妊娠大于40周孕妇分娩时机的临床分析

目的探讨正常妊娠40周以后,何时终止妊娠对母婴最有利. 方法 52例孕妇监测胎动、胎心、羊水指数(AFI)、血清游离雌三醇(E3)、胎盘泌乳素(HPL),并作胎盘病理检查,了解分娩方式、剖宫产因素及围生儿的结局,分析终止妊娠的时机. 结果 AFI随孕周增加逐渐下降,孕40周、41周和42周分别为(8.2±3.5)cm、(7.3±4.2)cm和(6.6±1.9)cm,AFI≤5 cm者孕41周为32.1 %(9/28),高于40周和42周分别为23.1 %(3/13)和27.3 %(3/11),相应的胎儿窘迫和新生儿窒息的发生率分别为10.1 %(3/28)、0和9.1 %(1/11),但差异均无显著性(P＞0.05);血中游离雌三醇(E3)随孕周增加而下降,孕40、41和42周E3分别为(243.2±138.1)nmol/L、(166.7±82.2)nmol/L和(118.2±70.2))nmol/L,差异有显著性(P＜0.01),胎盘泌乳素(HPL)3组分别为(6.2±1.6) mg/L、(4.8±2.2) mg/L及(5.9±1.8) mg/L,差异无显著性(P＞0.05);当AFI≤5 cm,E3及HPL下降不明显,但胎儿窘迫及新生儿窒息率明显增加;剖宫产中宫颈未成熟者占45.7 %(16/35). 结论 AFI 可作为终止妊娠时机的观察指标,当AFI≤5 cm,容易发生胎儿宫内窘迫与新生儿窒息,应适时终止妊娠,过早干预可导致剖宫产率增加.     

脂质代谢异常与妊娠期特发性肝脏损害

目前研究发现,脂质代谢异常与多种不同的脏器损害密切相关,例如高脂血症与脂肪肝、动脉血管粥样硬化有关,高游离脂肪酸(free fatty acid,FFA)与胰岛功能受损、胰岛素抵抗有关。而脂质代谢异常与不同脏器损害两者之间的关系,正引起各学科众多研究者越来越浓厚的兴趣。近年来,国外学者的研究发现,胎儿线粒体脂肪酸氧化代谢异常与孕妇妊娠期特发性肝损害——重度先兆子痫伴发的肝损害、HELLP综合征(hemolysis,elevated liver enzymes,low platelets,HELLP)及妊娠期急性脂肪肝(acute fatty liver of pregnancy,AFLP)有关。国内外的临床和病理学研究资料显示,重度先兆子痫、AFLP及HELLP综合征病例都存在有不同程度肝脏受损及肝脏脂肪浸润表现,提求3种疾病可能在某种程度上共享发病机制。     

早产临床风险因素的探讨

目的评估影响早产分娩的风险因素以及对早产干预措施影响的相关因素。方法选择2003年1月至2006年3月发生在34周前的自发性早产临产、早产胎膜早破、宫颈机能不全、先兆早产4种临床表现类型共221例,比较4种临床表现之间发病的风险因素及影响干预措施结局的相关因素。结果自发性早产临产的风险因素依次为:本次妊娠先兆流产史(OR8.917,95%CI2.308～34.457)、胎次(OR2.179,95%CI1.033～4.598)、宫颈长度改变(OR0.366,95%CI0.259～0.518);早产胎膜早破的风险因素依次为:自然流产史(OR4.922,95%CI1.115～21.720)、体外受精-胚胎移植(IVF-ET)(OR5.341,95%CI1.571～18.164);宫颈功能不全的风险因素依次为:早产史(OR9.010,95%CI2.032～39.940),IVF-ET(OR2.603,95%CI1.195～5.670)。发生早期早产分娩的影响因素依次为:血象升高(OR4.695,95%CI2.065～10.671)、宫颈长度变短(OR0.633,95%CI0.456～0.880)。对早产干预措施的影响因素为紧急宫颈环扎术(OR26.372,95%CI2.770～251.085)和血象升高(OR7.111,95%CI1.769～28.53)。结论影响早产的风险因素较多,应注重IVF-ET妊娠的早产风险;实施紧急宫颈环扎术及注重感染指标监测是减少34周前分娩的重要干预手段。     

