利托君对孕妇心脏储备功能影响的临床监测分析

目的:探讨利托君抑制宫缩时对孕妇心脏储备功能的影响.方法:2010年3～9月收治入重庆医科大学附属第一医院的符合先兆早产诊断的孕妇51例(用药组)与正常孕妇50例(对照组)作为研究对象.采用心音信号处理技术检测两组孕妇心脏储备功能各项指标,包括心率、第一心音幅值与第二心音幅值(S1/S2)比值、舒张期时限与收缩期时限(D/S)比值.用药组孕妇在用药前以及用药后5分钟、0.5小时、1小时、4小时、24小时各测量1次以上指标,然后隔日测量1次直到停止用药,数据取其均值.对照组只测量1次.比较用药前后及正常孕妇的血压和心脏储备功能指标的变化与用药时间的关系.结果:①用药组用药后孕妇的舒张压显著低于用药前和对照组,差异有统计学意义(P＜0.05);用药组用药后孕妇的心率和S1/S2比值均显著高于用药前和对照组,D/S比值显著低于用药前和对照组,差异均有高度统计学意义(P＜0.01).②利托君使用过程中孕妇的心率与S1/S2比值呈正相关(r=0.466,P＜0.05),与D/S比值呈负相关(r=-0.680,P＜0.01),当孕妇心率＞120/min时,D/S比值≤1.0的发生率为74.51％,孕妇心率≥140/min者有4例,D/S比值均≤0.8.③用药组用药24小时使用过程中孕妇心率的增加值随用药时间逐渐增大,并于用药后4小时达到最高值,用药后24小时心率增加值基本稳定.结论:利托君应用过程中随着孕妇心率的增加,心脏储备功能下降,应给予严密监测,以防发生妊娠不良结局.     

阿托西班、利托君治疗双胎晚期流产和早产的临床分析

目的：探讨阿托西班及利托君在双胎妊娠晚期流产和早产治疗中的临床价值。方法：回顾性分析郑州大学第二附属医院2015年1月-2017年1月收治的85例晚期流产及先兆早产的双胎妊娠孕妇,根据产妇使用宫缩抑制剂的情况分为阿托西班组20例,利托君组25例,利托君联合阿托西班组（联合用药组）40例。观察3组患者的保胎成功率、延长妊娠时间、新生儿情况、产后出血率及药物不良反应。结果：阿托西班组药物起效时间短,与其他两组比较差异有统计学意义（均P＜0.05）。3组孕妇抑制宫缩总有效率比较差异无统计学意义（χ2=0.30,P=0.86）。3组新生儿出生体质量、新生儿窒息率比较差异均无统计学意义（均P＞0.05）。3组患者无一例发生产后出血。白蛋白水平≤30 g/L、血红蛋白水平≤100 g/L、基础心率≥100次/min的患者出现利托君药物不良反应的风险大。结论：针对宫缩强、白蛋白水平≤30 g/L、血红蛋白水平≤100 g/L、基础心率≥100次/min的双胎孕妇可考虑阿托西班作为一线药物治疗。     

阿托西班、利托君治疗双胎晚期流产和早产的临床分析

目的:探讨阿托西班及利托君在双胎妊娠晚期流产和早产治疗中的临床价值。方法:回顾性分析郑州大学第二附属医院2015年1月—2017年1月收治的85例晚期流产及先兆早产的双胎妊娠孕妇,根据产妇使用宫缩抑制剂的情况分为阿托西班组20例,利托君组25例,利托君联合阿托西班组(联合用药组)40例。观察3组患者的保胎成功率、延长妊娠时间、新生儿情况、产后出血率及药物不良反应。结果:阿托西班组药物起效时间短,与其他两组比较差异有统计学意义(均P0.05)。3组孕妇抑制宫缩总有效率比较差异无统计学意义(χ~2=0.30,P=0.86)。3组新生儿出生体质量、新生儿窒息率比较差异均无统计学意义(均P0.05)。3组患者无一例发生产后出血。白蛋白水平≤30 g/L、血红蛋白水平≤100 g/L、基础心率≥100次/min的患者出现利托君药物不良反应的风险大。结论:针对宫缩强、白蛋白水平≤30 g/L、血红蛋白水平≤100 g/L、基础心率≥100次/min的双胎孕妇可考虑阿托西班作为一线药物治疗。     

