胎儿纤连蛋白在足月妊娠引产中的预测价值

目的 探讨宫颈阴道分泌物中胎儿纤连蛋白(fetal fibronectin,FFN)的检测结果在预测足月妊娠引产效果以及分娩方式中的应用价值.方法 前瞻性观察37例孕足月、需要并同意引产的患者,在引产前进行宫颈分泌物FFN检测并根据结果分为阳性和阴性两组,均选用普贝生引产,分别记录宫颈Bishop评分、分娩发动时间以及分娩方式.结果 37例中FFN阳性组25例,阴性组12例,使用普贝生促宫颈成熟有效率分别为88.00%和58.33%,引产成功率80.00%和33.33%,阴道分娩率68.00%和25.00%,两组间差异具有显著性.FFN预测引产成功的敏感性为83.30%,特异性为61.54%,阳性预测值为80.00%,阴性预测值为66.70%,预测结果优于宫颈Bishop评分.结论 胎儿纤连蛋白是反映宫颈成熟度的良好标志,对足月妊娠的分娩发动有一定的预测价值,且预测价值优于宫颈Bishop评分;进一步的大样本研究将有助于合理选择足月妊娠引产时机、降低剖宫产率.     

Side-effect and vital sign profile of nifedipine as a tocolytic for preterm labour

OBJECTIVE. To examine the side-effect and vital sign profile of nifedipine used as a tocolytic. DESIGN. Retrospective audit. SETTING. Tertiary care university hospital, Hong Kong. PATIENTS. Women presenting with preterm labour (before 34 weeks of gestation) between March 2001 and September 2004. MAIN OUTCOME MEASURES. Maternal heart rate, blood pressure, and foetal heart rate were monitored regularly. A four-point Likert scale multiple-choice questionnaire was used to assess the perceived degree of flushing, headache, nausea, dizziness, and shortness of breath. All assessments were performed at predefined intervals from the onset of treatment. Repeated measures analysis of variance was performed to identify any time-dependent association with nifedipine treatment. RESULTS. In all, 212 episodes of preterm labour were treated with nifedipine in 203 women. In 120 episodes, preterm labour was suppressed for more than 48 hours. Treatment was discontinued in three women because of profound hypotension (<90/60 mm Hg), and in one because of severe flushing. Only one patient developed maternal tachycardia (>=140 beats per minute), and in two foetal tachycardia (>=180 beats per minute) was encountered. Moderate headache was experienced in nine women, flushing in nine, dizziness in four, nausea in three, and shortness of breath in one. Repeated measures analysis of variance with time of measurement revealed a significant reduction in maternal blood pressure and increase in maternal heart rate that plateaued after 1 hour of therapy. The foetal heart rate returned to baseline values 3 hours after commencing therapy. CONCLUSION. In general, use of nifedipine as the first-line tocolytic was safe. However, severe maternal hypotension can occur and close monitoring of vital signs is warranted.     

先兆早产治疗后维持使用镁剂预防早产(摘要)

1 背景 早产是早期新生儿死亡的主要原因,同时也对早产存活儿产生直接致病和潜在远期致病作用。防治早产一直成为产科的目标,各种治疗的药物,如宫缩抑制剂,被用于抑制早产的发生。     

Current concepts in the management of preterm labour

Prematurity remains the major cause of perinatal mortality and morbidity in Singapore. Prevention of prematurity is therefore of vital importance. Epidemiological methods using historical variables have been superseded by ongoing pregnancy factors including work, exercise and cervical dilatation. PGF levels bear a positive correlation to duration and cervical dilatation but are not elevated at onset. PGE production is high in ruptured membranes. Progesterone and relaxin are potent inhibitors before labour. Infection must play an important role in developing countries as organisms not thought of to be pathogenic produce phospholipase A2. For prediction, cervical assessment and topography are proving important. In view of the dangerous side effects of tocolytic drugs and the difficulty in diagnosis of preterm labour, absence of fetal breathing is a useful index of progressive labour. In those labours that are advanced, whether to allow vaginal delivery or not will be determined by the presentation and condition of the fetus. The complementary role of other drugs to reduce morbidity from hyaline membrane disease and intraventricular haemorrhage is being studied. Fetal acidosis should be avoided and the infant delivered without trauma under optimal circumstances. In utero transfer to a facility with neonatal intensive care carries a better prognosis for the baby.     