先兆子痫及正常妊娠血脂代谢与凝血-纤溶活性相互影响探讨

目的探讨正常妊娠血脂代谢和凝血-纤溶活性变化规律及其相互影响，探讨血脂代谢和凝血-纤溶活性变化在先兆子痫发病中的作用。方法采用前瞻性研究方法，选取规律产前检查的孕妇114例，分别于孕10～14周、20～24周及30～34周测定血脂水平及凝血相关指标，其中4例发生轻度先兆子痫（晚发型，发病孕周〉34周）。分析比较血脂及凝血相关指标。统计学方法采用t检验、重复测量方差分析及相关性分析方法。结果正常妊娠妇女血清中TG、TCHO和LDL水平随妊娠周数增加而增加（P〈0．01）；血FIB和D—Di—mer水平随妊娠周数的增加而升高、AT-Ⅲ水平下降（P〈0．01）。先兆子痫与正常妊娠相比，TG和TG／HDL比值水平明显升高，HDL、TCHO及LDL水平明显降低，但差异无显著性（P〉O．05）；FIB水平升高，差异无显著性（P〉0．05）。相关性检验显示，血TCHO、TG及LDL水平与血FIB及D—Dimer水平成正相关（P〈0．01），与AT-Ⅲ水平成负相关（P〈0．01）。正常妊娠AT-Ⅲ／TG比值随妊娠周数增加而下降（P〈0．01）。先兆子痫与正常妊娠相比，AT-Ⅲ／TG比值下降，FIB／HDL比值升高，但差异无显著性（P〉0．05）。结论正常妊娠脂质代谢和凝血-纤溶活性变化存在着相关性，先兆子痫患者存在脂质代谢和凝血-纤溶活性异常变化趋势，脂代谢与凝血-纤溶活性对先兆子痫的影响还需要大样本多中心的研究。     

子痫前期患者血脂代谢调节的探讨

目的:探讨子痫前期患者脂代谢调节水平及其异常调节情况。方法:采取前瞻性研究方法,随机抽取317例正常孕妇,分别测定不同妊娠周数的血脂和游离脂肪酸(FFA)水平;选取产前规律检查的正常孕妇54例,分别于孕10~14周,20~24周及30~34周测定血脂代谢水平。并随机抽取孕周相同、年龄相同或相近的正常孕妇77例与重度子痫前期77例进行1:1配对研究,比较血脂代谢变化。结果:正常妊娠妇女血清中TG、TCHO和LDL水平随妊娠周数增加而增加,但FFA和HDL水平并未随妊娠的周数的增加而发生明显变化。重度子痫前期TG和FFA水平较对照组明显升高(P<0.05),而HDL水平下降(P<0.05);FFA/HDL和LDL/HDL比值较对照组明显升高(P<0.05),而FFA/TG、FFA/LDL及FFA/TCHO比值无明显变化(P>0.05)。早发型重度子痫前期患者中肝功损害组的TCHO和LDL水平较对照组明显增高(P<0.05)。结论:重度子痫前期患者存在脂质代谢调节异常,具有损伤作用的FFA增加,而具有保护作用的HDL下降,FFA/HDL比值升高,重度子痫前期正常的血脂代谢平衡发生变化,FFA增加可能在重度子痫前期脂质代谢异常调节方面起到一定作用。     

