阴道彩超及MRI诊断剖宫产术后子宫疤痕妊娠的临床价值

目的 探讨阴道彩超及MRI对剖宫产术后子宫疤痕妊娠的诊断价值.方法 回顾性分析经手术病理及临床证实的20例剖宫产术后子宫疤痕妊娠的临床资料,20例行阴道彩超,17例1周内行MRI检查.结果 20例中,阴道彩超诊断正确15例（75％）,误诊5例（25％）,阴道彩超诊断准确率为75％.阴道彩超分为两型：单纯妊娠囊型14例（70％）;混合回声包块型6例（30％）.MRI分为两型：单纯妊娠囊型：9例（约52.9％）;混杂团块型：8例（约47.1％）,17例MR检查均正确诊断.结论 剖宫产术后子宫疤痕妊娠的主要影像学表现为子宫疤痕处的囊性、囊实性结节或肿块.阴道彩超及MRI均可作出准确诊断,MRI在诊断子宫疤痕妊娠方面优于阴道彩超,可作为子宫疤痕妊娠的重要补充.     

不同浓度、剂量布比卡因用于剖宫产脊麻的效果比较

目的研究比较不同浓度、剂量,等比重布比卡因对产妇的麻醉效果及新生儿的影响,为临床麻醉提供参考依据。方法选择ASAⅠ~Ⅱ级初次足月妊娠拟择期剖宫产手术孕妇80例,随机分为A、B二组,每组各40例。均在左侧卧位下行腰-硬联合穿刺,L2-3进针,见脑脊液外流后,针斜面向下注入等比重布比卡因:A组:8mg(0·5%,1·6ml;配法:0·75%布比卡因2ml+脑脊液1ml);B组:9·6mg(0·6%,1·6ml;配法:0·75%布比卡因2ml+脑脊液0·5ml),20s注药完毕。记录麻醉前(基础值)和脊麻注药后1、3、5、7、10、15min各时间点的平均动脉压(MAP)、心率(HR)、脉搏血氧饱合度(SpO2)。测定并记录麻醉起效时间、平面固定时间、最高麻醉平面点(胸,T)、麻醉完全消退时间、下肢阻滞的最大程度、麻醉并发症等。结果A组感觉阻滞起效时间长于B组(69·27±21·48vs52·43±27·61s,P<0·05);两组最高阻滞平面(T4·50±1·44vsT4·10±0·57)及最高阻滞平面的固定时间(7·69±1·36vs7·35±1·22min)相似(P>0·05)。A组麻醉完全消退时间快于B组(218·40±18·57vs256·22±16·72min,P<0·05);Bromage评分A组明显小于B组(2·03±0·68vs2·93±0·21,P<0·05);麻醉后B组低血压发生率明显高于A组(P<0·05)。两组病人的麻醉效果均优,肌松满意。所有新生儿的Apgar评分均在7分以上,无组间差异。结论两组病人均产生了良好的脊麻效果,权衡利弊剖宫产脊麻时应用8mg(0·5%,1·6ml)布比卡因更为安全合理。     

Method to Calculate Nurse-Specific Cesarean Rates for the First and Second Stages of Labor

To date, efforts to safely lower the cesarean birth rate for women with low-risk pregnancies have largely ignored the influence of labor and delivery nurses on mode of birth. This is mainly because of the complexity involved in attributing outcomes to specific nurses whose care had the greatest effect on mode of birth. An additional level of complexity arises from the type of care given to the woman during different stages of labor. In this article, we describe a strategy to designate nurses to births using an electronic medical record flowsheet, and we describe a method to calculate nurse-specific cesarean birth rates for the first and second stages of labor. Similar to physician-specific rates, we found wide variation in nurse-specific cesarean birth rates in both stages of labor, which suggests an opportunity to learn from best practices.     