妊娠期肝内胆汁淤积症胎儿胆汁酸水平与肺表面活性物质的相关性研究

目的 探讨妊娠期肝内胆汁淤积症(ICP)胎儿总胆汁酸水平与胎儿肺表面活性物质(PS)的关系.方法 选择2008年4月至2010年2月在中南大学湘雅二医院住院行剖宫产分娩的ICP孕妇55例(ICP组),记录ICP组孕妇的新生儿出生至产后7 d的一般情况,凡符合胎儿窘迫、新生儿窒息、新生儿呼吸窘迫综合征其中1项者为病理围产儿,无上述情况为正常围产儿.另选同期健康孕妇23例为对照组.采用循环酶法测定两组孕妇血、脐血及羊水中总胆汁酸水平;ELISA法测定两组胎儿脐血肺表面活性蛋白A(SP-A)水平;高效液相色谱法测定两组羊水中磷脂酰胆碱(PC)、磷脂酰肌醇(PI)、溶血卵磷脂(LPC)、神经鞘磷脂(SM)的含量.结果 (1)ICP组孕妇血、脐血及羊水中总胆汁酸水平分别为(30.1±7.9)、(9.3±3.3)及(4.4 ±1.5)mmol/L,明显高于对照组的(4.8±2.2)、(4.9±0.9)及(1.4±1.1)mmol/L,两组分别比较,差异均有统计学意义(P＜0.05).(2)ICP 组胎儿脐血SP-A水平为(29.5±6.4)μg/L,明显高于对照组的(22.6±7.4)μg/L,两组比较,差异均有统计学意义(P＜0.05).(3)ICP组中病理围产儿20例,健康围产儿35例,病理围产儿脐血总胆汁酸及SP-A水平分别为(10.9±2.2)mmol/L及(37.0±5.9)μg/L,健康围产儿分别为(8.0±2.8)mmol/L及(26.7±4.8)μg/L,两者比较,差异有统计学意义(P＜0.05).(4)脐血总胆汁酸水平分别与孕妇血、羊水总胆汁酸水平呈正相关(r1=0.706,r2=0.763,P＜0.05);脐血SP-A水平与脐血总胆汁酸水平呈正相关(r3=0.494,P＜0.05).(5)ICP组羊水中PC及PI的含量分别为(65.4±7.2)及(3.8±0.6)mg/L,均明显低于对照组的(69.7±3.7)及(4.3±0.7)mg/L,两组比较,差异有统计学意义(P＜0.05);ICP组羊水LPC的含量为(4.8±0.9)mg/L,明显高于对照组的(4.2±0.6)mg/L,两组比较,差异有统计学意义(P＜0.05);ICP组羊水SM的含量为(3.5±0.8)mg/L,与对照组的(4.0±0.5)mg/L比较,差异无统计学意义(P＞0.05).(6)ICP组羊水PC/LPC比值(14.2±3.2)明显低于对照组(16.9±2.5),差异有统计学意义(P＜0.05).(7)脐血总胆汁酸水平与羊水PC、PI的含量均呈负相关(r1=-0.561,r2=-0.407,P＜0.05);与LPC含量无相关性(r3=0.260,P＞0.05).结论 ICP孕妇的胎儿脐血及羊水中总胆汁酸水平均明显高于健康孕妇,其胎儿PS的改变与胎儿体内高总胆汁酸水平有关.

