多胎妊娠的早期管理

多胎妊娠系高危妊娠,多胎妊娠妇女并发症,如流产、高血压疾病、产科出血、手术产和产科出血等均比单胎妊娠高;多胎分娩胎儿并发症,如死胎、早产、新生儿死亡率也均比单胎分娩高.因此,做好多胎妊娠早期管理非常重要,主要包括定期产前检査以及双胎输血综合征和唐氏综合征的早期诊断.     

高龄产妇妊娠并发症及妊娠结局分析

目的探讨单胎高龄产妇的妊娠并发症和妊娠结局。方法选取2009年1月至2017年12月广州医科大学附属第三医院/广州重症孕产妇救治中心围产资料数据库中46 518例单胎产妇资料,根据年龄分为20～34岁(适龄组)、35～39岁(高龄组)和≥40岁(超高龄组),回顾性分析各组妊娠并发症的发生率及妊娠结局。结果与适龄组相比,高龄组妊娠期糖尿病、妊娠期高血压疾病、子痫前期、HELLP综合征、产后出血、胎盘植入、前置胎盘、胎盘早剥、胎儿生长受限、胎儿畸形以及死胎的发生率显著升高(P 0.05)。与35～39岁(高龄组)相比,≥40岁组(超高龄组)妊娠期糖尿病、妊娠期高血压疾病、剖宫产、胎儿生长受限、死胎的发生率显著升高(P 0.017)。对产妇基本情况进行调整后评估患病风险显示,≥40岁组发生妊娠期糖尿病、妊娠期高血压疾病、剖宫产、胎儿生长受限、死胎的风险分别是35～39岁组的1.34倍、1.29倍、1.49倍、1.47倍、2.24倍(P 0.05)。结论高龄产妇中,40岁以上单胎高龄产妇的妊娠并发症和胎儿异常的发生率和患病风险会进一步升高。     

妊娠期肝内胆汁淤积症死胎14例临床分析

目的 :通过 14例妊娠期肝内胆汁淤积症孕妇发生死胎的病例分析 ,探讨死胎发生原因及预防处理措施。方法 :回顾性分析 1995年 1月至 2 0 0 0年 12月我院收治的妊娠期肝内胆汁淤积症死胎病例资料。结果 :14例妊娠期肝内胆汁淤积症死胎均发生于妊娠晚期 ,92 .9%发生于 37周左右 ,且胎死宫内之前无明显胎动减少或胎儿监护异常等征兆 ,但绝大多数孕妇有规律或不规律宫缩。尸检示胎儿在宫内存在急性缺氧。结论 :妊娠期肝内胆汁淤积症死胎常常突然发生 ,难以预测 ,对已确诊的妊娠期肝内胆汁淤积症患者应加强治疗及胎儿监护 ,适时终止妊娠 ,降低围生儿死亡率。     

妊娠合并急性肾功能衰竭

妊娠合并急性肾功能衰竭病因复杂、母婴病死率高。妊娠期肾功能容易受到损伤,了解妊娠期相关的生理改变和妊娠合并急性肾功能衰竭的常见病因,有助于快速、准确地发现诱发因素,同时积极处理,才能有效阻止疾病恶化,改善母胎预后。本文将从病因、诊断及治疗等方面对妊娠合并急性肾功能衰竭进行阐述。     

单胎妊娠晚期胎死宫内的病因分析与预防策略

目的 分析单胎妊娠晚期胎死宫内的病因,并在此基础上提出有效的预防和干预策略。方法 选取本院62例单胎妊娠晚期胎死宫内孕妇为研究对象,收集孕妇及胎儿的一般资料,采用单因素、多因素分析单胎妊娠晚期胎死宫内的影响因素。结果 多因素分析结果显示,妊娠期高血压疾病、妊娠期糖尿病、胎盘异常、胎儿生长受限、羊水异常是单胎妊娠晚期胎死宫内的影响因素（P<0.05）。结论 单胎妊娠晚期胎死宫内的影响因素复杂,其预防和管理需要综合评估,包括早期筛查和诊断、针对性干预及持续孕期监护等。     

孕期贫血与不良妊娠结局

孕期贫血会导致各种妊娠不良结局,如早产,出血耐受性降低,产后出血甚至失血性休克,产褥感染,以及新生儿低体重,新生儿死亡等,严重危害母胎健康。我国妊娠期铁缺乏和缺铁性贫血诊治指南建议通过积极监测血红蛋白及血清铁,加强饮食补铁,预防孕期贫血,从而避免不良妊娠结局的发生。     