Tocolytic treatment for the management of preterm labour: a systematic review

Spontaneous preterm labour and delivery accounts for approximately one-third of preterm births, which is the predominant cause of perinatal mortality and morbidity. This review aims to evaluate the evidence on the benefits and harms of five classes of tocolytic therapy, namely: betamimetics, calcium channel blockers, magnesium, non-steroidal anti-inflammatory agents, and atosiban. We performed a systematic review of the effectiveness of tocolytics to stop uterine contractions (first-line therapy). Reports of randomised controlled trials from searches of MEDLINE, bibliographies of review articles, Cochrane Collaboration and its Pregnancy and Childbirth Review Group between 1966 and 2003 were identified, using the search terms "randomised controlled trial" (RCT), "preterm labor", "tocolysis", "betamimetics", "ritodrine", "prostaglandin synthetase inhibitors", "indomethacin", "calcium channel blockers", "nifedipine", "oxytocin receptor blockers", "atosiban", and "magnesium sulphate". Studies on women with preterm labour comparing the effects of a tocolytic with a placebo or no treatment that met our inclusion criteria, were included. To our knowledge, the trials were conducted mainly before 1999 and there were no placebo-controlled trials after that. Of the 86 articles identified and evaluated, 14 first-line studies met more stringent requirements for meta-analyses. Tocolytics were associated with significant decreases in the odds of delivery within 24 hours (odds-ratio [OR] 0.54, 95 percent confidence interval [CI] 0.32-0.91) and 48 hours (OR 0.47, 95 percent CI 0.30-0.75). These effects were significant for beta-agonists, atosiban and indomethacin, but not magnesium sulphate. Maternal side-effects significantly associated with betamimetics were pulmonary oedema, cardiac arrhthymias and hypokalaemia. Although calcium antagonists have not been evaluated against placebo, comparative trials with beta-agonists have shown more favourable neonatal outcomes and better prolongation of gestation. In conclusion, the management of threatened preterm labour with first-line tocolytic therapy can prolong gestation. However, the time gained in-utero need to be optimised. There is no clear first-line tocolytic agent. The use of tocolytic agents should be individualised and based on maternal condition, potential side-effects and gestational age.     

Bacterial vaginosis and vaginal anaerobes in preterm labour

Maternal genital infections, particularly bacterial vaginosis has been implicated as a cause for preterm labour and adverse pregnancy outcomes. This prospective study aimed to study the association of bacterial vaginosis with preterm labour. The prevalence of bacterial vaginosis was studied in 60 women in preterm labour who had no recognisable cause for prematurity and in 60 term labour controls. Demographic factors, pregnancy outcome and reproductive history were also studied. Vaginal specimens for Gram-stain and culture were collected from posterior vaginal fomix and bacterial vaginosis was defined by evaluation of Gram-stained smear by Spiegel criteria. Bacterial vaginosis was diagnosed in 31.6% of women in preterm labour and in 15% of term labour controls ( p<0.05). In preterm labour group, preterm delivery occurred in 48 women (80%) out of which 18 women had bacterial vaginosis and term delivery occurred in only one woman with the condition. Anaerobes were significantly associated with bacterial vaginosis ( p<0.01) and were more common in women with preterm labour ( b>0.05). The results indicates that bacterial vaginosis has a significant association with preterm labour and adverse pregnancy outcome.     