Abstract：

Objective To explore the relationship between total bile acid(TBA)concentration and fetal pulmonary surfactant in intrahepatic cholestasis of pregnancy(ICP).Methods Fifry five patients with ICP(ICP group)who received cesarean section from April 2008 to February 2010 in Second Xiangya Hospital,Central South University,were recruited.The general conditions of the neonates within 7 days after birth in ICP group were recorded.Those with fetal distress,neonatal asphyxia,or neonatal respiratory distress syndrome were referred as pathological neonates, others were referred as normal neonates. Over the same period, 23 healthy gravidas were recruited as control group. Enzymatic method was used to detect the TBA concentrations in maternal blood, cord blood and amniotic fluid. ELISA was employed to measure the urfactant protein A (SP-A) concentration in cord blood. High performance liquid chromatography system was used to detect the concentrations of phesphatidylcholine (PC),phosphatidylinositol (PI),lysophosphatidylcholine ( LPC), and sphingomyelin(SM) in amniotic fluid. Results ( 1 ) The concentrations of TBA in maternal blood, cord blood and amniotic fluid were ( 30. 1 ± 7.9 ), (9. 3± 3. 3 ) and (4. 4 ± 1.5 ) mmol/L in ICP group, (4. 8 ± 2. 2), (4. 9 ± 0. 9) and ( 1.4 v 1.1 ) mmol/L in control group, respectively. The differences between the two groups were significant ( P ＜ 0. 05 ). ( 2 ) The SP-A concentration in cord blood in ICP group was ( 29. 5 ± 6. 4 ) μg/L, significantly higher than that in control group, which was ( 22. 6 ± 7. 4 )μg/L ( P＜ 0. 05 ). ( 3 ) There were 20 pathological neonates and 35 normal neonates in ICP group. In pathological neonates, the concentrations of TBA and SP-A in cord blood were (10.9 ± 2.2) mmol/L,(37.0 ± 5.9 ) μg/L, respectively; and were ( 8.0 ± 2. 8 ) mmol/L, ( 26. 7 ± 4. 8 ) μg/L in normal neonates. The differences were significant (P＜ 0. 05 ). (4) There was a positive correlation between TBA concentration in cord blood and in maternal blood ( r1 = 0. 706, P＜0. 05 ). The TBA concentration in cord blood was positively correlated with SP-A concentration as well ( r3 = 0. 494,P ＜ 0. 05 ). (5) The PC and PI concentrations in amniotic fluid were (65.4 ± 7.2) mg/L and ( 3. 8 ± 0. 6 ) mg/L in ICP group, ( 69. 7 ±3.7) mg/L and (4. 3 ± 0. 7 ) mg/L in control group, respectively. The differences were significant (P ＜0. 05 ). The concentration of LPC in amniotic fluid in ICP group was (4. 8 ±0. 9) mg/L, significantly higher than that in control group (P＜0. 05), which was (4. 2 ±0. 6) mg/L. The concentration of SM in amniotic fluid was (3.5±0. 8) mg/L in ICP group, (4. 0 ± 0. 5 ) mg/L in control group, with no significant difference ( P＞0. 05 ). (6) The ratio of PC/LPC in ICP group ( 14. 2± 3. 2 ) was significantly lower than that in control group ( 16. 9 ± 2. 5 ) ( P＜ 0. 05 ). ( 7 ) The TBA concentration in cord blood was negatively correlated with PC and PI concentrations (r1 = -0. 561, r2 = -0. 407, P ＜ 0. 05 ), and had no correlation with LPC concentration (r3 = 0. 260, P＞ 0. 05). Conclusions ( 1 ) The fetal TBA concentrations in both cord blood and amniotic fluid of patients with ICP was higher than those of healthy gravidas, they were also positively correlated with maternal TBA concentration. (2) ICP resulted in the change of fetal pulmonary surfactant and this change was associated with TBA concentrations in both cord blood and amniotic fluid.     

孕妇心脏安全性评估新指标的研究

目的探索孕期妇女心脏安全性评估的新指标及心脏储备的变化。方法2008年于重庆大学生物工程学院,84名孕妇和71名非孕妇志愿受试者纳入研究。根据心脏储备的无创性监测方法,测量、计算和分析孕妇与非孕妇的心率、第1与第2心音幅值之比(S1/S2)、舒张期与收缩期的时限之比(D/S)。结果研究组孕妇的心率[(95.24±12.80)/min]与S1/S2(2.14±0.83)均比对照组妇女[(75.97±9.78)/min、1.84±0.86]升高,差异均有统计学意义(P<0.05);但研究组D/S(1.24±0.21)比对照组(1.57±0.32)降低,差异有统计学意义(P<0.05)。结论孕妇在妊娠这一应激过程中动用了心脏储备,导致心脏负担加重。上述新指标的研究将有益于孕期妇女心脏安全性的评估。     

麦角新碱联合卡贝缩宫素与单用缩宫素预防剖宫产产后出血研究

目的比较麦角新碱联合卡贝缩宫素与单用缩宫素预防剖宫产产后出血的效果。方法采用真实世界研究方法,回顾性分析四川大学华西第二医院2017年1—12月收治的择期剖宫产孕妇424例。根据胎儿娩出后用药情况分为两组:给予麦角新碱联合卡贝缩宫素为研究组(208例),单用缩宫素为对照组(216例)。结果研究组术中额外用药率为2.4%,明显低于对照组22.2%,差异有统计学意义(P0.05)。研究组手术前后血红蛋白及红细胞压积分别为(126.9±9.9)g/L、(123.1±10.9)g/L及0.38±0.03、0.37±0.03,对照组分别为(126.6±12.1)g/L、(123.9±14.3)g/L及0.38±0.03、0.37±0.04,两组比较差异均无统计学意义(P0.05)。两组孕产妇失血量及按照单一合并症及并发症(妊娠期肝内胆汁淤积症、胎膜早破、妊娠期糖尿病、瘢痕子宫、胎盘粘连)估计失血量,两组比较差异均无统计学意义(P0.05);而严重产后出血率(出血量大于1000m L)研究组为1.4%,对照组为3.2%,两组之间的差异有统计学意义(P0.05)。结论麦角新碱联合卡贝缩宫素预防剖宫产严重产后出血及减少术中额外使用宫缩剂的效果较显著。     

