analysed using a random-effects model, with similar findings to those above. Nifedipine appeared to prolong pregnancy by a mean of 8.6 days (95% CI 5.8 to 11.5 days) over beta-agonists (p=0.03). There were significantly fewer serious side effects observed with nifedipine than with beta-agonists (pooled OR 0.22, 95% CI 0.06 to 0.80). There were eight instances in which beta-agonists were stopped due to serious adverse side effects, compared to only one instance with nifedipine (pooled OR 0.29, 95% CI 0.08 to 1.06).Conclusions: the available data suggest that there is no apparent difference, and possibly a greater tocolytic effect at both 48 hours and up to the time of delivery, with nifedipine, compared to beta-sympathomimetic agents. The number of serious maternal side effects with nifedipine are also fewer. In certain situations where sympathomimetics are poorly tolerated, oral or sublingual nifedipine can be tried for the medical management of preterm labour. A large randomized clinical trial is needed to compare the neonatal outcomes of the therapies, in addition to their relative cost, ease of administration and major maternal side effects.     

The Significance of Amniotic Fluid Interleukin-6 Levels in Preterm Labour

Summary: This study was performed to determine the prevalence of subclinical intraamniotic infection in patients with preterm labour and intact membranes, and to evaluate the significance of interleukin-6 levels for diagnosis and prognosis of tocolysis failure, amniocentesis-delivery interval and neonatal mortality and morbidity. Transabdominal amniocentesis was performed on 74 randomly-selected patients with preterm labour and intact membranes. The prevalence of amniotic fluid infection in this group was found to be 33.7% (25 of 74). The most sensitive test to identify the intraamniotic infection was found to be the measurement of interleukin-6 level. However the most specific test was confirmed to be Gram staining. Interleukin-6 level measurement was the best test to correlate with positive amniotic fluid culture and histological chorioamnionitis. Also, interleukin-6 level measurement had the advantage of predicting preterm delivery risk and neonatal complications compared to the other tests.     

Perceived Relationship With the Father of the Baby and Maternal Attachment in Adolescents

Objective: To examine the perceived relationship with the father of the baby and maternal attachment in pregnant adolescents.
Design: Exploratory, longitudinal, using a convenience sample.
Setting: Four antepartum clinics for low-income women.
Patients/Participants: Seventy-nine adolescents, ages 12-19 years, & lt; 20 weeks gestation; follow-up assessments at 20-29 weeks ( n = 64), 30-40 weeks ( n = 54), and within 1 week after birth ( n = 47). Chi-square analysis showed no differences in demographic characteristics or major variables of those who completed the study and those who dropped out ( p .89).
Main Outcome Measures: An investigator-developed Father of the Baby Scale, Cranley's Maternal-Fetal Attachment Scale, and Avant's Maternal Attachment Assessment Strategy.
Results: A close and satisfying relationship with the father of the baby was positively correlated with some aspects of maternal-fetal attachment ( r = .24 to .33, p & lt; .05) and maternal-infant attachment ( r = .38, p < .05).
Conclusions: The findings of this study lend tentative support to Rubin's theory of maternal identity formation. A close and satisfying relationship with the father of the baby has a positive influence on maternal attachment behaviors. Additional research related to the adolescent's relationship with the father of the baby is needed. Fathers of the babies of adolescent mothers should be included, where appropriate, in ongoing care of the mother and infant. JOGNN, 27 ,420-430; 1998.     

Maternal Serum Interleukin-6 Concentration as a Marker for Impending Preterm Delivery

Objective: To determine whether serum interleukin-6 concentrations predict impending preterm delivery.Methods: Blood samples were collected from 130 gravidas at 22–34 weeks’ gestation. The study group consisted of 89 women evaluated for preterm contractions or premature rupture of membranes, and these women were compared with 41 outpatient controls without evidence of labor or infection, chosen by clinicians at the time of routine prenatal visits. Serum interleukin-6 concentrations were measured using a specific enzyme-linked immunosorbent assay kit. Analyses were by the Mann-Whitney U and the Kruskal-Wallis tests.Results: All 41 control subjects had serum interleukin-6 concentrations less than 8 pg/mL. Sixteen of the 89 study patients had serum interleukin-6 concentrations greater than or equal to 8 pg/mL and 73 had values less than 8 pg/mL. When the serum interleukin-6 concentration was at least 8 pg/mL, the median interval from collection to delivery was significantly shorter than that among study and control subjects with serum interleukin-6 less than 8 pg/mL (5.5 versus 240 and 1801 hours, respectively; P < .001). The median gestational age at delivery was significantly lower when the serum interleukin-6 concentration was at least 8 pg/mL, compared with study and control subjects with serum interleukin-6 concentrations less than 8 pg/mL (29.6 versus 33.4 and 39.0 weeks, respectively; P < .001). In patients with preterm contractions, the interval from collection to delivery was significantly shorter when the serum interleukin-6 concentration was at least 8 pg/mL than when it was less than 8 pg/mL (3 versus 600 hours, P < .001). Similarly, the median gestational age at delivery was significantly lower when serum interleukin-6 was at least 8 pg/mL (29.0 versus 36.1 weeks, P < .001).Conclusion: Maternal serum interleukin-6 concentrations appear to be elevated in women destined to deliver prematurely. Measurement of this cytokine may prove useful in treating patients at high risk for preterm delivery.     

