择期经阴道宫颈环扎术与期待疗法治疗宫颈机能不全的效果比较

目的:比较择期经阴道宫颈环扎术以及期待疗法治疗宫颈机能不全的效果。方法:选择2017年10月~2019年10月我院收治的201例宫颈机能不全患者,将其随机分为两组。对照组100例患者采取期待疗法,即卧床休息,口服地屈孕酮,每次服用的剂量为10 mg,每日2次,一直服药到30孕周;观察组101例患者择期经阴道宫颈环扎术,比较两组的早产率、成功妊娠率、新生儿出生体重以及分娩孕周。结果:对照组100例宫颈机能不全患者中,22例患者流产(占22.00%),78例患者获得活婴(占78.00%),78例成功分娩的患者中,47例患者≥37周分娩,31例患者<37周分娩,早产率为39.74%(31/78)。观察组的101例患者中,8例患者流产(占7.92%),93例患者获得活婴(占92.08%)。93例成功分娩的患者中,81例患者≥37周分娩,12例患者<37周分娩,早产率为12.90%(12/93);12例早产的患者中,4例患者由于胎膜早破和胎儿窘迫,而在孕32~33周采取剖宫产手术,2例患者由于胎膜早破臀位,而在孕35~36周时采取剖宫产手术,6例患者在孕35~36周早产。观察组宫颈机能不全患者的早产率明显低于对照组(P<0.05),且成功妊娠率、新生儿出生体重以及分娩孕周明显高于或长于对照组(P<0.05)。结论:与期待疗法相比较,择期经阴道宫颈环扎术不但可以明显延长宫颈机能不全患者的分娩孕周,提高成功妊娠率,还能改善新生儿的预后、降低早产的风险。     

86例早产胎膜早破的临床观察及护理

早产胎膜早破又称未足月胎膜早破（PPROM）,是指发生在妊娠37周之前的胎膜破裂.孕妇中的PPROM发生率为3%,其中有约30%-40%导致早产[1].引起胎膜早破的易发因素为感染、宫腔压力不均、羊水过多、胎膜发育不良等,其主要危害是羊膜腔感染、羊水过少、早产、胎儿窘迫和新生儿呼吸窘迫综合征（NRDS）等.胎龄越小,死亡率越高.现就我院2007年1月-2010年9月收治的86例早产胎膜早破孕妇的护理体会报告如下.     

宫颈环扎术对PCOS双胎妊娠合并宫颈机能不全患者妊娠结局的影响及手术时机研究

摘要 目的：探讨宫颈环扎术对多囊卵巢综合征（PCOS）双胎妊娠合并宫颈机能不全患者妊娠结局的影响及手术时机。方法：回顾性分析2015年01月至2022年06月在南京医科大学附属妇产医院生殖医学中心行冻融胚胎移植后PCOS双胎妊娠合并宫颈机能不全的114例患者的临床资料。按照是否行宫颈环扎术分为手术组和非手术组。根据宫颈环扎手术时间,将行宫颈环扎的PCOS双胎妊娠合并宫颈机能不全患者分为孕周≤16周组和孕周＞16周组。收集患者的临床资料,比较不同组别的临床资料、妊娠结局,分析宫颈环扎术对PCOS双胎妊娠合并宫颈机能不全患者妊娠结局的影响和不同手术时机的治疗效果。结果：PCOS双胎妊娠合并宫颈机能不全患者中67例行宫颈环扎手术,47例未行宫颈环扎手术。手术组晚期流产率低于非手术组,胎膜早破率、产后出血率、剖宫产率、活产率高于非手术组（P＜0.05）。两组妊娠合并症、早产、足月产、新生儿结局组间比较,差异无统计学意义（P＞0.05）。孕周≤16周有33例,孕周＞16周有34例,孕周≤16周组的延长妊娠时间长于孕周＞16周组（P＜0.05）。结论：接受辅助生殖助孕的PCOS患者发生双胎妊娠,在任何孕周发现宫颈扩张并进行经阴道宫颈环扎术均可改善妊娠结局,减少晚期流产的发生,提高活产率,但会增加胎膜早破和产后出血的风险,因此需要做好围手术期的管理。同时在孕周≤16周时行宫颈环扎术可有效延长妊娠时间。     

