难治性产后出血治疗方法选择和转诊策略

难治性产后出血可导致产妇休克、弥散性血管内凝血、多器官功能衰竭,甚至死亡。根据分娩方式、出血特点、手术适应证选择不同的非保守止血方案(填塞术、手术治疗、介入甚至子宫切除等)可以发挥各自优势,术者选择较熟练的止血方法会获得良好效果;正确的液体复苏、抗休克治疗,准确抉择转诊及转诊时有效处置,可以减少并发症发生,挽救产妇生命。     

难治性产后出血的诊治

难治性产后出血严重威胁孕产妇生命安全。加强产前保健,纠正基础疾病,积极处理产程是预防产后出血的有效手段。采取行之有效的治疗手段,根据病因迅速做出反应,可大大降低难治性产后出血孕产妇的死亡率。     

Obstetric antecedents for postpartum pelvic floor dysfunction

OBJECTIVE: The purpose of this study was to evaluate prospectively the association between selected obstetric antecedents and symptoms of pelvic floor dysfunction in primiparous women up to 7 months after childbirth. STUDY DESIGN: All nulliparous women who were delivered between June 1, 2000, and August 31, 2002, were eligible for a postpartum interview regarding symptoms of persistent pelvic floor dysfunction. Responses from all women who completed a survey at or before their 6-month contraceptive follow-up visit were analyzed. Obstetric antecedents to stress, urge, and anal incontinence were identified, and attributable risks for each factor were calculated. RESULTS: During the study period, 3887 of 10,643 primiparous women (37%) returned within 219 days of delivery. Symptoms of stress and urge urinary incontinence, were significantly reduced (P < .01) in women who underwent a cesarean delivery. Symptoms of urge urinary incontinence doubled in women who underwent a forceps delivery (P = .04). Symptoms of anal incontinence were increased in women who were delivered of an infant who weighed >4000 g (P = .006) and more than doubled in those women who received oxytocin and had an episiotomy performed (P = .01). CONCLUSION: The likelihood of symptoms of pelvic floor dysfunction up to 7 months after delivery was greater in women who received oxytocin, who underwent a forceps delivery, who were delivered of an infant who weighed >4000 g, or who had an episiotomy performed. Women who underwent a cesarean delivery had fewer symptoms of urge and stress urinary incontinence.     

Maternal and foetal consequences of dengue fever during pregnancy

Objective

The aim of the study was to assess the maternal and foetal consequences of dengue fever infection during pregnancy.

Study design

A retrospective study was carried out from 1 January 1992 to 10 September 2006 on 53 pregnant women infected with the dengue virus during pregnancy. The women were patients of the obstetrics and gynaecology department of Saint Laurent du Maroni hospital. A dengue infection was confirmed either by the presence of specific IgMs or by isolation of the virus (PCR or culture). The data collected related to obstetric and foetal consequences both during pregnancy and at birth, as well as the effect on the newborn.The risk of maternal–foetal transmission was assessed from 20 samples of blood taken from the umbilical cord at birth.

Results

The principal maternal consequences were: premature labour (41%), premature birth (9.6%), haemorrhage during labour (9.3%: 5 cases) and retroplacental haematoma (1.9%: 1 case).Foetal consequences were: prematurity (20%), foetal death in utero (3.8%: 2 cases), late miscarriage (3.8%: 2 cases), acute foetal distress during labour (7.5%: 4 cases), maternal–foetal transmission (5.6%: 3 cases) and neonatal death (1.9%: 1 case).

Conclusions

Maternal infection with the dengue virus during pregnancy represents a real risk of premature birth.There is also a risk of haemorrhage both for the mother and the baby when infection occurs near term.     