妊娠期糖尿病合并慢性高血压孕妇胰岛素抵抗水平及其对妊娠结局的影响

目的探讨妊娠期糖尿病(gestational diabetes mellitus,GDM)合并慢性高血压(chronic hypertension,CHT)孕妇的胰岛素抵抗(insulin resistance,IR)水平及其对妊娠结局的影响。方法本研究为回顾性病例对照研究。纳入2014年1月1日至2016年12月31日在北京大学第一医院规律产前检查并参加GDM一日门诊的单胎妊娠GDM孕妇2457例。回顾临床资料,采用稳态模型评估IR水平(homeostasis model assessment insulin resistance,HOMA-IR)。根据GDM孕妇是否合并CHT分为GDM合并CHT组(n=47)和GDM未合并CHT组(n=2410),并进一步根据孕前体重指数(body mass index,BMI)分为孕前BMI正常组(n=1590)及孕前超重和肥胖组(n=863)进行分层分析。采用两独立样本t检验、χ2检验分析组间孕妇年龄、HOMA-IR、孕前BMI、孕期增重、血糖等临床特征的差异。采用logistic回归模型分析HOMR-IR水平对妊娠结局的影响。结果合并CHT的GDM孕妇HOMA-IR(3.5±1.8与2.6±1.5,t=-3.290)、空腹血浆葡萄糖[(5.4±0.5)与(5.2±0.5)mmol/L,t=-3.005]、孕前BMI[(26.7±4.7)与(23.3±3.4)kg/m2,t=-4.842]以及发生子痫前期的比例[14.9%(7/47)与2.5%(61/2410),χ2=21.790]高于未合并CHT的GDM孕妇,但孕期增重少于未合并CHT者[(9.6±5.8)与(12.2±4.7)kg,t=3.790](P值均<0.01)。根据孕前BMI分层后,超重和肥胖孕妇中,GDM合并CHT组子痫前期的比例高于GDM未合并CHT组[15.2%(5/33)与4.2%(35/830),χ2=6.290,P=0.012],但HOMA-IR差异无统计学意义(P>0.05);而对于孕前BMI正常的孕妇,GDM合并CHT组HOMA-IR(3.0±1.5与2.3±1.2,t=-2.217)、空腹血浆葡萄糖[(5.4±0.5)与(5.1±0.5)mmol/L,t=-2.299]和子痫前期的比例[2/14与1.6%(26/1576),χ2=6.545]均高于未合并CHT组(P值均<0.05)。对于GDM合并CHT孕妇,HOMA-IR水平不会增加剖宫产、早产、大于胎龄儿、小于胎龄儿和巨大儿的发生风险(P值均>0.05)。控制年龄、空腹血浆葡萄糖、孕前BMI、孕期增重后,对于未合并CHT的GDM孕妇,HOMA-IR水平的增加会使早产的发生风险增加(OR=1.223,95%CI:1.093~1.369,P<0.001)。结论GDM合并CHT孕妇胰岛素抵抗程度更重,子痫前期的发病率更高,但其他不良妊娠结局的发生风险未见增加。     

