胎膜早破性早产儿妊娠结局的研究

目的探讨胎膜早破性早产(preterm premature rupture of membranes,PPROM)儿的妊娠结局。方法对312例PPROM的孕妇及其分娩的320例早产儿进行回顾性分析,对不同潜伏期的新生儿结局,孕28～33+6周与孕34～37周胎膜早破性早产儿情况进行比较分析。结果潜伏期平均为30 h,新生儿死产,死亡,感染的发生率在破水时间超过40h组大于破水时间在40h内者,有统计学差异(P<0.05)。孕28～33+6周与孕34～37周间PPROM分娩方式的比较,无统计学差异(P>0.05)。孕28～33+6周PPROM新生儿呼吸窘迫综合征(neonatal respiratory distress syndrom,NRDS)的发生率和死亡率明显高于孕34～37周者(P<0.01)。80%PPROM新生儿死亡发生在32周之前。结论 PPROM的潜伏期尽量控制在40小时内,孕28～34周PPROM宜采取期待疗法,以减少新生儿合并症的发生。对于孕周小者,尽量延长孕周至32周以上,最好达到34周,以降低新生儿死亡率。     

36例多胎妊娠新生儿预后及其影响因素的分析

目的分析多胎妊娠新生儿预后及影响预后的因素。方法对我院近五年36例多胎妊娠的新生儿预后资料及其影响因素进行回顾性分析。结果（1）5年孕妇总数2665例,双胎妊娠33例,发生率为1.238%。3胎妊娠3例,发生率为1.125‰。（2）双胎早产率27.28%,3胎早产率100%。（3）双胎新生儿窒息18.18%（Apgar评分≤7）,3胎新生儿窒息77.78%（Apqar评分≤7）。（4）二次住院保胎率,双胎90.90%,3胎100%。建卡率均为100%。（5）双胎平均分娩孕周为37＋2w,剖宫产率78.79%,新生儿体重平均（2415±955）g。3胎平均分娩孕周为34＋4w,剖宫产率100%,新生儿体重平均（2000±1000）g。结论多胎妊娠发生率有所提高。加强围产期高危监护,实行孕期住院保胎,仍是提高多胎妊娠分娩孕周、新生儿体重,降低早产率、新生儿窒息率的有效方法。     

双胎妊娠-胎宫内死亡20例临床分析

目的探讨双胎妊娠-胎宫内死亡的原因、临床处理及预后。方法回顾性分析1994年3月至2008年2月北京大学第三医院双胎妊娠-胎宫内死亡的病例共20例。结果双胎-胎宫内死亡的发生率为3．2％,其中双卵双胎17例,单卵双胎3例。28w前发现-胎宫内死亡者6例,平均期待治疗95．8天,平均分娩孕周为34．4w（32^＋4-39w）;28w后发现-胎宫内死亡者14例,平均期待治疗10．1天,平均分娩孕周为34．6w（29^＋4-39^＋2w）;仅2例新生儿发生轻度窒息。无一例孕妇发生凝血功能障碍。追踪新生儿6月至14年,1例新生儿因合并隐性脊柱裂及早产原因早期死亡,1例患儿3岁时发生运动障碍性脑瘫（分娩孕周为29^＋6w）,4例失访,其余均健康存活。结论双胎妊娠-胎宫内死亡后可采取期待治疗,严密监测存活胎儿宫内状况,尽量延长孕周,可提高存活胎儿的生存质量。     

妊娠合并宫颈浸润癌14例临床分析

 目的 分析妊娠合并宫颈浸润癌患者的临床特点、治疗方案及母婴结局。方法 回顾性分析自2005年1月至2012年1月北京协和医院收治的妊娠合并宫颈浸润癌患者14例,总结其临床特点、治疗方案及生存情况。结果 14例患者中肿瘤诊断时早孕期4例（29%）,中孕期7例（50%）,晚孕期3例（21%）。所有早孕期（4/4,100%）及绝大部分中孕期（6/7,86%）患者一经诊断即放弃胎儿开始规范肿瘤治疗,1例中孕27周的ⅠB1期患者延迟治疗至孕37周行剖宫产,产后42天行宫颈锥切术;3例晚孕期患者中,1例延迟治疗3周至孕32周行剖宫产后开始肿瘤治疗,1例先期化疗1程后于孕34周剖宫产分娩后开始肿瘤治疗,1例孕33+6周的ⅡA2期患者行剖宫产分娩后直接放化疗。14例患者中2例失访,7例无瘤生存,5例复发死亡,中位无瘤生存时间为10个月（6-57）,3年及5年无瘤生存率分别为70.1%及46.8%。分别计算不同孕期、肿瘤分化程度、肿瘤大小、肌层浸润深度患者5年无瘤生存率,Log-rank检验显示差异无统计学意义。本研究共分娩4例新生儿,3例存活。结论 本研究妊娠期宫颈癌的特点是虽然大部分有出血症状但仍诊断较晚,预后与国外研究相比差,应加强孕期宫颈细胞学筛查及阴道检查;采用个体化治疗方案,尝试了根治性宫颈切除、孕期NACT及延迟治疗等方法,获得了良好的母婴结局,但仍需提高早产儿的救治水平。     

