产后出血的高危因素分析

目的　分析产后出血发生的相关危险因素 ,探讨预防和减少产后出血的措施。方法　对我院1 990年 1月～ 2 0 0 2年 1 2月间住院分娩的产妇出现产后出血的产妇 31 9例 ,对照 6 38例。通过多元Logistic回归分析评价各危险因素的相对危险性。结果　产后出血的发病率为 2 0 9%。相对独立的多个危险因素作用大小的顺位为 :胎盘粘连或植入、前置胎盘、多胎妊娠及胎儿体重≥ 4 0 0 0g、重度妊高征、流产次数≥ 2次、胎盘早剥 ;在阴道分娩的产妇中 ,作用相对独立的危险因素的顺位为胎盘粘连或植入、胎儿体重≥ 4 0 0 0g、妊高征、第三产程 >1 0min、流产次数≥ 2次。结论　避免产前非意愿妊娠以减少前置胎盘、胎盘粘连或植入 ;减少巨大儿、多胎的发生 ,有助于预防和减少产后出血     

DIAGNOSIS OF CONGENITAL CYTOMEGALOVIRUS INFECTION BY EXAMINATION OF PLACENTA: Application of Polymerase Chain Reaction and in Situ Hybridization

We examined the placentas of 12 patients in whom congenital cytomegalovirus CMV infection was suspected from serological and or pathological evaluation. Seven patients died including four intrauterine deaths and five survived. On histological examination, the characteristic inclusion bodies were detected in only three placentas, and villitis with plasma cell infiltration was seen in eight placentas. Immunohistochemistry using a specific antibody against CMV improved the sensitivity of CMV detection 10 cases were positive . With the polymerase chain reaction PCR following the extraction of DNA from formaldehyde-fixed placenta samples, CMV DNA was detected in seven cases. All 12 subjects were diagnosed with CMV infection by additional Southern blot analysis after the PCR. CMV DNA was also detected by an in situ hybridization method in all cases. With current molecular biological techniques the placenta can be reliably used for the diagnosis of congenital CMV infection.     

Increased placental apoptosis in intrauterine growth restriction

OBJECTIVES: Our purpose was to investigate a possible role for apoptosis in the pathophysiologic mechanisms of intrauterine growth restriction. STUDY DESIGN: Placental samples were obtained from 43 uncomplicated third-trimester pregnancies and from 26 pregnancies complicated by intrauterine growth restriction. The definition used to identify cases of intrauterine growth restriction depended on three criteria: clinical evidence of suboptimal growth, ultrasonographic evidence of deviation from an appropriate growth percentile, and individualized birth weight ratios <10th percentile. Light microscopy was used to quantify the incidence of apoptosis. Electron microscopy and TUNEL (terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick end labeling) staining were used to confirm the occurrence of apoptosis. RESULTS: Quantification of apoptosis (medians and interquartile ranges) resulted in the following values: normal third trimester (n = 43) 0.14% of cells (0.08% to 0.20%) and intrauterine growth restriction third trimester (n  = 26) 0.24% of cells (0.16% to 0.29%). The incidence of apoptosis was significantly higher in placentas from pregnancies with intrauterine growth restriction compared with normal third-trimester placentas (p < 0.01, Mann Whitney U test). CONCLUSIONS: These results suggest that apoptosis may play a role in the pathophysiologic mechanisms of intrauterine growth restriction.(Am J Obstet Gynecol 1997;177:401)     

Intraplacental Choriocarcinoma Associated with Viable Pregnancy: Pathologic Features and Implications for the Mother and Infant

Choriocarcinoma arising in the placenta, or intraplacental choriocarcinoma, has seldom been reported, particularly in the absence of maternal metastases. Reluctance to diagnose choriocarcinoma in the presence of chorionic villi can delay diagnosis; however, timely diagnosis of choriocarcinoma is prognostically important, both for the mother and infant. We report the clinicopathologic findings in five mothers and infants in whom choriocarcinoma was identified in the placenta. None of the mothers had a history of gestational trophoblastic disease in previous pregnancies. Three placentas were similar with a single small lesion grossly suggesting a small infarct; microscopically these consisted of infarcted areas surrounded by choriocarcinoma. These three mothers were unusual in that none had metastatic choriocarcinoma; two were treated with chemotherapy and remained disease-free; the third was lost to follow-up shortly following delivery. The remaining two mothers had known pulmonary metastases at time of delivery. One of these latter two placentas contained a large marginal lesion microscopically identified as choriocarcinoma. The fifth placenta had rare microscopic foci of choriocarcinoma, and sheets of necrotic choriocarcinoma were identified in “blood clot” submitted with the placenta. In four of the five cases the choriocarcinoma appeared to be arising from otherwise normal chorionic villi, and in no case was there invasion of the villous stroma. All of the infants survived, and none had evidence of choriocarcinoma. These cases support the concept that choriocarcinoma associated with otherwise normal pregnancy arises in the placenta and may be more common than reported. Received August 11, 1997; accepted December 8, 1997.     

新生儿窒息513例临床分析

目的 探讨新生儿窒息的相关因素及预防措施。方法 对1995年1月～2004年12月哈尔滨二四二医院住院分娩发生的新生儿窒息513例临床资料进行分析。结果 新生儿窒息与胎儿窘迫高度相关。脐带因素、产程异常、胎盘功能不全是新生儿窒息的主要产科原因。结论 新生儿窒息是胎儿窘迫产程中缺氧在出生后的表现和继续。应以预防为主：要重视产前检查，对高危妊娠进行系统管理，指导胎动计数，加强产程监护，综合判断后选择最佳分娩方式。一旦发生，及时进行复苏术。     

Effects of di-(2-ethylhexyl)-phthalate (DEHP) and its metabolites on fatty acid homeostasis regulating proteins in rat placental HRP-1 trophoblast cells.

