糖尿病史女性孕前管理

有糖尿病史的女性,如果孕前血糖没有得到良好的控制,妊娠后其母儿合并症和并发症发生率明显升高。重视糖尿病史女性的孕前咨询、孕前监测和评估并进行孕前干预是获得良好妊娠结局的关键。文章结合国内外指南,详细阐述糖尿病史女性的孕前管理方案,为临床工作提供参考。     

遗传性疾病史女性孕前咨询要点

随着人类对遗传性疾病认识的加深以及检测技术的快速发展,越来越多的有遗传病史的家庭可以通过产前诊断或者植入前诊断的方式获得健康后代。为了更加准确地提供相关咨询信息,遗传性疾病的诊断与遗传咨询已经成为产科医生必须掌握的技能之一。详细询问病史后利用遗传学基本知识与相应的检测技术,通过对患者及其家系成员实施遗传检测与咨询,寻找导致疾病表型的染色体或基因问题,从而为孕前咨询和获得健康后代提供确诊及预防的依据亦变得尤为重要。文章对有遗传性疾病史的女性如何进行孕前咨询进行阐述。     

高龄女性孕前管理

随着二孩政策的实行,近年来我国高龄孕妇人群明显增多。与非高龄孕妇人群相比,高龄孕妇在孕前及孕期面临更多问题,包括不孕、妊娠期合并症以及出生缺陷发生率高等,因此需要对该群体进行针对性的孕前管理。     

不良孕产史人群中血栓前状态易感基因分布调查

Objective?To explore the distribution of prethrombotic state susceptibility gene polymorphisms in the population with a history of poor pregnancy. Methods?From December 2018 to June 2021, 410 women with a history of poor pregnancy and childbirth (research group) and 111 normal women (control group) were collected as the research subjects. EDTA anticoagulated whole blood of the two groups were collected,its genomic DNA were extracted,fluorescence quantitative PCR technology was used to detect the distribution of prethrombotic state susceptibility gene polymorphisms. Results?① There was no significantly difference in MTHFR A1298 C, PAI-1 5G/4G, FⅤ A1691G, FⅡG20210A gene polymorphisms between the two group (P>0.05);② There were significantly difference in the distribution of genotypes in MTRR A66G sites AA,AG,GG between the two group (P<0.05).③ There were significantly difference in the AA,AG,GG genotypes and the G, A allele frequencies at the C677T site of MTHFR between the two group (P<0.05). Conclusion?The prethrombotic state susceptibility gene MTRR A66G locus and MTHFR C677T locus polymorphisms are related to the history of adverse pregnancy and childbirth.     

不良孕产史人群中血栓前状态易感基因分布调查CSCD

目的 探究血栓前状态易感基因多态性在不良孕产史人群中的分布。方法 收集2018年12月至2021年6月在山西省太原市妇幼就诊的410例有不良孕产史的女性(病例组)和111例无不良孕产史备孕女性(对照组)作为研究对象。采集两组人群EDTA抗凝全血,提取其基因组DNA,利用荧光定量PCR技术检测血栓前状态易感基因多态性在两组人群中的分布。结果 (1) MTHFR A1298 C、PAI-1 5G/4G、FⅤA1691G、FⅡG20210A基因多态性在对照组和病例组中分布差异无统计学意义(P> 0.05);(2) MTRR A66G位点AA、AG、GG基因型在对照组和病例组中分布差异有统计学意义(P <0.05);(3) MTHFR C677T位点AA、AG、GG基因型及G、A等位基因频率在对照组和病例组中的分布差异有统计学意义(P <0.05)。结论 血栓前状态易感基因MTRR A66G位点、MTHFRC677T位点多态性与不良孕产史密切相关。     

复发性流产孕前管理

        复发性流产在育龄期妇女中的发生率约为1%~5%,给育龄期女性造成身体和情感的双重打击。反复的清宫操作损伤子宫内膜,形成局部感染,导致宫腔粘连;多次的妊娠丢失给患者和家庭带来巨大的精神创伤,导致患者产生焦虑、紧张、沮丧等不良情绪。因此,复发性流产患者再次妊娠前急于向医师寻求帮助,然而复发性流产的病因复杂,约50%病因不明,临床诊治方面存在诸多争议,孕前管理非常棘手。因此,高度重视复发性流产女性的孕前管理,对促使再次成功妊娠并预防孕期并发症非常重要。本文主要针对复发性流产的孕前管理对象、病因筛查和孕前管理进行阐述。     