肾病综合征型妊娠高血压疾病43例临床分析

目的探讨肾病综合征型妊娠期高血压疾病的临床特点和治疗。方法对中山市陈星海医院2000年6月-2006年6月收治的肾病综合征型妊娠期高血压疾病患者43例（按终止妊娠时孕周分为A组：孕周≤33w 12例,B组：33^1/7-36w17例,C组：≥36^1/7 w14例）及其新生儿46例进行回顾性分析,观察指标包括患者临床表现、治疗方法、并发症及预后、围产儿结局。结果肾病综合征型妊娠高血压疾病除具有妊娠期高血压疾病的特点外,主要表现为大量蛋白尿（〉3.5g/24h）、低蛋白血症（〈30g/L）、高度水肿及高脂血症,可出现严重并发症。治疗以综合治疗为主,并适时终止妊娠。围产儿结局较差,各组比较B组较A、C组好（P〈0.05）。结论肾病综合征型妊娠高血压疾病病情严重,围产儿预后不佳,应选择病例予综合治疗,并要严密监测母婴情况,适时终止妊娠可改善母婴预后。     

825例重度子痫前期患者的分娩时机与围产儿结局分析

目的探讨重度子痫前期孕妇的分娩时机及新生儿的结局。方法对825例重度子痫前期的患者,根据病情进一步治疗,期待治疗和终止妊娠,分析不同治疗方法的预后。结果孕周〉32周的新生儿和围产儿病死率低于32周前终止妊娠者,（P〈0.01）结论孕周已近34周的重度子痫前期患者,经促胎肺治疗后即可终止妊娠。而孕32周之前的重度子痫前期患者,在严密监测下尽量延长孕周,以增加胎儿的成熟度并不增加母亲并发症。     

替比夫定联合乙肝免疫球蛋白阻断HBV母婴传播疗效研究

目的 探讨替比夫定阻断HBV母婴垂直传播的疗效.方法 收集2007年11月至2009年6月在杭州市第六人民医院就诊的64例孕妇,将其分为对照组（36例）和治疗组（28例）,2组孕妇在妊娠第28、32和36周均肌注HBIG 200IU各1次,治疗组孕妇在孕28周时同时口服替比夫定,600 mg/d,观察2组新生儿HBV DNA载量和HB8Ag水平.结果 对照组所生新生儿HBsAg阳性率为30.56%（11/36）,治疗组所生新生儿HBsAg阳性率为7.14%（2/28）,2组相比差异有统计学意义（χ^2=3.985,P=0.046）,对照组所生新生儿HBV DNA阳性率为16.67%（6/36）,治疗组所生新生儿HBV DNA阳性率为0,2组比较差异具有统计学意义（P＜0.05）.所有孕妇及新生儿在治疗期间未出现不良反应.结论 替比夫定在一定程度上可以降低HBV母婴垂直传播的风险.     

干预性早产的临床分析与探讨

目的 分析及探讨干预性早产的因素构成、分娩时机的选择、新生儿预后。方法 对本院33例干预性早产者的早产因素构成、不同孕周新生儿并发症进行临床分析。结果 干预性早产最常见因素为妊高征(48．48％)；其次为前置胎盘(24.24％)、试管婴儿合并多胎妊娠(15．15％)，以及妊娠合并内科疾病：心脏病、肾炎等。RDS仅发生于孕周小于32w者，出生时窒息多见于孕周32—34w。肺炎、颅内出血、新生儿黄疸可发生于各个孕周。结论 干预性早产最常见因素为妊高征、其次为前置胎盘、试管婴儿合并多胎妊娠；分娩时间以治疗后选择34—36w为最佳，早产儿常见并发症以呼吸系统疾病常见，产前促胎肺成熟极为重要。     