The Impact of Maternal Obesity on Maternal and Fetal Health

The increasing rate of maternal obesity provides a major challenge to obstetric practice. Maternal obesity can result in negative outcomes for both women and fetuses. The maternal risks during pregnancy include gestational diabetes and preeclampsia. The fetus is at risk for stillbirth and congenital anomalies. Obesity in pregnancy can also affect health later in life for both mother and child. For women, these risks include heart disease and hypertension. Children have a risk of future obesity and heart disease. Women and their offspring are at increased risk for diabetes. Obstetrician-gynecologists are well positioned to prevent and treat this epidemic.Key words: Obesity, Maternal health, Diabetes, Fetal health, Birth outcomesThe worldwide prevalence of obesity has increased substantially over the past few decades. Economic, technologic, and lifestyle changes have created an abundance of cheap, high-calorie food coupled with decreased required physical activity. We are eating more and moving less. There is evidence for metabolic dysregulation among obese individuals that has been linked with a number of possible environmental factors, including contaminants from modern industry. Obesity is a significant public health concern and is likely to remain so for the foreseeable future. Maternal obesity increases the risk of a number of pregnancy complications, including preeclampsia, gestational diabetes mellitus (GDM), and cesarean delivery (1 Excessive weight gain during pregnancy and postpartum retention of pregnancy weight gain are significant risk factors for later obesity in women.² Additionally, maternal health can have a significant impact on the in utero environment and, thus, on fetal development and the health of the child later in life (3

Table 1

Obstetric Complications in Obese Pregnant Women

Marijuana During Labour: A Survey of Maternal Opinions

ObjectiveThere is increasing use of marijuana during pregnancy, and online accounts indicate that women are considering use of marijuana for labour pain. However, the number and attitudes of women who would consider this are unknown.MethodsIn a university hospital, over a period of 1 month, a total of 132 women with vaginal deliveries completed a survey exploring attitudes towards labour analgesia and marijuana use. Patients who would and would not consider marijuana for labour pain were compared using chi-square analysis.ResultsThe percentages of respondents who reported having epidural or intravenous analgesia were 83% (95% confidence interval [CI] 76–89) and 30% (95% CI 23–38), respectively, with 87% (95% CI 79–92) and 86% (95% CI 71–94) being satisfied. However, 34% (95% CI 26–43) of the respondents reported that they would consider the use of marijuana for labour pain. Of these, 25% (95% CI 14–41) had previously used marijuana for pain compared with 0% (95% CI 0–0) who had not, and 72% (95% CI 56–84) thought it acceptable to use marijuana non-medically compared with 35% (95% CI 26–47) who did not (P < 0.001 for both). The greatest worry was the effect of marijuana on the baby, with 26% (95% CI 19–34) being highly worried and 26% (95% CI 19–34) being extremely worried. Many women (60%; 95% CI 51–68) indicated a lack of knowledge of the side effects of marijuana in labour. However, 59% (95% CI 50–67) of respondents said they would feel comfortable discussing this topic with their obstetrician.ConclusionOne third of women would consider the use of marijuana for labour pain, although many are unsure of its effects. Most women would feel comfortable discussing this topic with their obstetrician.     

To Study the Maternal and Neonatal Outcome in Postdated Women Undergoing Induction of Labour Versus Spontaneous Labour

IntroductionEnsuring safety of the mother along with the delivery of a healthy baby is the ultimate objective of all obstetricians. Labour induction is increasingly becoming one of the most common obstetric interventions in India. The aim of the study is to compare the feto-maternal outcome of induction of labour versus spontaneous labour in postdated women.MethodThis was a prospective observational comparative study. A total of 100 patients were selected, 50 who had induction of labour (study group) and 50 who had spontaneous labour (control). A structured proforma and partographs were used to obtain data.Result42% nulliparous women had induction of labour as compared to 29% multiparous women. The rate of cesarean section (58%) was substantially higher in those who had been induced. Non-progression of labour or failure of induction was the commonest indication for cesarean section. Post-partum haemorrhage was a complication found more commonly in the study group. Perineal tears were found more commonly in the control group.The mean birth weight of babies born to mothers who had been induced was significantly higher than that of those born to women who went into spontaneous labour. The APGAR scores were comparable in both groups. There was a higher incidence of hyperbilirubinemia in the study group.ConclusionAlthough induction of labour is a relatively safe procedure, some foetal and maternal risks were found to be higher in induced group than in those with spontaneous labour. Induction must be carried out only when necessary and not as a routine elective procedure.     