心脏病史女性孕前保健和管理

心脏病女性在妊娠期易发生心血管并发症,是孕产妇非产科因素死亡的重要原因,应加强孕前保健和管理。结合患者病史和检查进行孕前风险评估,能够手术矫正者建议其孕前手术治疗,不宜妊娠者应建议其避孕,允许继续妊娠者孕期应联合多学科管理,提高妊娠分娩安全性。     

染色体平衡易位伴不良孕史3例

目的报道3例染色体平衡易位伴不良孕史的病例。方法应用G显带技术对3例伴有不良孕史的女性患者进行染色体核型分析,检测到核型异常后用荧光原位杂交技术(FISH)进行验证。结果 3例患者均为平衡易位,核型分别为t(3;5)(p13;q13.3)、inv(4)(p16q13)和ins(4;7)(p15.2;q32q34),后用FISH验证结果与核型分析相符,经查询国内外权威数据库均未见3例异常核型相同报道。结论平衡易位是不明原因反复流产的重要因素之一,携带者再次妊娠应积极配合医生进行产前诊断。     

肾脏病史女性孕前保健

慢性肾脏病（CKD）妊娠不良结局包括流产、并发子痫前期、胎儿发育异常、胎儿生长受限、早产等。CKD女性妊娠需多学科共同管理,调整使用对胎儿影响较小的药物;帮助CKD患者选择合适的妊娠时机;指导患者调整生活状态,适应孕期的生理变化。     

血栓弹力图、血栓前状态与早期复发性流产的关系

目的:研究早期复发性流产(RSA)患者血栓弹力图(TEG)的改变,为早期RSA的诊断和治疗提供有效的检测指标。方法:对62例RSA患者和72例正常生育期妇女进行孕前及孕后的血栓弹力图(TEG)检测,统计各组TEG参数及妊娠丢失率。结果:(1)非孕状态时,RSA组与正常组相比,最大凝块振幅(MA)增高(P0.05)。(2)孕前MA≥64mm时,预测流产的敏感性和特异性分别为68%和82%。(3)RSA患者孕前异常MA纠正后,孕后TEG参数异常率及妊娠丢失率与孕前未纠正者比较,差异有统计学意义(P0.05)。结论:血栓弹力图可在非妊娠时鉴别部分RSA女性是否处在血栓前状态。在这样状态下未经治疗的RSA再次妊娠流产的风险增高。监测TEG有助于RSA的病因诊断,指导抗血小板药物的应用。     

Ultrasound examination at term for predicting the outcome of delivery in women with a previous cesarean section

Objective: To evaluate if ultrasound variables at term are associated with the mode of delivery in women with previous cesarean section (PCS).

Methods: This was a prospective study of singleton pregnant women who planned a trial of vaginal birth after cesarean delivery. Cervical length, posterior cervical angle, head–perineum distance, and estimated fetal weight were measured at 37–39 weeks of gestation.

Results: One hundred forty-four pregnancies were examined and vaginal delivery was achieved in 98 women (73%). Logistic regression analysis identified cervical length, head–perineum distance, age, previous vaginal delivery, previous cesarean for dystocia, and Bishop score as predictors of vaginal delivery. Combining ultrasound and clinical parameters, two models for risk scoring that differ in the variable Bishop score or cervical length were constructed. The AUC of these models was 0.867 and 0.855, respectively.

Conclusions: In women with a PCS, measurement of cervical length and head–perineum distance at term is associated with the mode of delivery. A combination of clinical and sonographic parameters at term can predict the likelihood of vaginal delivery.     

剖宫产术后瘢痕子宫妊娠中晚期引产方式探讨

目的 探讨剖宫产术后瘢痕子宫妊娠的中晚期引产方式的选择和临床效果。 方法 回顾性分析中国医科大学附属盛京医院2008年1月至2013年12月收治的98例孕周为16~32周、因母体因素或胎儿异常原因行引产的瘢痕子宫妊娠孕妇的临床资料,其中米非司酮联合水囊组44例,米非司酮联合依沙吖啶组54例,对比其产程、产后出血量、引产成功率、胎盘胎膜残留率。结果 两组孕妇产后出血量比较差异无统计学意义(P>0.05)。米非司酮联合水囊组孕妇引产时间明显短于米非司酮联合依沙吖啶组,两组比较差异有统计学意义（P<0.05）。米非司酮联合依沙吖啶组引产的成功率为98.15%,米非司酮联合水囊组引产的成功率为88.64%,两组比较差异无统计学意义(P>0.05)。米非司酮联合依沙吖啶组产后清宫率较米非司酮联合水囊组高（88.89% vs. 50.00%）。 结论 米非司酮联合水囊或依沙吖啶引产均适用于瘢痕子宫妊娠的中晚期引产;在某些情况下,水囊引产也是可以应用的相对安全有效的引产方式,但需要进行严密监测。     