孕34-36~(+6)周胎膜早破母儿预后的影响因素

目的研究妊娠34-36~(+6)周胎膜早破妇女及其新生儿预后的影响因素。方法对孕34-36~(+6)周胎膜早破者按是否合并绒毛膜羊膜炎分组。统计产妇年龄,产次,破水孕周,破水至分娩时间间隔,产前激素、抗生素治疗情况,产前白细胞计数,分娩方式,新生儿性别、体重、收住院情况,分析新生儿住院的影响因素。结果 56例妊娠34-36~(+6)周胎膜早破妇女中绒毛膜羊膜炎发生率为10.7%。合并绒毛膜羊膜炎组的新生儿住院率与无绒毛膜羊膜炎组的相比有显著差异(P=0.034)。剖宫产率、产后住院日、新生儿的体重、性别、新生儿窒息的发生率在2组间无显著差异。Logistic同归分析提示,新生儿体重为新生儿住院的有效白变量(P=0.035)。结论妊娠34-36~(+6)周的胎膜早破妇女合并绒毛膜羊膜炎和低出生体重是新生儿住院治疗的风险因素。     

早发型重度子痫前期的临床分析

目的 探讨早发型重度子痫前期对围生期母婴预后的影响.方法 对2003年2月至2006年2月3年中84例早发型重度子痫前期病例进行分析根据其发病孕周分为3组,即A组（孕周＜28w）,B组（28孕周≤孕周＜32孕w）,C组（32孕周≤孕周＜34孕w）.观察发病情况、病情特点及母婴并发症.结果 早发型重度子痫前期3组患者并发症发生率无统计学意义;3组间新生儿窒息率和围产儿死亡率均随孕周延长而下降,且3组间差异均有统计学意义（P＜0.05）;B组期待治疗时间均明显长于其他两组（P＜0.05）.各组患者的分娩方式均以剖宫产为主.结论 早发型重度子痫前期有较高的母婴病死率,是重度子痫前期的一种特殊类型,在期待治疗过程中,应严密监护母婴情况,适时终止妊娠,终止妊娠方式首选剖宫产.     

IL-6、MMP-9、TNF-α在胎膜早破早产孕妇血清、羊水中的表达及意义

目的研究IL-6、MMP-9、TNF-α在未足月胎膜早破早产孕妇的血清、羊水中的含量及表达,探讨其与胎膜早破早产的关系。方法采用酶联免疫吸附法检测30例胎膜早破早产孕妇（PPROM组）与20例正常孕妇（对照组）血清和羊水中的IL-6、MMP-9、TNF-α的含量,同时进行胎膜的病理检查。结果 PPROM组母血清及羊水中IL-6、MMP-9的含量均高于对照（P〈0.05）,羊水中TNF-α的含量较对照组高（P〈0.05）。PPROM组绒毛膜羊膜炎者血清、羊水中IL-6、TNF-α（P〈0.05）、MMP-9（P〈0.01）水平均高于非绒毛膜羊膜炎者。结论孕妇血清、羊水中IL-6、MMP-9、TNF-α水平与PPROM感染引起的早产有关,检测其水平可作为PPROM良好的预测指标。     

Interleukin-6 as a predictor of subclinical chorioamnionitis in preterm premature rupture of membranes

Citation Gulati S, Bhatnagar S, Raghunandan C, Bhattacharjee J. Interleukin‐6 as a predictor of subclinical chorioamnionitis in preterm premature rupture of membranes. Am J Reprod Immunol 2012; 67: 235–240 Problem One of the major challenges faced by the clinicians in preterm premature rupture of the membranes (PPROM) is to correctly identify when a significant chorioamnionitis is evolving and decide timely delivery of the fetus. Measuring interleukin‐6 levels in maternal serum can be useful for the identification of asymptomatic intrauterine infections in subjects with PPROM. Method of study A total of 75 pregnant women, of which 45 pregnant women presenting with PPROM between 24 and 34 weeks gestation and 30 healthy pregnant women without PPROM, were included in the study. Serum IL‐6 levels were determined by solid‐phase sandwich enzyme‐linked immunosorbent assay (Diaclone Research, Besancon, France). Results The mean serum IL‐6 value at admission in the control group was 2.48 ± 2.7 pg/mL and in the study group was 11.86 ± 14.5 pg/mL (P = 0.001). Mean serum IL‐6 concentrations at admission in subjects without histological chorioamnionitis were 3.98 ± 3.9 pg/mL and in those who had histological chorioamnionitis were 20.09 ± 16.8 pg/ml (P < 0.001). Conclusion Maternal serum IL‐6 levels were significantly elevated in subjects with PPROM with infectious morbidity as compared to those without infectious morbidity in the present study. There was a significant rise in maternal serum IL‐6 levels with increased duration of rupture of membranes and with evidence of histological chorioamnionitis and funisitis in the placenta.     