Di-(2-ethylhexyl)-phthalate (DEHP) is a widely used plasticizer and ubiquitous environmental contaminant. The potential health hazards, including teratogenicity, from exposure to DEHP may be related to the role of DEHP or its metabolites in the trans-activation of peroxisome proliferator-activated receptors (PPARs). Fetal essential fatty acid (EFA) homeostasis is controlled by directional transfer across the placenta through a highly regulated process, including PPAR activation. Using HRP-1 rat trophoblastic cells, the effects of DEHP and two of its metabolites, mono-(2-ethylhexyl)-phthalate (MEHP) and 2-ethylhexanoic acid (EHA), on the mRNA and protein expression of the three known PPAR isoforms (alpha, beta, and gamma), fatty acid transport protein 1 (FATP1), plasma membrane fatty acid binding protein (FABPpm), and the heart cytoplasmic fatty acid binding protein (HFABP) were investigated. This study also investigated the functional effects of exposure on the uptake and transport of six long chain fatty acids (LCFAs): arachidonic acid (AA), docosahexaenoic acid (DHA), linoleic acid (LA), alpha-linolenic acid (ALA), oleic acid (OA), and stearic acid (SA). In the presence of DEHP, MEHP, and EHA, the expression of PPARalpha, PPARgamma, FATP1, and HFABP were up-regulated in a dose- and time- dependent manner, while PPARbeta and FABPpm demonstrated variable expression. The uptake rates of EFAs (AA, DHA, LA, ALA) increased significantly upon exposure, and the transport of AA (omega-6) and DHA (omega-3) were directionally induced. These results suggest that DEHP, MEHP, and EHA can influence EFA transfer across HRP-1 cells, implying that these compounds may alter placental EFA homeostasis and potentially result in abnormal fetal development.     

Fetal circulation and placental blood flow in monochorionic twins

Objectives. Twin to twin transfusion syndrome (TTTS) is one of the most important problems for perinatal management of monochorionic twins. Since TTTS is deeply related to the prognoses of both fetuses, fetal circulation and placental blood flow of monochorionic twins were studied with the purpose of clarifying characteristic features.

Methods. The patterns and numbers of vascular anastomoses were checked on the placental surface, arterio-arterial (A-A) anastomosed vessels by ultrasound, and circulatory changes were studied with relation to uterine contraction.

Results. The high risk of monochorionic twin pregnancies was largely related to the patterns of vascular anatomy of the placenta and numbers of anastomosed vessels. The first placental vascular connection detected in vivo was the A-A anastomosis characterized by the bidirectional flow waveform in pulsed Doppler velocimetry.

Conclusion. TTTS is related to anastomosed vessels on the surface of placenta. To manage and prevent TTTS, fetal circulation and placental blood flow should be carefully observed.     

剖宫产瘢痕妊娠期待治疗的不良妊娠结局分析

【目的】探讨剖宫产瘢痕妊娠（CSP）与胎盘植入的关系及CSP期待治疗的风险评估。【方法】回顾性分析2014年1月至2018年12月在中山大学附属第三医院就诊并要求期待治疗的3例CSP的自然病程,总结其临床特点、超声表现及其不良妊娠结局。【结果】3例CSP患者既往子宫下段剖宫产次数为1~2次,临床症状包括：反复阴道流血、血尿及剧烈腹痛。3例CSP首次超声诊断CSP的孕周为6+2周、7周及7+4周;超声分型分别为Ⅰ、Ⅱ及Ⅲ型;其首次超声诊断胎盘植入的时间分别为24+4周、12+2周及13+1周,中孕期超声均诊断为穿透性胎盘植入。3例CSP分别因反复大量阴道流血、血尿及膀胱血块填塞及子宫破裂而在中孕期终止妊娠,无活产婴儿;术中均被证实为穿透性胎盘植入,1例行子宫次全切除获得术后病理确诊,出血量均超过2500mL,无孕产妇死亡。【结论】CSP与胎盘植入的关系密切,在期待治疗的过程中应警惕穿透性胎盘植入。CSP的自然病程常合并严重的不良妊娠结局,不可盲目的选择期待治疗。     

剖宫产术中娩出胎儿前膀胱下推法在凶险性前置胎盘手术中的应用效果

目的评价剖宫产手术时娩出胎儿前膀胱下推法在凶险性前置胎盘手术中的应用效果。方法选择2016年1月至2017年12月安徽医科大学第一附属医院产科收治凶险性前置胎盘孕产妇89例,根据剖宫产时下推膀胱的时机不同,分为A组(47例)与B组(42例),A组为娩出胎儿前膀胱下推组,B组为娩出胎儿后下推膀胱组。比较两组孕产妇一般情况(年龄、孕次、产次、孕周、胎盘植入率)、平均手术出血量、平均输血量、手术时间、术后住院时间、产褥病率、子宫切除、膀胱损伤和新生儿窒息方面的差异。结果 A、B组孕产妇术中出血量分别为(1 927. 76±356. 31) mL、(2 859. 55±477. 80) mL,输血量分别为(861. 72±91. 58) mL、(1 285. 73±162. 69) mL,手术时间分别为(1. 83±0. 87) h、(2. 71±0. 94) h,术后住院时间分别为(5. 37±1. 72) d、(6. 83±1. 56) d,产褥病率分别为10. 64%、28. 57%,子宫切除率分别为14. 89%、35. 71%,新生儿窒息发生率分别为4. 26%、19. 05%,两组差异有统计学意义(P <0. 05)。结论凶险性前置胎盘娩出胎儿前膀胱下推法疗效满意,值得临床推广应用。