救援性宫颈托治疗紧急宫颈环扎术后再次宫颈缩短和/或宫口扩张的临床观察

摘要 目的：观察救援性宫颈托治疗在治疗紧急宫颈环扎术后发生进一步宫颈缩短和/或宫口开大患者的临床结局。方法：2021年05月31日至2022年01月13日于哈尔滨医科大学附属第一医院产科行紧急宫颈环扎术的患者,术后超声监测宫颈长度、内诊,对于超声提示宫颈缩短和/或宫口扩张,经阴道检查可见宫颈管扩张伴胎胞暴露的患者（单胎）进行救援性宫颈托治疗（11例）。随访观察其妊娠结局及不良反应。结果：进行紧急宫颈环扎术孕周为107-201天（平均165.5±34.9天）;救援性宫颈托放置孕周为169-262天（平均205.9±26.1）;分娩孕周为193-269天（平均249.5±24.9天）;延长天数为18-160天（平均84.0±46.3天）。未出现医源性胎膜早破及绒毛膜羊膜炎。11例患者中10例患者获得新生儿。存活的10例新生儿4例于新生儿科住院治疗,均后期顺利出院,新生儿存活率为100%。结论：本组病例使用救援性宫颈托明显延长紧急宫颈环扎术后宫颈缩短和/或宫口扩张患者的孕周,改善妊娠结局。     

彩色多普勒超声用于评估妊娠高血压缺氧程度的临床价值

目的:探讨彩色多普勒超声用于评估妊娠高血压缺氧程度的临床价值。方法:将我院自2017年6月至2019年6月收治的妊娠高血压患者106例作为研究组及同期产检正常孕妇103例作为对照组,采用彩色多普勒超声检查仪监测两组孕妇的子宫动脉血流动力学情况,并分析新生儿的缺氧程度。结果:研究组孕妇脐血流搏动指数(pulsatility index,PI)、脐血流阻力指数(resistance index,RI)和脐动脉血流收缩期/舒张期(S/D)水平均明显高于对照组(P0.05),舒张早期切迹发生率为47.17%,亦明显高于对照组8.74%(P0.05)。研究组孕妇平均孕周、新生儿体重和体重指数均明显少于对照组(P0.05),其早产率为19.81%、剖宫产率为64.15%、胎儿窘迫发生率为15.09%,均明显高于对照组(5.83%、19.42%、4.85%,P0.05)。研究组中切迹组孕周、新生儿体重均明显小于非切迹组(P0.05)。研究组羊水异常发生率为16.00%,早产率为40.00%,新生儿窒息率为14.00%,胎儿窘迫发生率为26.00%,均明显高于对照组(5.36%、1.79%、1.79%、5.38%,P0.05)。结论:采用彩色多普勒超声仪检测孕妇子宫动脉血流频谱可作为了解子宫-胎盘-胎儿循环的检查方式,评估妊娠并发症的发生风险,监测胎儿宫内生长发育。     

妊娠中晚期孕妇阴道菌群紊乱的改变对不良妊娠结局的影响

目的探讨妊娠中晚期孕妇阴道菌群紊乱的改变对不良妊娠结局的影响。方法选取产科门诊就诊的妊娠28-34周的患者150例。根据检查结果将其分为菌群正常组48例和菌群失常组102例。观察并对比两组患者的不良妊娠结局。结果 102例菌群失常患者中滴虫6例,假丝酵母菌67例,衣原体17例,淋菌2例,细菌性阴道病10例。假丝酵母菌感染率明显高于其他致病菌(P0.05)。菌群失常组患者早产、胎膜早破、剖宫产、产褥感染发生率分别为15.69%、22.55%、35.29%和18.63%,均明显高于菌群正常组的4.17%、8.33%、18.75%和6.25%(P0.05)。菌群失常组患者新生儿黄疽、新生儿感染和低出生体重儿发生率分别为24.51%、21.57%、16.67%,均明显高于菌群正常组的10.42%、8.33%、4.17%(P0.05),在胎儿窘迫的发生率方面两组比较差异无统计学意义(P0.05)。结论妊娠中晚期阴道菌群紊乱中以假丝酵母菌感染发生率最多,与不良妊娠结局密切相关,增加了早产、胎膜早破、剖宫产、产褥感染、新生儿黄疸、新生儿感染和低出生体重儿等与不良妊娠结局的发生率。     