重度子痫前期患者临床发病前预警信息分析

Objective To identify the early warning signs of severe preeclampsia (SPE). Methods A case-control (1: 2) observational study was conducted. Forty-seven pregnant women with SPE, who attended the prenatal clinics of Peking University Third Hospital regularly from Jan. 2002 to Dec. 2007, were selected as the study group, including 12 early onset and 35 late onset ones. The control group consisted of 94 healthy singleton pregnant women at the same period. Clinical data were collected and analyzed. Results (1) The basal body mass index (BMI) showed no difference between the study and control group [(23.27±4.31)kg/m2 vs (21.52±3.09)kg/m2, P>0.05]. (2) The net increase of BMI in the study group before the onset of SPE was higher than that in the control [(5.60±2.17)kg/m2 vs (4.85±1.52)kg/m2, P<0.05] and the increase of BMI per week was also higher [(0.74±0.41)kg/(m2*w)-1 vs (0.23±0.18)kg/(m2*w)-1, P<0.01]. The sensitivity and specificity of BMI increase per week in predicting SPE was 84% and 81% at a cut-off value of 0.39 kg/(m2*w)-1, respectively, and 79% and 91% at 0.41 kg/(m2*w)-1 correspondingly. (3) During the third trimester and before the onset of SPE, the weight gain per week in the study group was higher than that of the control [(0.93±0.70)kg vs (0.63±0.20)kg, P<0.01]. Significant difference was also found in the net weight gain between the two groups (P<0.01), but not in the percentage of women with excessive weight gain (>0.50 kg/w) [60%(25/42) in the study group vs 63%(53/84) in the control group, P>0.05]. (4) Higher percentage of women experienced pre-hypertension in the study group than in the controls [17%(8/47) vs 5%(5/94), P<0.01]. (5) In the study group, 53%(25/47) of the women had edema before SPE onset, but the figure dropped to 18% (17/94) in the controls(P<0.01). (6) Eight women in the study group and one in the control group suffered from hypoproteinemia before SPE onset with the average level of plasma albumin of (32.6±1.6)g/L and(38.4±2.1)g/L(P<0.01), respectively. (7) Proteinuria was reported in 10 cases (21%)in the study group and 4(4%) in the controls (P<0.01). (8) Logistic regression analysis showed that the risk factors for SPE included edema (OR=6.16,95%CI:2.29-16.57),pre-hypertension (OR=6.21,95%CI:1.56-24.77),proteinuria (OR=9.68,95%CI:1.86-50.30), and weight gain >0.85 kg/w during the third trimester (OR=11.60,95%CI:3.54-37.97). Conclusions Edema, excessive weight gain,pre-hypertension and hypoproteinemia are early warning signs of SPE. Pregnant women with the above signs required close monitoring during prenatal care.     

重度子痫前期患者临床发病前预警信息分析

Objective To identify the early warning signs of severe preeclampsia (SPE). Methods A case-control (1: 2) observational study was conducted. Forty-seven pregnant women with SPE, who attended the prenatal clinics of Peking University Third Hospital regularly from Jan. 2002 to Dec. 2007, were selected as the study group, including 12 early onset and 35 late onset ones. The control group consisted of 94 healthy singleton pregnant women at the same period. Clinical data were collected and analyzed. Results (1) The basal body mass index (BMI) showed no difference between the study and control group [(23.27±4.31)kg/m2 vs (21.52±3.09)kg/m2, P>0.05]. (2) The net increase of BMI in the study group before the onset of SPE was higher than that in the control [(5.60±2.17)kg/m2 vs (4.85±1.52)kg/m2, P<0.05] and the increase of BMI per week was also higher [(0.74±0.41)kg/(m2*w)-1 vs (0.23±0.18)kg/(m2*w)-1, P<0.01]. The sensitivity and specificity of BMI increase per week in predicting SPE was 84% and 81% at a cut-off value of 0.39 kg/(m2*w)-1, respectively, and 79% and 91% at 0.41 kg/(m2*w)-1 correspondingly. (3) During the third trimester and before the onset of SPE, the weight gain per week in the study group was higher than that of the control [(0.93±0.70)kg vs (0.63±0.20)kg, P<0.01]. Significant difference was also found in the net weight gain between the two groups (P<0.01), but not in the percentage of women with excessive weight gain (>0.50 kg/w) [60%(25/42) in the study group vs 63%(53/84) in the control group, P>0.05]. (4) Higher percentage of women experienced pre-hypertension in the study group than in the controls [17%(8/47) vs 5%(5/94), P<0.01]. (5) In the study group, 53%(25/47) of the women had edema before SPE onset, but the figure dropped to 18% (17/94) in the controls(P<0.01). (6) Eight women in the study group and one in the control group suffered from hypoproteinemia before SPE onset with the average level of plasma albumin of (32.6±1.6)g/L and(38.4±2.1)g/L(P<0.01), respectively. (7) Proteinuria was reported in 10 cases (21%)in the study group and 4(4%) in the controls (P<0.01). (8) Logistic regression analysis showed that the risk factors for SPE included edema (OR=6.16,95%CI:2.29-16.57),pre-hypertension (OR=6.21,95%CI:1.56-24.77),proteinuria (OR=9.68,95%CI:1.86-50.30), and weight gain >0.85 kg/w during the third trimester (OR=11.60,95%CI:3.54-37.97). Conclusions Edema, excessive weight gain,pre-hypertension and hypoproteinemia are early warning signs of SPE. Pregnant women with the above signs required close monitoring during prenatal care.     