分娩相关基因在早产和足月产子宫肌层的差异表达及其意义

目的研究分娩相关基因白介素-8(IL-8)、缩宫素受体(oxytocin receptor,OTR)和前列腺素H合成酶-2(prostaglandin H synthase type-2,PGHS-2)在早产和足月产子宫肌层的差异表达。方法选取17例早产临产(preterm labour,PTL)和31例早产未临产(preterm no labour,PTNL)孕妇作为研究组,6例足月临产(term labour,TL)和6例足月未临产(termno labour,TNL)孕妇作为对照组,活检取子宫(下段)肌层组织,采用实时荧光定量PCR(qRT-PCR)及Westernblot法检测各组子宫肌层中IL-8、OTR和PGHS-2mRNA及蛋白的表达水平,结合临床资料对检测结果进行统计学分析。结果子宫下段肌层中,IL-8mRNA的表达在PTL组显著低于TL组(P0.01),但均显著高于对应的未临产组(PTNL,P0.05;TNL,P0.01);PGHS-2mRNA表达水平在PTL组显著低于TL组(P0.05),而后者又显著高于TNL组(P0.01);OTR mRNA和蛋白表达水平在各组中均未见显著差异(P0.05);PGHS-2蛋白表达在TL组要显著高于TNL组(P0.05)而在PTL与PTNL组间则未见明显区别(P0.05)。Spearman非参数相关性分析显示在PTNL组中IL-8基因表达与孕周显著相关(r=0.294,P=0.042)。多元线性回归显示,早产组IL-8、OTR及PGHS-2基因表达均存在一定程度的相互影响,但在足月产组中则不明显。结论早产与足月产子宫肌层分娩相关基因表达存在显著的差异,可能与早产进程相关。     

Increased saliva oestriol to progesterone ratio before preterm delivery: a possible predictor for preterm labor?

Saliva oestriol, oestradiol, and progesterone concentrations were measured in 23 women who went into spontaneous preterm labour. The patients fell clinically and biochemically into two groups. The 13 who went into preterm labour with intact membranes had a saliva oestriol to progesterone ratio greater than one in every case and greater than the 95th centile for their length of gestation in 12 cases; by contrast, all those who went into spontaneous preterm labour after prolonged rupture of the membranes had an oestriol to progesterone ratio less than one and below the 50th centile for their period of gestation in the one to four days before delivery. Saliva oestradiol to progesterone ratios were randomly distributed throughout the normal range in both groups. It appears that preterm labour without prior prolonged rupture of the membranes is, like term labour, preceded by an increase in the saliva oestriol to progesterone ratio. It may therefore be possible to use this ratio to predict preterm labour.     

The tocolytic role of nifedipine in preventing preterm labour pain

This study was undertaken to evaluate the efficacy of oral nifedipine to reduce labour pain in patient with preterm labour, to complete the doses of steroids in lung maturity and in utero transfer to the Neonatal Intensive Care Unit (NICU) and to evaluate the maternal adverse effects and neonatal outcome. Diagnosed cases of preterm labour (between 24 to 34 weeks gestation) were randomly selected. Among them 50 patients were given oral nifedipine (n=50) and 50 patients were observed with no treatment (n=50). There were no statistically significant differences in age, race, parity, preterm delivery risk factor between the groups. At first the labour pain were observed through Continuous CTG in first hour, then intermittent CTG. The patient in the Nifedipine group can prolong the pregnancy time 36.0±3.2 wks than 30.6±3.1 wks in the control group (p<0.05) with reduced neonatal complications and admission to NICU. Oral nifedipine in patients with preterm labour pain as Tocolytic therapy has significantly prolonged pregnancy with lesser neonatal problems and fewer maternal adverse effects.     

Persistent human papillomavirus infection as a predictor of cervical intraepithelial neoplasia.