早发型重度子痫前期孕妇期待治疗中不良妊娠结局的危险因素分析

目的 探讨早发型重度子痫前期孕妇实施期待治疗过程中发生不良妊娠结局的危险因素.方法 选择2007年1月至2008年6月在首都医科大学附属北京妇产医院住院的早发型重度子痫前期并实施期待疗法的孕妇136例.按照妊娠结局分为良好结局组101例和不良结局组35例.采用回顾性分析方法,分析两组孕妇人院时的一般资料、妊娠结局、尿常规、血流动力学及血常规指标、肝肾功能,另分析不良妊娠结局的危险因素.结果 (1)一般资料:良好结局组与不良结局组孕妇入院时出现子痫前期症状的发生率(分别为35.6%及57.1%)比较,差异有统计学意义(P<0.05).两组孕妇年龄、孕次、孕前体质指数、入院时并发症发生率及规律产前检查率比较,差异均无统计学意义(P>0.05).(2)妊娠结局:良好结局组孕妇期待疗法平均天数为(6.5±8.2)d,不良结局组平均为(6.8±10.0)d,两组比较,差异无统计学意义(P>0.05).不良结局组孕妇主要并发症为胎盘早剥13例,心功能衰竭及肺水肿10例,溶血、肝酶升高和低血小板计数(HELLP)综合征5例,胎死宫内5例,无子痫发生.良好结局组孕妇均无以上并发症发生.(3)期待疗法中发病孕周及分娩孕周、血压及尿蛋白比较:良好结局组的发病孕周及分娩孕周[分别为(33.0±4.9)及(34.0±3.6)周]明显晚于不良结局组[分别为(31.3±3.4)及(32.1±3.0)周],收缩压及尿蛋白定量明显低于不良结局组.良好结局组中尿蛋白定性(+++)比例明显低于不良结局组.以上指标两组比较,差异均有统计学意义(P<0.05).(4)血流动力学及血常规:良好结局组孕妇血液黏度[(4.6±0.4)mPa·s]明显低于不良结局组,两组比较,差异有统计学意义(P<0.05).而心输出量、心脏指数、外周阻力及血管顺应性等指标在两组孕妇中比较,差异均无统计学意义(P>O.05).良好结局组孕妇血小板计数[(189±69)×10~9/L]明显高于不良结局组,而红细胞计数[(3.9±0.5)×10~(12)/L]和红细胞压积(0.34±0.05)却明显低于不良结局组.两组比较,差异均有统计学意义(P<0.01).(5)肝肾功能:良好结局组孕妇丙氨酸氨基转移酶[ALT,(18±12)U/L]、天冬氨酸氨基转移酶[AST,(24±9)U/L]、乳酸脱氢酶[LDH,(175±53)U/L]及尿素氮[BUN,(4.6±1.8)mmol/L,]水平明显低于不良结局组.两组比较,差异均有统计学意义(P<0.05).而血浆总蛋白(TP)、血浆白蛋白(Alb)、尿酸(UA)及血肌酐(cr)水平在两组中比较,差异均无统计学意义(P>0.05).(6)不良结局的危险因素分析:进入logistic回归方程的自变量分别为红细胞计数(OR值为3.68,P=0.000),血小板计数(OR值为0.99,P=0.006)及分娩孕周(OR值为0.87,P=0.001).显示红细胞计数越高,则在期待疗法中越有可能出现不良妊娠结局;血小板计数越低、分娩孕周越早,则提示期待疗法中愈易出现不良妊娠结局.结论 红细胞计数升高、血小板计数降低及分娩孕周过早,是早发型重度子痫前期孕妇实施期待疗法过程中发生不良妊娠结局的危险因素.     

两种不同药物干预孕期缺铁性贫血的随机对照试验研究

目的:比较琥珀酸亚铁及蚕砂提取物对缺铁性贫血(IDA)孕妇的治疗效果。方法:纳入2018年7月至2019年2月于上海交通大学医学院附属仁济医院正规产前检查的IDA孕妇160例,琥珀酸亚铁组及蚕砂提取物组按1∶1比例分配每组各80例,采用前瞻性随机对照研究并在用药后随访3个月。每月随访1次血红蛋白(Hb)、铁蛋白(SF)、血清铁(SI)、转铁饱和度(TS)值,观察两种药物的治疗效果及副反应。结果:①琥珀酸亚铁组患者的Hb、TS值在用药后1～3月均较入组时明显升高(P0.05);SF、SI值在用药2个月、3个月后明显高于入组时(P0.05)。蚕砂提取物组患者在用药2个月、3个月后的Hb值明显高于入组时(P0.05),在用药3个月后的SF值明显高于入组时(P0.05);而SI、TS值在入组时、用药1个月、2个月、3个月后4个检测时间点比较,差异均无统计学意义(P0.05)。②除琥珀酸亚铁组在用药1个月后,其SI增量与蚕砂提取物组间差异无统计学意义(P0.05)之外,用药1～3个月后Hb、SF、SI及TS增量在琥珀酸亚铁组均明显高于蚕砂提取物组(P0.05)。③在用药3个月后,琥珀酸亚铁组患者的治疗有效率显著高于蚕砂提取物组(86.3%vs 50.0%,P0.05),维持用药率明显低于蚕砂提取物组(8.8%vs 47.5%,P0.05)。④琥珀酸亚铁组患者用药后出现恶心、呕吐、胃部烧灼感、黑便、铁锈味等副反应比例显著高于蚕砂提取物组(P0.05)。两组患者用药后便秘及腹泻的副反应发生比例差异无统计学意义(P0.05)。结论:在治疗IDA中,琥珀酸亚铁的疗效优势显著高于蚕砂提取物。琥珀酸亚铁的明显起效时间为用药后2个月,而蚕砂提取物的明显起效时间为用药后3个月。琥珀酸亚铁的部分副反应比例高于蚕砂提取物。     