阴道分娩前后血红蛋白与出血量的关系研究北大核心CSCD

目的探讨产后血红蛋白变化与阴道出血量之间的关系。方法前瞻性随机选取2017年12月至2018年1月在北京大学第三医院产科住院阴道分娩的200例孕妇(除外血液系统疾病、妊娠期高血压疾病及产前出血)。按产后2 h出血量分为轻度出血组(产后2 h出血小于400 ml)、中度出血组(产后2 h出血400～1 000 ml)、重度出血组(产后2 h出血大于等于1 000 ml)。分别比较各组在产后2 h及产后24 h血红蛋白等指标变化情况。结果轻度出血组及中度出血组在产后2 h实际血红蛋白变化值与理论血红蛋白变化值差异无统计学意义(P>0.05),而产后24 h差异有统计学意义[15(10, 21) vs 9(8, 10)],[30(20, 34) vs 15(14, 18)](P <0.05)。重度出血组在产后2 h实际血红蛋白变化值与理论血红蛋白变化值差异有统计学意义[3(-4, 21) vs 28(24, 31)](P <0.05),而产后24 h差异无统计学意义(P>0.05)。结论产后失血量程度不同的产妇,产后血红蛋白变化与阴道失血量关系不同:阴道分娩后2 h内出血低于1 000 ml者产后24 h血红蛋白变化与失血量不相符,而严重产后出血者产后2 h的血红蛋白变化不能准确评估阴道失血量。     

规律产前检查子痫前期患者早期临床发病特点分析

目的 分析接受规律产前检查的轻重度子痫前期（PE）发病的影响因素和早期临床特征,以及不同产前检查模式的影响,探讨延缓PE发展、降低重度PE发生的临床监控和干预时机。方法 收集2008年1月至2011年12月在北京大学第三医院接受规律产前检查发生和诊治的238例PE病历临床资料,采用历史前瞻性队列分析方法对发生轻度PE（M-PE）与重度PE（S-PE）的风险因素和临床发病特征进行对比分析。并对比分析接受强化产前检查与常规产前检查病例间临床预警信息及PE发生孕期时段和诊断时限。结果 （1）轻与重度PE间发病风险因素及临床首发症状差异无统计学意义（P>0.05）。（2）单胎妊娠单纯性轻与重度PE早期临床特征分析：①诊断前预警信息：S-PE组在诊断前存在高血压前期、低蛋白血症、血小板（PLT）下降趋势比例高于M-PE组（P<0.05）;S-PE组血清白蛋白<29 g/L、PLT下降大于40%比例显著高于M-PE组（P<0.05）。②S-PE组预警信息出现至临床症状出现时间短于M-PE组,预警信息出现至做出PE诊断标准时间也短于M-PE组（P<0.05）。（3）产前检查模式分析显示：强化产检组PE重度发病率低于常规产检组（P<0.05）。强化产检组发现临床症状早于常规产检组 ,但PE发生时间迟于常规产检组（P<0.05）。（4）多因素回归分析显示孕早期超重（OR 2.480,P=0.035）,高血压前期（OR 3.304,[WTBX]P[WTBZ]=0.046）,低蛋白血症（OR 3.951,[WTBX]P[WTBZ]=0.035）、PLT下降趋势（OR 2.582,[WTBX]P[WTBZ]=0.047）、强化产检（OR 0.321,[WTBX]P[WTBZ]=0.041）是子痫前期发病轻重的独立影响因素。结论 发病前临床预警信息在轻与重度PE存在明显异质性。强化产检可显著降低S-PE发病率,提早发现临床症状,延缓S-PE发病时间。孕早期超重、高血压前期、胎儿生长受限、强化产检是影响子痫前期轻与重的独立因素。      

早发型重度子痫前期的期待治疗

如何选择病例和如何实施期待治疗是早发型重度子痫前期保守处理的关键.应选择无严重并发症和病情稳定的病例在三级医院监管,其治疗措施包括医患间的良好沟通、母胎状况的严密监测、抗高血压和硫酸镁预防性抗痉药的应用,及时终止妊娠和个体化处理原则可以降低母儿的死亡率.