CONTEXT: Human papillomavirus (HPV) infection is believed to be the central cause of cervical cancer, although most of the epidemiological evidence has come from retrospective, case-control studies, which do not provide information on the dynamics of cumulative or persistent exposure to HPV infection. OBJECTIVE: To assess the risks of cervical neoplasia related to prior persistent HPV infections. DESIGN AND SETTING: Longitudinal study of the natural history of HPV infection and cervical neoplasia in women residing in the city of S?o Paulo, Brazil, which was conducted between November 1993 and March 1997 and involved repeated measurements of HPV and lesions with follow-up until June 2000. PARTICIPANTS: A total of 1611 women with no cytological lesions at enrollment and HPV test results available from the first 2 visits. MAIN OUTCOME MEASURE: Cervical specimens taken for Papanicolaou cytology and HPV testing every 4 months in the first year and twice yearly thereafter. Incident cervical cancer precursor lesions ascertained by expert review of all cytology smears. RESULTS: The incidence rate of squamous intraepithelial lesions (SILs) was 0.73 per 1000 women-months (95% confidence interval [CI], 0.5-0.9) among women free of HPV at the 2 initial visits and 8.68 (95% CI, 2.3-15.1) among women with HPV type 16 or 18 infections persisting over both visits. Relative to those negative for HPV oncogenic types at both initial visits, the relative risk (RR) of incident SIL was 10.19 (95% CI, 5.9-17.6) for persistent infections with any known oncogenic HPV types. The equivalent RR of incident high-grade SIL was 11.67 (95% CI, 4.1-33.3). The RRs of lesions were considerably higher for persistent infections with HPV type 16 or 18. CONCLUSION: A strong relationship exists between persistent HPV infections and SIL incidence, particularly for HPV types 16 and 18.     

Spontaneous preterm labour and delivery at under 34 weeks' gestation

The management and outcome of 242 infants delivered between 26 and 34 weeks' gestation in an obstetrical and neonatal regional referral centre as a result of spontaneous preterm labour were recorded prospectively. Results of the survey show that the decision to intervene and delay delivery will depend on the availability of neonatal intensive care facilities. Infants likely to require intensive neonatal care should be transferred in utero to a centre with these facilities. The use of steroids reduces the mortality of preterm infants. The maximum effect occurs between 30 and 32 weeks' gestation, and there is no benefit after 34 weeks. If the weight is over 1500 g the mode of delivery of the preterm infant presenting by the breech does not influence outcome; if under 1500 g a caesarean section improves survival over those infants born by vaginal breech delivery.     

早产儿童学龄前的屈光状况分析

目的 探讨早产儿童学龄前的屈光状况。方法 选取2009 年2 月-2010 年1 月于青海大学附属医 院接受体检的3 岁早产儿193 例（386 眼）作为早产组,并随机选取同期到该院接受体检的3 岁足月儿190 例 （380 眼）作为足月组,比较两组儿童学龄前的屈光度和屈光状态。结果 两组儿童的等效球镜值、球镜度数 及柱镜度数比较有差异（P <0.05）。两组儿童远视率、正视率及近视率比较有差异（P <0.05）。两组5 和6 岁儿童散光率比较有差异（P <0.05）。结论 早产儿童学龄前的屈光状况较差,更易发展为近视或散光,临床 上应加强对早产儿屈光检查的力度,定期进行随访及干预。     

富阳市早产发生现状及早产儿结局的调查分析

目的探讨富阳市早产发生现状、危险因素及早产儿的结局。方法对243例早产产妇临床资料和早产儿结局进行分析。结果本次调查早产发生率为7.33%(243/3 316),以晚期早产占比最高(P<0.05),早期早产以自发性早产为主要原因,中期早产和晚期早产均以医源性早产为主要原因,晚期早产胎儿出生体重最大(P<0.05)。胎膜早破、胎盘位置异常、孕期产妇/丈夫吸烟、孕期阴道流血是早产发生的危险因素,孕期体重增加是早产发生的保护因素(P<0.05)。早期早产的早产儿治愈率较中期早产、晚期早产低,放弃治疗和死亡率均较中期早产、晚期早产高(P<0.05),医源性早产死亡率高于自发性早产、PPROM(P<0.05)。结论早期早产的新生儿死亡率更高,应减少医源性早产,积极预防PPROM、胎膜早破、胎盘位置异常,避免孕期吸烟、孕期阴道流血及低体重是降低早产发生率的重要措施。     