妊娠期糖尿病孕妇耐量试验分项指标异常对血脂及胎儿生长发育的影响

目的探讨妊娠期糖尿病(gestational diabetes mellitus,GDM)孕妇口服葡萄糖耐量试验(oral glucose tolerance test,OGTT)不同血糖指标异常对血脂及胎儿生长发育的影响。方法收集2020年1月1日至2020年6月30日在重庆市妇幼保健院产前检查,符合条件的足月、单胎分娩的3120例孕妇资料,根据OGTT结果分为血糖正常组2679例,GDM组441例。441例中仅空腹血糖异常为GDM-A组96例(21.77%)、空腹血糖正常而餐后任一时间点血糖异常为GDM-B组240例(54.42%),空腹血糖异常合并餐后任一时间点血糖异常为GDM-C组105例(23.81%),比较各组孕妇体重指数(BMI)、孕期增重、血脂及新生儿生长指标等。结果 (1)GDM组孕妇年龄大于血糖正常组[(30.46±3.89)岁vs.(29.06±4.18)岁,P=0.002]、孕前BMI也大于血糖正常组(23.29±3.69 vs. 22.09±3.35,P0.001);GDM-A、B、C组的年龄、孕前BMI呈逐渐升高趋势,3组比较,差异均有统计学意义(P=0.004);GDM组中,GDM-B组孕期增重大于GDM-A组、GDM-C组[(13.13±4.61)kg vs.(12.54±4.03)kg、(10.26±4.32)kg,P0.001]。(2)GDM组甘油三酯水平明显大于血糖正常组[(5.64±3.19)mmol/L vs.(4.13±1.42)mmol/L,P0.001];GDM-C组甘油三酯水平明显大于GDM-A组、GDM-B组[(6.97±5.74)mmol/L vs.(4.19±3.21)mmol/L、(5.64±5.13)mmol/L,P0.001];GDM-B组低密度脂蛋白水平大于GDM-A组、GDM-C组[(3.24±0.99)mmol/L vs.(2.71±0.67)mmol/L、(2.96±1.03)mmol/L,P=0.003]。(3)GDM组新生儿体重稍大于血糖正常组,但差异无统计学意义(P0.05),两组间巨大儿发生率分别为8.62%(38/441)、6.08%(163/2679),差异有统计学意义(P=0.046)。GDM组新生儿胸围大于血糖正常组[(33.24±1.07)cm vs.(32.75±1.07)cm,P0.001],胸/头围比值也大于正常血糖正常组(0.958±0.191 vs. 0.950±0.019,P=0.009)。GDM-C组新生儿出生体重、胸围、胸/头围均大于GDM-A、GDM-B组,差异有统计学意义(P值分别为0.015、0.001和0.001)。结论 OGTT试验空腹血糖与餐后血糖均异常的孕妇较空腹血糖或餐后血糖单项异常的孕妇对血脂水平及胎儿的生长发育影响更大。     

Terbutaline versus nifedipine for prolongation of pregnancy in patients with preterm labor.

OBJECTIVE: To compare the effectiveness, safety, and possible adverse effects of terbutaline and nifedipine in prolonging pregnancy beyond 48 h. METHODS: A randomized controlled trial was conducted with 174 pregnant women admitted with preterm labor randomized into 2 groups, which were given terbutaline (95 patients) and nifedipine (79 patients), respectively. Bivariate and multivariate analyses, using logistic regression, were used to analyze the data. RESULTS: No statistically significant difference was found between the 2 groups in terms of prolongation of gestation to 48 h. The failure rate in terms of prolonging gestation for 24 h was found to be 12.6% for the terbutaline group and 10.1% for the nifedipine group, which was not found to be statistically significant (P value=0.61). Side effects were significantly more common in the terbutaline group, except for maternal hypotension. CONCLUSION: Terbutaline and nifedipine appear to be equally effective in their tocolytic action. However, nifedipine did have the advantage of ease of administration. It also had significantly less effect on the fetal heart rate.     