剖宫产切口瘢痕缺损诊治的几个问题

剖宫产切口瘢痕缺损(cesarean scar defect,CSD)属于剖宫产远期并发症,是剖宫产切口瘢痕处的肌层愈合不良形成的凹陷结构[1].进行性升高的剖宫产率已成为严重的全球性公共卫生问题,我国的剖宫产率在2008年至2014年期间已经从28.8％上升到34.9％,二孩政策全面放开后会进一步增高.CSD可引发各...     

疤痕子宫间隔1年内妊娠再次足月剖宫产102例分析

目的:探讨剖宫产后1年内妊娠再次足月剖宫产的安全性。方法:收集近3年深圳市福田区妇幼保健院及深圳福永人民医院收治的剖宫产术后1年内妊娠至足月的102例孕妇(研究组)及剖宫产术后2~3年妊娠至足月的100例孕妇(对照组)。分析孕妇再次妊娠距前次剖宫产的时间、再次妊娠的原因及此次妊娠的结局。结果:剖宫产术后1年内妊娠者多为4~11个月后妊娠,其终止妊娠方式均为剖宫产,其再次妊娠原因主要为未哺乳或母乳喂养少于4个月,未避孕或避孕失败;子宫下段厚度平均为(0.61±0.28)cm,与对照组(0.53±0.24cm)比较,差异有统计学意义(P0.05)。研究组患者中盆腔粘连16例、前置胎盘5例、胎盘黏连3例、胎盘植入1例、产后出血6例、隐性子宫破裂2例,与对照组比较(分别为15例、1例、0例、0例、4例、0例),差异无统计学意义(P0.05);两组的新生儿结局比较,差异无统计学意义(P0.05)。结论:剖宫产术1年内妊娠并维持至足月,并未增加新生儿风险,但其安全性需高度重视。对剖宫产产妇,需在产褥期做好宣教,指导避孕,最好于术后2年再孕,若短期内已妊娠者,应密切观察及时予以适当的产科处理。     

A randomized comparative trial of early initiation of oral maternal feeding versus conventional oral feeding after cesarean delivery

Objective

To compare the effects of two maternal feeding policies—early versus conventional oral feeding—after cesarean delivery.

Methods

This prospective multicenter randomized comparative trial was conducted at tertiary care hospitals in Sindh, Pakistan, from 2010 to 2012. Women with an uncomplicated cesarean delivery under spinal anesthesia were allocated to an intervention of early (after 2 hours) or conventional (after 18 hours) initiation of oral feeding. Outcomes included maternal ambulation, maternal satisfaction, gastrointestinal functions, and length of hospital stay.

Results

In total, 1174 women (n = 587 per group) were included in the final analysis. Gastrointestinal complications were not significantly different between the two groups. Lower intensities of thirst and hunger and a higher rate of maternal satisfaction were observed in the early feeding group (P < 0.05), and 53.8% of women in this group were able to ambulate within 15 hours of surgery, compared with 27.9% of women in the conventional feeding group. The frequencies of readmission, febrile morbidity, and wound infection were insignificant.

Conclusion

Early oral dietary initiation after cesarean delivery resulted in early ambulation, greater maternal satisfaction, and reduced length of hospital stay, with no detrimental outcomes, making this practice cost-effective. Hence, day-care cesarean delivery might be an option in resource-constrained settings.Trial Registration number: ChiCTR-TRC-13003651, http://www.chictr.org     

Are Women’s and Obstetricians,Views on Mode of Delivery Following a Previous Cesarean Section Really OCEANS Apart?

Purpose

Most women with one previous cesarean section (CS) are suitable for either a vaginal birth after CS (VBAC) or an elective repeat CS. Previously, nurse-led prenatal education and support groups have failed to have an impact on the mode of delivery, which women opted for after one CS. A novel one-stop obstetrician-led cesarean education and antenatal sessions (OCEANS) has been developed to inform and empower women in their decision-making following one previous CS. The objective of our study was to evaluate how OCEANS influences the mode of delivery for women who have previously had one CS.