凝血酶原时间延长早产儿体内的维生素K水平

目的：研究凝血酶原时间（PT）延长的早产儿出生后一个月时体内的维生素K水平。方法：对出生时预防性给予0．2～0．5mg维生素K1而PT仍异常的21例早产儿，检测其体内维生素K的水平。结果：所有要儿的维生素K1浓度正常或超出生理范围，除一名有微量的维生素K缺乏酶-Ⅱ（PIVKA-Ⅱ）浓度之外，其他早产儿PIVKA-Ⅱ均未检出，这就说明患儿的维生素K水平不低。结论：胎龄〈32周、生后接受≥0．2mg维生素K1的早产儿，其出生后第一个月时的PT延长并非由于维生素K缺乏所致。     

Quantitative heel ultrasound as a predictor for osteoporosis

OBJECTIVE: To determine the diagnostic value of quantitative ultrasound (QUS) to predict bone mineral density (BMD) categories as defined by dual-energy x-ray absorptiometry. DESIGN: Cross-sectional survey. SETTING: Rheumatology department of a tertiary care hospital (Royal North Shore Hospital, Sydney, NSW), 1997-1998. SUBJECTS: 326 healthy women aged 45-80 years who had volunteered for a twin study. Our study included both members of non-identical twin pairs but only one randomly selected member of identical twin pairs. MAIN OUTCOME MEASURES: BMD categories as defined by dual-energy x-ray absorptiometry of lumbar spine and left hip, and QUS of calcaneus; sensitivity, specificity and likelihood ratios (LRs) of QUS parameters to diagnose osteoporosis as defined by BMD. RESULTS: The sensitivity of QUS to diagnose BMD osteoporosis varied between 9% and 47%, depending on the QUS parameter. The specificity of QUS was high (88%-100%). If all QUS parameters were normal, osteoporosis was unlikely (LR, 0-0.2). One QUS parameter, broadband ultrasound attenuation (BUA), was highly predictive of osteoporosis by BMD when in the osteoporotic range (LR, infinity), but had low sensitivity (9%). QUS results in the osteoporotic range for other parameters and all QUS results in the osteopenic range were less predictive (LR, 1.0-5.2) of osteoporotic BMD. CONCLUSION: These results suggest that, for most of those tested for osteoporosis by QUS in the community, uncertainty remains about expected BMD.     

早产孕妇血浆中游离胎儿DNA-SRY基因片段的定量检测

目的建立实时荧光定量聚合酶链反应(RQ-PCR)检测早产孕妇血浆中游离胎儿DNA的男性性别决定基因(SRY)的方法。方法利用RQ-PCR技术检测25例正常孕妇和102例早产孕妇血浆中游离胎儿DNA-SRY基因,用一系列稀释的标准品建立此检测方法的标准曲线。结果RQ-PCR检测到早产孕妇血浆中游离胎儿DNA-SRY基因的存在,其特异性为100%,灵敏度92.7%,准确率96.1%。早产孕妇血浆中游离胎儿DNA-SRY的中位浓度为321.8拷贝数/mL,较正常孕妇高(P<0.05)。结论RQ-PCR能简单、快速、方便地对孕妇血浆的游离胎儿DNA-SRY基因进行检测,其灵敏度高,特异性好,能定量分析,对进一步了解早产的病理生理情况可能有一定的应用价值。     

早产孕妇血浆中游离胎儿DNA-SRY基因片段的定量检测

目的 建立实时荧光定量聚合酶链反应(RQ-PCR)检测早产孕妇血浆中游离胎儿DNA的男性性别决定基因(SRY)的方法. 方法 利用RQ-PCR技术检测25例正常孕妇和102例早产孕妇血浆中游离胎儿DNA-SRY基因,用一系列稀释的标准品建立此检测方法的标准曲线. 结果 RQ-PCR检测到早产孕妇血浆中游离胎儿DNA-SRY基因的存在,其特异性为100%,灵敏度92.7%,准确率96.1%.早产孕妇血浆中游离胎儿DNA-SRY的中位浓度为321.8拷贝数/mL,较正常孕妇高(P＜0.05). 结论 RQ-PCR能简单、快速、方便地对孕妇血浆的游离胎儿DNA-SRY基因进行检测,其灵敏度高,特异性好,能定量分析,对进一步了解早产的病理生理情况可能有一定的应用价值.