Comparison of Induction of Labour and Expectant Management in Postterm Pregnancy: A Matched Cohort Study

Randomized clinical trials have shown that induction of labour does not result in higher caesarean delivery rates in women who are postterm. Despite this evidence, the policy of inducing women who are postterm is not generally applied in the Netherlands. This provides us with the opportunity to assess whether the findings from randomized studies can also be observed in nonrandomized studies and to validate these findings in the Dutch obstetric population. We performed a retrospective matched cohort study (1:1 ratios for both age and parity) in women with uncomplicated pregnancies of 42 weeks' duration and compared induction of labour with a policy of serial antenatal monitoring. Analyses were made by the intention to treat principle. We studied 674 women. Among the 337 women in the expectant management group, 42 (12.5%) underwent caesarean delivery, compared to 46 (13.6%) of the 337 women in the induction group (relative risk [RR], 0.9; 95% confidence interval [CI], 0.6–1.4). However, the incidence of shoulder dystocia (RR, 4.3; 95% CI, 1.3–15) and meconium‐stained amniotic fluid (RR, 1.8; 95% CI, 1.4–2.3) were higher in the expectant management group. Induction of labour does not result in an increased risk of caesarean delivery in women who are postterm. Because epidemiologic studies suggest an increased risk of perinatal death and birth injury beyond 42 weeks' gestation, induction of labour should be offered to all women who are postterm.     

Study of Cervicovaginal Fetal Fibronectin Status to Guide Treatment of Threatened Preterm Labour

Summary: A sequential controlled pilot study of 48 women (16 study, 32 controls) was performed to explore the place of bedside fetal fibronectin testing in the managment of apparent preterm labour; 80% of the study group were successfully managed without tocolytic therapy, on the basis of fetal fibronectin test results, without detriment to the babies. Rapid bedside fetal fibronectin testing holds promise that protocols for management of women in apparent preterm labour, with intact membranes and without significant cervical dilatation, may be altered so that most of the unnecessary use of tocolytic drugs is avoided.     

Placental Gene Expression Responses to Maternal Protein Restriction in the Mouse

ObjectiveMaternal protein restriction has been shown to have deleterious effects on placental development, and has long-term consequences for the progeny. We tested the hypothesis that, by the use of microarray technology, we could identify specific genes and cellular pathways in the developing placenta that are responsive to maternal protein deprivation, and propose a potential mechanism for observed gene expression changes.MethodsWe fed pregnant FVB/NJ mice from day post-coitum 10.5 (DPC10.5) to DPC17.5, an isocaloric diet containing 50% less protein than normal chow. We used the Affymetrix Mouse 430A_2.0 array to measure gene expression changes in the placenta. We functionally annotated the regulated genes, and examined over-represented functional categories and performed pathway analysis. For selected genes, we confirmed the microarray results by use of qPCR.ResultsWe observed 244 probe sets, corresponding to 235 genes, regulated by protein restriction (p < 0.001), with ninety-one genes being up-regulated, and 153 down-regulated. Up-regulated genes included those involved in the p53 pathway, apoptosis, negative regulators of cell growth, negative regulators of cell metabolism and genes related to epigenetic control. Down-regulated genes included those involved in nucleotide metabolism.ConclusionsMicroarray analysis has allowed us to describe the genetic response to maternal protein deprivation in the mouse placenta. We observed that negative regulators of cell growth and metabolism in conjunction with genes involved in epigenesis were up-regulated, suggesting that protein deprivation may contribute to growth restriction and long-term epigenetic changes in stressed tissues and organs. The challenge will be to understand the cellular and molecular mechanisms of these gene expression responses.     

Preterm Prelabour Rupture of Membranes: Effect of Latency on Neonatal and Maternal Outcomes

ObjectivesTo compare risks of infection and prematurity-related outcomes according to latency periods among women with preterm prelabour rupture of membranes (PPROM).MethodsWomen with PPROM occurring between 24+0 and 36+6 weeks of gestation were identified from a provincial population-based perinatal database in Nova Scotia. The primary outcomes included composite variables for serious maternal and neonatal infectious morbidity and neonatal prematurity-related morbidity. Logistic regression was used to quantify the relationship between latency period (< 24 hours, 24 hours to < 48 hours, 48 hours to < 7 days, and ≥ 7 days) and maternal and neonatal outcomes. Separate analyses were conducted for gestational age groups 24+0 to 33+6 weeks and 34+0 to 36+6 weeks.ResultsThere were 4329 women included in the cohort. The composite variables representing serious maternal or neonatal infectious morbidity were not significantly associated with latency for either gestational age group. For PPROM occurring at gestational ages of 24+0 to 33+6 weeks, the odds of neonatal prematurity-related morbidity were significantly decreased at the latency periods of 48 hours or more compared with < 24 hours latency. For PPROM at 34+0 to 36+6 weeks of gestation, the odds of prematurity-related morbidity at 48 hours to < 7 days latency was decreased compared with latencies < 24 hours (OR 0.4; 95% CI 0.2 to 0.8).ConclusionPostponing delivery following PPROM may contribute to less prematurity-related morbidity, even close to term, without putting mother or neonate at substantial risk for serious infectious morbidity. Generalization of these findings to other obstetric populations should be informed by the underlying risk of infection.