Study Design

Two-hundred and sixty-six women who had a single previous lower segment CS were invited to attend OCEANS, which is a 1-h discussion group of women between 5 and 15 in number, facilitated by an experienced obstetrician. Data were collected prospectively on women who were invited to attend OCEANS over a 12-month period commencing on the 1st January 2012.

Results

188 (71 %) attended the group, while 20 (8 %) canceled their appointment and 58 (22 %) did not keep their appointment. Those who attended OCEANS were 38 % more likely to opt for a VBAC than those who did not attend. There was no difference in the rates of successful vaginal delivery between women who attended OCEANS and those who did not (56 vs. 61 %, p = 0.55).

Conclusions

While nurse-led prenatal education and support groups have no impact on mode of delivery after one CS, a dedicated obstetrician-led clinic increases the rate of those opting for VBAC by 38 %. Such clinics may be a useful tool helping in empowering women in their decision-making and reduce the rate of CSs.     

Emergency Peripartum Hysterectomy: A 13-Year Review at a Tertiary Center in Kuwait

Objective

To determine the incidence, indications, risk factors, and complications of emergency peripartum hysterectomy (EPH) and to evaluate total versus subtotal hysterectomy for EPH.

Materials and Methods

This is a retrospective case series involving thorough examination of the files of all women who had EPH between January 2000 and December 2012 in the department of Obstetrics and Gynecology, Al-Jahra hospital, Kuwait after taking approval from the ethics committee. Incidence, indications, risk factors, type of hysterectomy, and complications of EPH were obtained from patient files.

Results

There were 63,337 deliveries of which 70.3 % were vaginal deliveries, and 29.6 % were by cesarean section (CS). Sixty-eight women underwent EPH representing an overall incidence of 1 case per 1,000 deliveries. The indications for EPH included abnormal placentation (77.4 %), uterine atony (14.5 %), and uterine rupture (8.1 %). There was one maternal death. Maternal morbidity occurred in 25 (40.3 %) women. The most common complications were mild to severe coagulopathy (19.35 %) and injury to the urinary tract (17.74 %). Injury to the ureter was avoided by placing ureteric stents preoperatively. Our population was significant in having higher rate of CS deliveries (91.9 %), women with prior CS (83.87 %), and high parity (mean 5.8).

Conclusion

Abnormal placentation was the most common indication to perform EPH. The relative risk of EPH was 27 for CS deliveries as compared to vaginal deliveries. There was no significant difference between subtotal versus total hysterectomy with respect to age, parity, previous CS, operative time, blood transfusion, and intra and post operative complications.     

宫腔填塞联合米索前列醇预防高危因素剖宫产产后出血的临床疗效观察

目的:探讨宫腔填塞联合米索前列醇预防高危因素剖宫产产后出血的临床疗效。方法:有剖宫产产后出血高危因素产妇125例,随机分为A组(n=63)和B组(n=62)。A、B组所有患者均于胎儿娩出后给予子宫壁肌肉内注射缩宫素20 U、静脉滴注缩宫素10 U,手术结束后给予肛塞米索前列醇400μg。但A组另于胎盘娩出、宫腔清理后给予纱布填塞宫腔。观察术中、术后2 h、术后24 h出血量及手术时间、产褥感染、不良反应情况。结果:A组术中、术后2 h、术后24 h出血量分别为:150.3±42.3 ml,282.2±55.2 ml,355.8±92.5 ml;产后出血率为1.59%;B组术中、术后2 h、术后24 h出血量分别为:206.7±33.9 ml,456.2±75.3 ml,568.4±83.2 m1;产后出血率为12.90%;A组出血量及产后出血发生率明显低于B组(P0.05),而手术时间、产褥感染、不良反应情况组间无统计学差异(P0.05)。结论:宫腔填塞纱布联合米索前列醇预防高危因素剖宫产产后出血疗效显著,可明显减少产后出血发生率。