蛋白S缺乏症与产科并发症研究现状

妊娠期妇女血液系统呈生理性的高凝状态,以减少分娩相关的出血并发症。易栓症是一种异常的高凝状态,蛋白S缺乏症是一种常见的遗传性易栓症。研究发现蛋白S缺乏症与产科不良妊娠结局,如复发性流产、妊娠期高血压疾病、胎儿生长受限、死胎等有着密切联系,但对于孕期蛋白S缺乏的检验指标和正常参考范围,存在着较大争议,本文对蛋白S缺乏症与产科不良妊娠结局的研究现状进行综述,以期为临床工作提供参考。     

穿透性植入胎盘二例

例1.患者31岁,第7胎,妊娠32周,因下腹部坠痛6小时,于1985年4月15日入院。患者既往妊娠6次,初孕(79年)双胎并妊高征,于孕32周早产2死婴;第2胎(80年)妊娠24周死胎流产;第3胎(81年)孕12周过期流产行清宫术;第4胎(82年)也因过期流产清宫1次;第5胎(83年)妊娠28周死胎;第6胎(84年)妊娠26周死胎流产。检查:BP120/80mmHg,发育正常,营养欠佳,贫血貌。宫底脐剑     

护理干预对妊娠期糖尿病患者妊娠结局的影响

妊娠期糖尿病是指妊娠期发生或首次发现的糖尿病,常伴有明显的代谢紊乱,发病率为1%～5%[1]。妊娠期糖尿病属高危妊娠,是妊娠期常见的并发症,如得不到及时治疗,可出现一系列并发症及合并症,如孕妇可发生酮症酸中毒、妊娠期高血压疾病（妊高病）、感染和羊水过多等;也可出现巨大儿、死胎、早产、     

多胎妊娠妊娠期并发症及处理

多胎妊娠与单胎妊娠相比 ,妊娠期并发症如早产、妊高征、贫血及羊水过多等明显增加 ,而胎儿畸形、多胎之一胎死宫内、妊娠期肝内胆汁淤积症、双胎输血综合征等也较常发生。因此 ,要加强多胎妊娠的妊娠期监护 ,早期发现其并发症并及时处理 ,减少严重并发症的发生率 ,降低围生期死亡率。1　早产早产是多胎妊娠最主要并发症。发生率约占多胎妊娠的 5 0 % ,比单胎妊娠明显增加。Ｋｉｅｌｙ[1] 报道 ,在 3 2周前 ,单胎、双胎及三胎妊娠的早产率分别为 1 2 %、10 0 %及3 0 9% ,双胎妊娠在 3 7周前分娩达 5 0 % (见表 1)。表 1　单胎、双胎及三胎…     

Maternal medical disease: risk of antepartum fetal death

Although certain maternal medical conditions increase the risk of antepartum fetal death, improvements in medical and obstetric care have decreased the likelihood of stillbirth. This article examines the current stillbirth rates reported in pregnancies complicated by common medical diseases. The reported stillbirth rates are expressed as the number of stillbirths occurring at > or = 20 weeks of gestation per 1,000 births in patients with the condition. Overall, about 10% of all fetal deaths are related to maternal medical illnesses such as hypertension, diabetes, obesity, systemic lupus erythematosus, chronic renal disease, thyroid disorders, and cholestasis of pregnancy. The early recognition of maternal medical diseases provides an opportunity for increased surveillance and interventions that may lead to more favorable pregnancy outcomes.     

Prediction and prevention of recurrent stillbirth

Stillbirth is one of the most common adverse pregnancy outcomes in the United States, occurring in one out of every 200 pregnancies. There is a paucity of information on the outcome of pregnancies after stillbirth. Prior stillbirth is associated with a twofold to 10-fold increased risk of stillbirth in the future pregnancy. The risk depends on the etiology of the prior stillbirth, presence of fetal growth restriction, gestational age of the prior stillbirth, and race. Categorization of the cause of the initial stillbirth will allow better estimates of individual recurrence risk and guide management. A history of stillbirth also increases the risk of other adverse pregnancy outcomes in the subsequent pregnancy such as placental abruption, cesarean delivery, preterm delivery, and low birth weight infants. Prospective studies have revealed an increased risk of stillbirth with low pregnancy-associated plasma protein A, elevated maternal serum alpha fetoprotein, abnormal uterine artery Doppler studies, and antiphospholipid antibodies. However, the positive predictive value of these factors individually is poor. Because fetal growth restriction is associated with almost half of all stillbirths, the correct diagnosis of fetal growth restriction is essential. The use of individualized or customized growth standards will improve prediction of adverse pregnancy outcome by distinguishing growth-restricted fetuses from constitutionally small, healthy fetuses. Antepartum fetal surveillance and fetal movement counting are also mainstays of poststillbirth pregnancy management.     