Role of pelvic sensory signalling during delivery in postpartum mental health

Background: Animal research demonstrates that pelvic sensory signalling at parturition initiates behavioural and emotional changes that are protective for mother and offspring. In contrast, research with humans has found no effect of caesarean delivery (i.e. procedure that blocks pelvic signalling) on mother's mental health. The lack of effect may reflect little consideration for the use of epidurals, another intervention that blocks pelvic signalling. The following study examines whether blocking pelvic signalling during delivery predicts postpartum depression symptomatology. Method: Longitudinal mental health data were collected prospectively from 142 primiparous women who had a caesarean delivery and/or received epidural anaesthesia (Intervention) or delivered vaginally without anaesthesia (No‐Intervention). Measurements began in late pregnancy and continued through the first postpartum year. Results: Intervention mothers reported more depressive symptoms at the end of the first postpartum year compared to those in the No‐Intervention group. This effect was independent of socio‐cultural factors known to predict levels of depressive symptoms. Conclusion: These results suggest that pelvic sensory signalling may help to prepare women for the postpartum period. Considering there are many factors influencing the mental health of mothers, the present finding suggest that populations vulnerable to postpartum depression should consider a delivery without intervention, when medically permissible.     

Hemodynamic changes during pregnancy and postpartum: a prospective study using thoracic electrical bioimpedance

Objective.?To describe hemodynamic changes in normal pregnancy and postpartum by means of thoracic electrical bioimpedance (TEB).

Methods.?Eighteen healthy pregnant women were included in the study. Eight different hemodynamic variables were measured by thoracic electrical bioimpedance, from 12th week of gestation until 6th month of postpartum period. Data along pregnancy and postpartum were analyzed with SAS statistical software to compare the different values, so normality curves are reported.

Results.?Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and peripheral vascular resistances (PVRs) seem to significantly decrease until 24th week of gestation, and then they seem to increase until delivery, recovering normal values gradually during postpartum period. End-diastolic volume (EDV), systolic volume (SV), cardiac output (CO), and ejection fraction (EF) seem to decrease until 48?h after delivery; statistical significance was found.

Conclusions.?Thoracic electrical bioimpedance may be the most appropriate and accurate technique to measure normal hemodynamic changes during pregnancy and postpartum.     

Uterine necrosis following pelvic arterial embolisation for postpartum haemorrhage: Case report

We report a case of uterine necrosis in a 38 year-old patient, who underwent a caesarean section for placenta praevia and an embolisation of the uterine arteries for postpartum haemorrhage. The pelvic embolisation was performed with absorbable gelatine sponge pledgets. This woman presented with abdominal pain and fever three weeks after delivery and a computed tomography scan revealed the presence of gas in the myometrium and endometrium and allowed the diagnosis of uterine necrosis. A total abdominal hysterectomy was performed with adnexal conservation and the diagnosis of uterine necrosis was confirmed histologically. The complications of pelvic embolization and the risks of surgical procedures for the management of intractable obstetric hemorrhage are described.     

盆底肌肉训练对产后女性盆底肌功能重建的研究

目的：评价盆底肌肉训练对盆底肌肉张力的影响及对盆底功能的作用。方法：选取2011年4月至2011年11月在我院进行复查的产后40～70天的妇女。经测定盆底肌力小于Ⅲ级者,分为训练组（30例）和对照组（30例）,训练组采用盆底肌肉训练（每周两次,10次为一疗程）,产后对照组进行健康教育及产后操锻炼。两组患者治疗前后进行盆底肌力测定。结果训练组和对照组的治疗后盆底肌力的比较差异有统计学意义（0．01〈P〈0．05）．结论盆底肌肉训练能有效提高肌肉张力,产后42天后开始治疗效果更好。     

Uterine necrosis associated with acute suppurative myometritis after angiographic selective embolization for refractory postpartum hemorrhage

We report a case of a woman in whom uterine arterial embolization was performed using absorbable gelfoam particles for control of refractory postpartum hemorrhage. Ten days after delivery, the woman experienced high fever and low abdominal pain. Histologic findings after hysterectomy were consistent with uterine necrosis and acute suppurative myometritis.     