Successful prenatal treatment of congenital heart block with ritodrine administered transplacentally

Congenital heart block (CHB) is rather rare, and a poorer prognosis has been documented in fetuses with a ventricular rate <55 beats per minutes (bpm), in which therapeutic interventions during pregnancy have been warranted. We present a case of CHB associated with maternal anti-SSA/Ro antibody, diagnosed at 28 weeks’ gestation. Fetal echocardiography revealed atrioventricular dissociation, with an atrial rate of 170 bpm and a ventricular rate of 54 bpm. To increase the fetal heart rate, maternal intravenous ritodrine infusion was undertaken, fetal ventricular rate was rapidly increased to 65 bpm. The pregnancy successfully continued until term, and a female infant weighing 2919 g was delivered by cesarean section with Apgar scores of 8 and 8 and 1 and 5 min. The infant is now 12 months of age and growing normally on oral terbutaline without pacing. In a case of fetal heart block, maternal administration of ritodrine may be a therapeutic intervention to improve the fetal and neonatal prognosis. Received: 27 May 2001 / Accepted: 20 August 2001 Correspondence to H. Matsushita     

Terbutaline Tocolysis Prior to Cesarean Section for Fetal Distress

Two hypotheses are examined: l) side effects of terbutaline tocolysis are limited to maternal tachycardia and 2) terbutaline tocolysis at the diagnosis of fetal distress will facilitate intrauterine resuscitation while preparation for cesarean delivery is underway. This is a 10-year chart review of terbutaline tocolysis as part of the management of acute fetal distress prior to cesarean delivery. All charts were reviewed for side effects of terbutaline use. During the final 27 months, efficacy of terbutaline resuscitation was studied by comparing the scalp-pH-to-cord-pH difference of individual fetuses in the terbutaline group with those where terbutaline was not used. The mean maternal pulse after terbutaline was 113 ± 20 (SD) beats per minute (bpm). A pulse of ≥140 bpm occurred in 11.7% of the terbutaline group (n = 368). A pulse of ≥140 bpm was more common (51.0%) when preoperative vagolytic medication (n = 119) was also administered. A pulse of ≥140 bpm occurred in 1.9% of the control group (n = 215). Mean arterial pressure was not changed by terbutaline, even in the presence of preeclampsia. Of those in the terbutaline group with a scalp pH value <7.25, there were significantly fewer low, 5-min Apgar scores; fewer fetuses demonstrating a fall in pH between the paired scalp and cord values; and a greater mean pH increase than in the respective control group. Of strong clinical pertinence is that the fetuses with the lowest scalp pH had the greatest increase in pH value. Our study supports the safety and efficacy of intrauterine resuscitation by terbutaline tocolysis.     

Single injection of terbutaline in term labor. I. Effect on fetal pH in cases with prolonged bradycardia

Thirty-three patients with prolonged fetal bradycardia (fetal heart rate baseline less than 100 bpm for a minimum of 3 minutes or less than 80 bpm for at least 2 minutes) in labor were studied. They were treated with a bolus injection of terbutaline if the bradycardia persisted at less than 80 bpm for 2 minutes and other efforts to improve the fetal heart rate (oxygen, positional changes) had failed. After the bolus injection a scalp blood pH (or a cord arterial pH in abdominal deliveries) was obtained within 30 minutes. Fetal acidosis was common if the bradycardia lasted 10 minutes or more, particularly if the rate was less than 80 bpm with a flat baseline for 4 minutes or more. The fetal heart rate improved after injection in 30 cases; 23 patients had vaginal delivery of infants in good condition. Ten underwent cesarean section: three for no improvement in fetal heart rate, two for cord prolapse, four for later ominous fetal heart rate, and one for failure to progress. These results suggest that tocolysis in selected cases can be of benefit for the fetus with prolonged bradycardia. In cases with an ominous fetal heart rate pattern preceding the bradycardia and in abruptio placentae immediate operative intervention without delay is probably better. Administration of terbutaline should be regarded as a temporary measure until it is apparent that the fetal heart rate has recovered. Preparation for emergency delivery should be made while a recovery is awaited.     