Pre-existing type I and type II diabetes in pregnancy

Women with pre-gestational diabetes are high-risk pregnancies. Hyperglycaemic is toxic to the developing fetus and is associated with a higher incidence of congenital malformation, miscarriage, macrosomia and stillbirth. Complications can be reduced with tight glycaemic control, and management should ideally start pre-conceptually. During pregnancy a woman’s insulin requirements change and those managed pre-pregnancy on diet or oral medication may need to start insulin. Pre-gestational diabetics require close maternal and fetal monitoring, including screening for the progression of maternal diabetic complications such as retinopathy and nephropathy, and fetal growth scans. Their pregnancies are complex and a multidisciplinary approach should be used. In this article we will discuss the background physiology, the effect of pregnancy on diabetes, the potential fetal and maternal complications, and how these can be minimized by intensive management from pre-conception to the post-natal period, including the contribution of recent studies and guidelines.     

Pregnancy Outcome After Previous Stillbirth Resulting from Causes Other Than Maternal Conditions and Fetal Abnormalities

Background: An adequate fetomaternal circulatory system may be compromised by a variety of disturbances leading to stillbirth. The purpose of this study was to assess subsequent pregnancy outcome in women with a history of stillbirth as a result of causes other than maternal conditions and fetal abnormalities. Methods: Ninety‐two deliveries after stillbirth were identified among 11,910 deliveries of parous women recorded in the birth registry at Kuopio, Finland. Using logistic regression, pregnancy outcome measures were compared with those of a parous healthy obstetric population (n= 11,818). Results: Women with a history of stillbirth as a result of causes other than maternal conditions and fetal abnormalities were older than their unaffected controls (32.4 yr vs 30.3 yr). Stillbirth in an earlier pregnancy was associated with a significantly higher (p < 0.001) frequency of placental abruption in subsequent pregnancy (5.4% vs 0.7%). A history of stillbirth was predictive of preterm delivery (OR = 2.25) and low‐birthweight infants (OR = 2.70). No recurrence was reported. Conclusions: Pregnancy with a history of stillbirth as a result of causes other than maternal conditions and fetal abnormalities is a moderate risk state, with prematurity and low‐birthweight rates somewhat higher than those in the general population. The overall probability of a favorable outcome is good. These findings may be useful in counseling pregnant women with a history of stillbirth.     

A kick from within--fetal movement counting and the cancelled progress in antenatal care

Interest for maternal fetal movement counting as a method of screening for fetal well-being boomed during the 1970's and 1980's. Several reports demonstrated that the introduction of counting charts significantly reduced stillbirth rates. However, in 1989, a large study appeared in The Lancet that annihilated research in this field by deeming charts ineffective. In retrospect, it seems evidence was lacking. This review revisits the subject of the significance of fetal movement counting in predicting outcome and reducing stillbirth rates. A structured search was performed to identify studies relating to pregnancy outcome and its association with maternal perception of fetal movements. Suspected preliminary or redundant material was excluded. Only publications from Western countries dating from after 1970 were included. Twenty-four studies were identified. Available data demonstrate that reduced fetal movements are associated with adverse pregnancy outcome, both in high and low risk pregnancies. Increased vigilance towards maternal perception of movements (e.g. by performing movement counting studies) reduces stillbirth rates, in particular stillbirths deemed avoidable. While screening for fetal well-being by maternal fetal movement counting can reduce fetal mortality rates, a resurrection in research activity is urgently needed to optimize its benefits.     

Postdates and antenatal testing

The standard definition of a prolonged pregnancy is 42 completed weeks of gestation. The incidence of prolonged pregnancy varies depending on the criteria used to define gestational age at birth. It is estimated that 4 to 19% of pregnancies reach or exceed 42 weeks gestation. Several studies that have used very large computerized databases of well-dated pregnancies provided insights into the incidence and nature of adverse perinatal outcome such as an increased fetal and neonatal mortality as well as increased fetal and maternal morbidity in prolonged pregnancy. Fetal surveillance may be used in an attempt to observe the prolonged pregnancy while awaiting the onset of spontaneous labor. This article reviews the different methodologies and protocols for fetal surveillance in prolonged pregnancies. On the one hand, false-positive tests commonly lead to unnecessary interventions that are potentially hazardous to the gravida. On the other hand, to date, no program of fetal testing has been shown to completely eliminate the risk of stillbirth.     