早产前应用不同疗程地塞米松对于早产孕妇母儿预后的影响

目的探讨产前应用不同疗程地塞米松对于早产孕妇母儿预后的影响。方法回顾性分析85例28-34周早产母儿临床资料。结果在≤34周早产孕妇产前应用地塞米松可以显著降低新生儿呼吸窘迫综合征（NRDS）的发生率（P〈0.05）,多疗程与单疗程治疗组之间无明显差异（P〉0.05）;地塞米松未增加新生儿缺血缺氧性脑病,新生儿感染及新生儿死亡率,对孕妇产褥感染也无明显的影响（P〉0.05）;伴胎膜早破应用多疗程地塞米松组产褥感染率明显增加,高于对照组及单疗程治疗组（P〈0.05）。结论在≤34周早产孕妇应用地塞米松可预防NRDS发生,多疗程应用未增加对NRDS保护作用,对胎膜早破者增加产褥感染机率。     

Choriodecidual inflammatory syndrome (CoDIS) is the leading, and under recognised, cause of early preterm delivery and second trimester miscarriage

Severe preterm birth (delivery before 32 completed weeks of gestation), with or without preterm premature rupture of the membranes (PPROM), remains the leading cause of perinatal mortality. It is proposed that localized inflammation of the chorion and decidua in the membranes immediately above the internal cervical os, with or without amniotic cavity infection and inflammation, is the leading, but under recognised, cause of second trimester miscarriage and severe preterm delivery. The term 'CoDIS' (choriodecidual inflammatory syndrome), may provide a better understanding of the underlying pathophysiology than currently used terminology which over emphasizes the importance of overt intra-amniotic infection as opposed to localized extra-amniotic inflammation which stimulates uterine evacuation.     

Metronidazole to prevent preterm delivery in pregnant women with asymptomatic bacterial vaginosis. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units

BACKGROUND: Bacterial vaginosis has been associated with preterm birth. In clinical trials, the treatment of bacterial vaginosis in pregnant women who previously had a preterm delivery reduced the risk of recurrence. METHODS: To determine whether treating women in a general obstetrical population who have asymptomatic bacterial vaginosis (as diagnosed on the basis of vaginal Gram's staining and pH) prevents preterm delivery, we randomly assigned 1953 women who were 16 to less than 24 weeks pregnant to receive two 2-g doses of metronidazole or placebo. The diagnostic studies were repeated and a second treatment was administered to all the women at 24 to less than 30 weeks' gestation. The primary outcome was the rate of delivery before 37 weeks' gestation. RESULTS: Bacterial vaginosis resolved in 657 of 845 women who had follow-up Gram's staining in the metronidazole group (77.8 percent) and 321 of 859 women in the placebo group (37.4 percent). Data on the time and characteristics of delivery were available for 953 women in the metronidazole group and 966 in the placebo group. Preterm delivery occurred in 116 women in the metronidazole group (12.2 percent) and 121 women in the placebo group (12.5 percent) (relative risk, 1.0; 95 percent confidence interval, 0.8 to 1.2). Treatment did not prevent preterm deliveries that resulted from spontaneous labor (5.1 percent in the metronidazole group vs. 5.7 percent in the placebo group) or spontaneous rupture of the membranes (4.2 percent vs. 3.7 percent), nor did it prevent delivery before 32 weeks (2.3 percent vs. 2.7 percent). Treatment with metronidazole did not reduce the occurrence of preterm labor, intraamniotic or postpartum infections, neonatal sepsis, or admission of the infant to the neonatal intensive care unit. CONCLUSIONS: The treatment of asymptomatic bacterial vaginosis in pregnant women does not reduce the occurrence of preterm delivery or other adverse perinatal outcomes.     