产后盆底肌力筛查及其临床意义

目的探讨产妇产后盆底肌力改变及其临床意义。方法选择2011年3月至2011年9月在北京大学第一医院产科分娩并于产后6～8周复查的产妇1008例,其中阴道分娩产妇551例（阴道分娩组）,剖宫产457例（剖宫产组）,分别对其进行盆底肌力筛查,观察各影响因素与盆底肌力的相关性。结果阴道分娩组与剖宫产组产妇I类肌纤维肌力异常率分别为36.3%（200/551）和39.4%（180/457）,Ⅱ类肌纤维肌力异常率分别为36.5%（201/551）和39.4%（180/457）,两组比较,差异无统计学意义（P〉0.05）;产妇分娩前体质指数是I类肌纤维肌力异常的相关因素（OR=-0.095,P〈0.05）;产妇年龄、新生儿出生体质量、第二产程时间、产次、产钳助产及会阴情况等与盆底肌力测量值无相关性（P〉0.05）;第二产程延长组及高龄组I类肌纤维肌力异常率分别为55.6%（5/9）和39.3%（57/145）,Ⅱ类肌纤维肌力异常率分别为55.6%（5/9）和38.6%（56/145）,两组I类、Ⅱ类肌纤维肌力异常率均有升高趋势;会阴裂伤组I类、Ⅱ类肌纤维肌力异常率分别为35.7%（15/42）和31.0%（13/42）,均较会阴侧切组和会阴侧切＋产钳组有下降趋势;进入产程剖宫产组I类肌纤维肌力异常率为44.1%（52/118）,Ⅱ类肌纤维肌力异常率为44.1%（52/118）,均较选择性剖宫产组有升高趋势,但差异均无统计学意义（P〉0.05）。结论剖宫产对盆底组织无明显保护作用;分娩前体质指数过大是影响盆底功能的因素,应避免孕期体质量增长过多。     

The use of magnesium sulfate for women with severe preeclampsia or eclampsia diagnosed during the postpartum period

This was a systematic review of randomized controlled trials comparing anticonvulsants with placebo or no anticonvulsant for prevention (a) of eclampsia in women with severe preeclampsia diagnosed during the postpartum period or diagnosed before delivery but without previous treatment and (b) prevention of seizures recurrence in women with eclampsia postpartum. We did not find study with full inclusion criteria. However, a total of two randomised controlled trials meet inclusion criteria as subgroup analysis; one for severe preeclampsia diagnosed during the postpartum period and one for eclampsia postpartum. For severe preeclampsia diagnosed during postpartum, there was no clear difference between the groups reporting eclampsia (relative risk: 0.54, 95% confidence interval: 0.16–1.80). For seizure recurrence, magnesium sulfate was superior to diazepam, but there was no significant difference compared with phenytoin. No conclusion can be drawn on the role of magnesium sulfate post partum as established in antepartum pre-eclampsia/eclampsia management because of lack of powered randomised controlled trials.     

An intervention to support postpartum women to quit smoking or remain smoke-free

Effectiveness studies among pregnant and postpartum women indicate that pregnancy and the postpartum period provide a window of opportunity to promote smoking cessation and smoke-free families. Yet, there is a lack of information about interventions that are portable to routine care. The goal of this article is to describe the structure, basic strategies, and the application of a smoking cessation and relapse prevention intervention for postpartum women in the general population. By using the stages of change concept and motivational interviewing, a classification of current and former smokers is given, and basic strategies and techniques are described to counsel women postpartum with regard to smoking.     

Social support,religious commitment,and depressive symptoms in pregnant and postpartum women

Objective: Social support and religious commitment were examined in relation to antenatal and postpartum depressive symptoms in a prospective, longitudinal study to determine whether religious commitment explained variance in depression scores beyond that accounted for by social support. Background: Social support and religiosity are positively related to good mental/physical health, and depression is related to poor health outcomes in pregnancy and postpartum. It was hypothesised that social support and religious commitment would be inversely related to depressive symptoms, and that religious commitment would predict variance in depression scores over and above social support. Methods: In 106 mostly low SES Appalachian pregnant women, social support and religious commitment were measured during the first trimester. First and third trimester (Center for Epidemiological Studies Depression Scale – 10 item version), and 6 weeks and 6 months postpartum (Edinburgh Postnatal Depression Scale) depression symptoms were measured. Hierarchical regression examined relative contributions of social support (Prenatal Psychosocial Profile) and religious commitment (Religious Surrender and Attendance Scale – 3 Item Version) to depressive symptoms at each time point while controlling for education and marital status. Results: Regression results indicated that social support and religious commitment explained 10–18% and 0–3% of the variability in depression scores, respectively. Conclusion: Both social support (all time points) and religious commitment (only at 6 months postpartum) were inversely related to depression. Pregnant women low in social support and postpartum women low in social support or religious commitment may be at increased risk for depression.