Maternal obesity and stillbirth

The current obesity epidemic appears to contribute significantly to adverse fetal outcomes, and in this work we compile up-to-date evidence for the link between maternal obesity and risk of stillbirth. The review revealed a preponderance of evidence showing that the risk of stillbirth is increased among obese mothers with amplified risk estimates as the severity of obesity increases. Changes in interpregnancy body mass index (BMI) influence subsequent fetal survival and obese women that normalize their BMI values experience enhanced fetal survival in future pregnancies. The elevated risk of stillbirth among obese mothers affect all gestations regardless of fetal number, with the most profound risk (4-fold increase) noted among triplet gestations. The literature has predominantly reported a strong association between maternal prepregnancy obesity and stillbirth. The considerable magnitude of association, consistency of positive results for the association between maternal obesity and stillbirth, the establishment of temporality between maternal obesity and stillbirth, the incremental elevation in risk with ascending BMI values, as well as the improvement in fetal survival with decrease in interpregnancy BMI among obese mothers strongly provide sufficient evidence that the relationship between maternal obesity and stillbirth may be causal.     

Maternal blood pressure in pregnancy and stillbirth: a case-control study of third-trimester stillbirth

An immense body of literature on the effects of hypertension on perinatal morbidity and mortality exists, but only a handful of studies have reported adverse outcomes associated with low maternal blood pressure during pregnancy. This study aimed to investigate if there is an increased risk of fetal loss associated with hypotension during pregnancy. A matched case-control study of stillbirth and maternal blood pressure was conducted in which maternal blood pressures for a total of 124 pregnancies culminating in stillbirth were compared with maternal blood pressures in 243 (matched) pregnancies resulting in a liveborn infant. Women whose diastolic blood pressures fell in a borderline range (60 to 70 mm Hg) were consistently at greater risk of stillbirth relative to normotensive pregnancies. Women who had three or more mean arterial pressure values < or = 83 mm Hg during the course of their pregnancy were at nearly twice the risk of stillbirth (odds ratio 1.78; 95% confidence interval [CI] 1.06 to 2.99; P = 0.03). Systolic hypotension was not significantly associated with stillbirth, but proportionately more control women were noted to have systolic hypertension (SBP > or = 130 mmHg) than cases, and the adjusted odds of stillbirth in women who were hypertensive at either their first or last antenatal visit or whose antenatal average SBP was > or = 130 mm Hg were all very close to 0.4 (95% CI 0.37 to 0.43; P = 0.02 to 0.03) relative to normotensives. We concluded that maternal hypotension, particularly borderline hypotension, may be a contributory risk factor for stillbirth. Women with hypertension in pregnancy may now be at a decreased risk of stillbirth as a result of the close care and treatment they receive.     

Ambulatory management of chronic hypertension in pregnancy

Chronic hypertension in pregnancy is one of the most common medical diseases affecting pregnancy. It is associated with serious maternal and fetal complications, including superimposed pre-eclampsia, fetal growth restriction, premature delivery, placental abruption, and stillbirth. Baseline evaluation as early as possible is important to differentiate women with essential hypertension from those with severe hypertension, coexisting end-organ damage, and secondary causes of hypertension, as their risks of poor outcomes are increased. An optimal plan for maternal treatment and fetal surveillance can then be formulated. Coordination of care after delivery is important for long-term maternal health and future pregnancies.     

Clinical implications from monitoring fetal activity

The monitoring of fetal motion in high-risk pregnancies has been shown to be worthwhile in predicting fetal distress and impending fetal death. The maternal recording of perceived fetal activity is an inexpensive surveillance technique which is most useful when there is chronic uteroplacental insufficiency or when a stillbirth may be expected. The presence of an active, vigorous fetus is reassuring, but documented fetal inactivity required a reassessment of the underlying antepartum complication and further fetal evaluation with real-time ultrasonography, fetal heart rate testing, and biochemical testing. Fetal distress from such acute changes as abruptio placentae or umbilical cord compression may not be predicted by monitoring fetal motion. Although not used for routine clinical investigation, electromechanical devices such as tocodynamometry have provided much insight into fetal behavioral patterns at many stages of pregnancy and in pregnancies with an antepartum complication.