Induction of labour for women with a previous Caesarean birth: a systematic review of the literature

AIMS: To compare the benefits and harms of planned elective repeat Caesarean section with induction of labour and to assess different methods of cervical ripening and induction of labour for women with a previous Caesarean birth who require induction of labour in a subsequent pregnancy. METHODS: The Cochrane controlled trials register and MEDLINE (1966-current) were searched using the following terms: vaginal birth after C(a)esare(i)an, trial of labo(u)r, elective C(a)esare(i)an, C(a)esare(i)an repeat, induction of labo(u)r, prostaglandins, prostaglandin E(2), misoprostol, prostaglandin E(1) analogs, mifepristone, oxytocin, Syntocinon, randomis(z)ed controlled trial, randomis(z)ed trial and clinical trial, to identify all published randomised controlled trials with reported data comparing outcomes for women and infants who have a planned elective repeat Caesarean section with induction of labour; and different methods of induction of labour, where a prior birth was by Caesarean section. RESULTS: There were no randomised controlled trials identified where women with a prior Caesarean birth, whose labour required induction in a subsequent pregnancy, compared elective repeat Caesarean section with induction of labour. There were three randomised controlled trials identified in which women with a prior Caesarean section were allocated to different methods of induction of labour - vaginal prostaglandin E(2) versus intravenous oxytocin; mifepristone versus placebo; and vaginal misoprostol versus intravenous oxytocin. These studies varied considerably in the methods used and meta-analysis was not appropriate. CONCLUSIONS: There is a paucity of safety information for induction of labour agents in the women with a scarred uterus, and caution should be exercised in their use.     

Glycaemic control throughout pregnancy and risk of pre-eclampsia in women with type I diabetes

The aim of this study was to examine the influence of pre-pregnancy care and its effect on early glycaemic control and also the effect of glycaemic control in later pregnancy on risk of pre-eclampsia in women with type I diabetes. A prospective cohort study of 290 consecutive nonselected pregnancies in women with type I diabetes was performed from 1991 to 2002. We examined the relationship of monthly glycosylated haemoglobin (HbA1c) level, pre-pregnancy care, parity, diabetes duration, microvascular complications, maternal age, weight and smoking with risk of pre-eclampsia. Pre-eclampsia developed in 31/243 singleton births (12.8%). HbA1c level at 24 weeks was significantly increased in women with pre-eclampsia compared with women without pre-eclampsia (6.0 versus 5.6%, P= 0.017) and was, after nulliparity, the strongest independent predictor of increased risk (OR 1.65 for each 1% increase in HbA1c; P= 0.01). In contrast, there was no relationship between pre-pregnancy care or HbA1c level at booking and risk of pre-eclampsia.     

Group prenatal care for women with gestational diabetes*

Objective: We aimed to determine if group prenatal care affects the progression to A2 gestational diabetes mellitus (GDM) when compared with conventional care for women with GDM.

Methods: Prospective observational cohort of women diagnosed with GDM who attended group visits compared with a historical control group of women who received conventional obstetrical care in the year prior but would have met inclusion criteria for group care. The primary outcome was progression to A2 GDM. Secondary outcomes included antepartum, intrapartum and postpartum maternal outcomes and neonatal outcomes.

Results: A total of 165 subjects were included: 62 in group care and 103 in conventional care. Compared with patients with conventional care, group subjects were more likely to attend a postpartum visit (92% versus 66%; p?=?0.002) and were almost 4 times more likely to receive recommended diabetes screening postpartum (OR 3.9, CI 1.8–8.6). Group subjects were much less likely to progress to A2 GDM (OR 0.15, CI 0.07–0.30). There were no differences in neonatal outcomes.

Conclusions: Group prenatal care for women with diabetes is associated with decreased progression to A2 GDM and improved postpartum follow-up for appropriate diabetes screening without significantly affecting obstetrical or neonatal outcomes.