基质金属蛋白酶-9、白介素-1β与未足月胎膜早破的关系

目的探讨基质金属蛋白酶-9（MMP-9）、白细胞介素-1β（IL-1β）与未足月胎膜早破（PPROM）及绒毛膜羊膜炎的关系。方法采用双抗体夹心酶联免疫吸附法检测未足月胎膜早破组56例、足月胎膜早破组38例、正常妊娠组30例孕妇的血清、羊水、脐血中MMP-9、IL-1β的水平,并进行胎膜的病理检查。结果胎膜早破孕妇的血清、羊水、脐血中MMP-9、IL-1β水平明显高于对照组,而且未足月胎膜早破孕妇的MMP-9、IL-1β水平亦高于足月胎膜早破者（P〈0.01）;未足月胎膜早破组的绒毛膜羊膜炎的发生率明显高于足月胎膜早破组（P〈0.01）;发生绒毛膜羊膜炎的胎膜早破孕妇的血清、羊水、脐血中MMP-9、IL-1β水平明显高于非绒毛膜羊膜炎的胎膜早破孕妇（P〈0.01）。结论检测孕妇血清的MMP-9、IL-1β水平可作为未足月胎膜早破良好的预测指标,测定孕妇血清、羊水的MMP-9、IL-1β水平还有助于胎膜早破并绒毛膜羊膜炎的早期诊断。     

Evaluation of Preterm Delivery between 32+0-33+6 Weeks of Gestation

Preterm labor after 34 weeks of gestation has shown no great difference from full-term labor in terms of neonatal morbidity and mortality when proper antepartum management (antibiotics or steroids treatment) is done. However, various studies have discussed different views on the risks and safety of preterm delivery at 32⁺⁰-33⁺⁶ weeks of gestation. We evaluated the complications of different preterm groups that included the neonates born at 32⁺⁰-33⁺⁶ weeks of gestation (142), stratified randomly selected neonates born at 34⁺⁰-36⁺⁶ weeks of gestation (267) and neonates born after 37⁺⁰ weeks of gestation (356) at our hospital between December 1999 and April 2006. As a result, it was found that neonates born at 34⁺⁰-36⁺⁶ weeks of gestation showed no great difference from infants born at full term. However, neonates born at 32⁺⁰-33⁺⁶ weeks were more likely to be admitted to neonatal intensive care unit or develop neonatal complications significantly than the neonates born at 34⁺⁰-36⁺⁶ weeks and at full term. Therefore, it is suggested that neonates born at 32⁺⁰-33⁺⁶ weeks have higher risk of neonatal complications following their preterm labor than those born at later than 34⁺⁰ weeks. Thus, it would be difficult to accept the idea that preterm labor at 32⁺⁰-33⁺⁶ weeks is safe.     

Preterm birth in rural Malawi: high incidence in ultrasound-dated population

BACKGROUND: Preterm birth is the major cause of neonatal death, and has an incidence in industrialized countries of 7%. We have found a high incidence (25-30%) previously in a population of anaemic, pregnant women in southern Malawi, studied with ultrasound dating. METHODS: Cohort study of 512 unselected pregnant women in rural communities in Malawi. All had ultrasound fetal measurements before 24 weeks. RESULTS: 20.3% of women delivered before 37 completed weeks of pregnancy. Babies born before 37 completed weeks but after 32 weeks (16%) were twice as likely to die as babies born at term (6.9 versus 3.4%) but this difference did not achieve statistical significance. For those born between 24 and 33 weeks gestation (4.4%) there was a highly significant increase in perinatal mortality (75%) (p <0 .000001). CONCLUSIONS: This population has a very high rate of preterm birth, which is probably infection-related. It may be representative of many rural populations in sub-Saharan Africa. Tackling the problem of neonatal mortality in low income countries will require effective methods to prevent preterm birth.     

11例妊娠合并肺炎的临床分析

目的 分析妊娠合并肺炎的临床特点、诊断、治疗及母婴预后。方法 我院2003年5月至2008年4月共收治妊娠并发肺炎者15例，我们对其中11例的临床资料进行回顾性分析。结果 ①11例孕妇病人以发热为主要表现，外周血白细胞增高，肺部X线病变表现明显。②15例中4例孕早期合并肺炎，治愈，母婴结局良好；另11例妊娠合并肺炎患者（其中双胎1例）8例早产，3例足月产，新生儿窒息6例，新生儿死亡2例，孕妇均治愈出院。结论 有产科合并症的孕妇发生肺炎时容易早产，新生儿窒息增多。妊娠合并肺炎发病早期正规积极治疗，对改善母儿结局十分重要。