Terbutaline: effects on the fetal heart at term

The aims of this study were to evaluate the cardiac effects of subcutaneous terbutaline on the mother and fetus. Terbutaline was given in 250 or 500 μg doses to term gravidas not in labor. The mean arterial pressure (MAP), pulse, and uterine activity were measured. The fetal heart rate (FHR), accelerations, and decelerations were recorded. There were significant increases in maternal heart rate, FHR, and FHR accelerations, and a decrease in uterine basal activity after 500 μg, but not significantly after 250 μg of terbutaline. MAP was not significantly increased with either dose, although a small mean increase was observed. Terbutaline has a direct effect on the fetal heart apart from the effect of uterine relaxation.     

Beta 1-, beta 2-effects of ritrodine and terbutaline in the treatment of preterm labor (author's transl)

beta 2-Stimulants are at present the most effective tocolytic agents. The aim of the study was to evaluate the beta 1- . beta 2-effects of terbutaline and ritodrine in the treatment of preterm labor. 1) Terbutaline, administered intravenously at a rate of 0.4-1.2 microgram/min, and ritodrine also at a rate of 50-300 microgram/min, effectively inhibited uterine activity during 180 minutes. Among the patients there was no difference in responses between those who received terbutaline and ritodrine. 2) The levels of c-AMP and c-GMP in the blood after administration of terbutaline or ritodrine increased and showed dose-response. The levels of c-AMP during a 180-minute infusion increased from 15 to 27 pmol/ml. 3) The action of c-AMP related substances on the circulatory systems was manifested as the dose-response of beta 1 action to the maternal blood pressure, maternal and fetal heart rate. Both beta 2-stimulants produced a tolerable changes in maternal heart rate and blood pressure, no significant changes during the infusion.     

Intrapartum vibratory acoustic stimulation of the human fetus during episodes of decreased heart rate variability

The effects of intrapartum vibratory acoustic stimulation during periods of decreased fetal heart rate variability were studied in 25 healthy term fetuses. Fetal monitoring and real-time ultrasound scanning were used simultaneously to detect fetal response. Vibratory acoustic stimulation was provided by an artificial larynx generating a signal at 85 dB and 85 Hz. This stimulus was applied for 5 seconds on the maternal abdomen over the fetal head after a 20-minute period of decreased fetal heart rate variability. All fetuses reacted with an immediate fetal heart rate acceleration of at least 10 bpm (range: 10 to 35 bpm, mean +/- SD = 18.4 +/- 7.0), and 19 fetuses also had sudden fetal body movement. A deceleration of the fetal heart rate after the initial acceleration was observed in nine fetuses (range: 15 to 70 bpm, mean +/- SD = 45.5 +/- 16.5). The implications of these findings are discussed in relation to the possible use of fetal vibratory acoustic stimulation for intrapartum surveillance.     

Intrauterine resuscitation with terbutaline: a method for the management of acute intrapartum fetal distress

Terbutaline, a selective beta-2 adrenergic receptor stimulator, has been used to decrease myometrial activity and improve uteroplacental blood flow in 15 patients with acute intrapartum fetal distress. In all cases electronic monitoring gave evidence of partial or total fetal recovery after therapy. Thirteen of these patients were delivered by cesarean section and two were allowed to resume labor and deliver vaginally. In 10 cases the initial Apgar score was 7 or more and in all cases the score was 7 or more after 5 minutes of life. No significant maternal morbidity occurred as a consequence of the treatment. These results suggest that inhibition of uterine activity with terbutaline may be a valuable maneuver in the management of patients with severe intrapartum fetal distress.     

Terbutaline (intravenous bolus) for the treatment of acute intrapartum fetal distress

beta 2-Sympathomimetics have been used in acute intrapartum fetal distress to abolish uterine contractions and thus enable the fetal metabolism to recover before delivery. Because some serious complications were reported when a terbutaline intravenous bolus (0.25 mg) was used as a tocolytic, we assessed its safety and efficacy when used in patients not affected by cardiovascular disease, tachycardia greater than 100 beats/min, thyrotoxicosis, fluid overload, corticoids, atropine, or severe abruptio placentae. No maternal or fetal complications occurred in the 36 patients studied; a well-tolerated tachycardia developed in most patients. Fetal heart rate tracings and pH improved in 32 patients. Thirty-four neonates were delivered in good clinical and metabolic condition. We conclude that terbutaline intravenous bolus 0.25 mg is a safe and efficacious procedure when the proper indications and contraindications are followed.