胎儿纤维连接蛋白与自发性早产预测的研究进展

早产是围生儿死亡和患病的重要原因之一,有效的风险评估可以降低潜在的早产发生风险。胎儿纤维连接蛋白(fetal fibronectin,f FN)是一种细胞外基质的糖蛋白,在胎盘植入、胎盘子宫的细胞黏附、正常妊娠的维持等方面均起重要作用。研究表明,多种产科情况都可导致f FN的异常,临床上通过对孕妇的宫颈阴道分泌物、血浆、羊水中的f FN进行检测,能够预测分娩时间、评估引产的困难程度和胎膜早破发生早产的风险。目前,f FN的测定主要是采取ELISA快速测定方法。本文主要对f FN与早产预测的研究进展进行了综述,其中对f FN的来源以及f FN测试单独或联合宫颈超声预测自发性早产的临床价值作了重点阐述。     

溶脲脲原体对胎儿发育影响的研究

对７７例住院初产妇羊水进行溶脲脲原体（ｕｕ）检查,结果１５例早产,５例ｕｕ阳性,阳性率３３３％;８例新生儿低体重,２例ｕｕ阳性,阳性率２５％;死胎２例,１例ｕｕ阳性。胎儿正常者５２例,２例ｕｕ阳性。结果显示溶脲脲原体感染可影响胎儿发育,应对孕妇及早检查与诊治     

胎膜早破与孕妇阴道微生态及血清IL-10、IL-22、NF-κB的相关性

目的 探讨胎膜早破与孕妇阴道微生态及血清IL-10、IL-22、NF-kB的相关性。方法 选取我院妇产科收治的84例胎膜早破孕妇为胎膜早破组,100例正常孕妇为正常孕妇组及100例正常未怀孕妇女为正常妇女组。比较3组对象阴道分泌物各细菌阳性率、阴道微生态状态及各组间血清IL-10、IL-22、NF-kB水平。对胎膜早破孕妇阴道微生态失衡与血清IL-10、IL-22、NF-kB水平进行Pearson相关性分析。结果 胎膜早破组孕妇阴道乳杆菌（79.8%）、大肠埃希菌（48.8%）、溶血葡萄球菌（22.6%）检出率均显著高于正常孕妇组和正常妇女组（均P<0.05）。胎膜早破组患者阴道pH（6.87±0.75）、阴道微生态失衡率（40.5%）均显著高于正常孕妇组和正常妇女组,H2O2阳性率（11.9%）低于正常孕妇组（21.0%）和正常妇女组（23.0%）,差异均有统计学意义（均P<0.05）。胎膜早破组孕妇血清IL-10、IL-22、NF-kB水平[（51.28±6.58）pg/mL、（45.91±7.13）pg/mL、（30.47±3.27）ng/mL]均显著高于正常孕妇组和正常妇女组。经过Pearson相关性分析,IL-10、IL-22、NF-kB水平与胎膜早破孕妇阴道微生态失衡呈正相关（r=0.657、0.692、0.732,P<0.05）。结论 孕妇阴道微生态环境发生改变引起阴道菌群失调及血清免疫因子的变化,可能是引发胎膜早破的作用机制之一。     

胎儿体重相关因素分析以及多元回归方程的建立

目的:寻找更为准确的预测胎儿体重的方法,并探讨腹围增加值在预测胎儿体重中的价值。方法:回顾性分析山东省烟台市芝罘区妇幼保健院2010年3月至12月期间出生的280例新生儿的临床资料,将孕妇身高、体重、孕期增重、宫高、足月腹围、孕期腹围增加值及胎儿的双顶径、股骨长等,与新生儿出生体重进行相关及回归分析,得出回归方程并检验其显著性和与实际出生体重的符合率,并与以往临床常用方法比较。结果:宫高、腹围增加值、双顶径和股骨长与胎儿体重显著相关,建立的多元回归方程计算胎儿体重预测值与实际胎儿体重符合率达70.71%,远高于其它方法。结论:采用宫高、腹围增加值、双顶径、股骨长建立的多元回归方程对胎儿体重预测符合率高,有较好的临床应用价值。     

The possibility of respiratory distress syndrome prevention of premature born children

Pregnant women and premature born children were classified into four groups. In each group there were thirty of them. The first group included the pregnant women with premature rupture of membranes and amniotic fluid effluxed for 72 hours before the delivery. The second group included the pregnant women with amniotic fluid effluxing less then 72 hours before the delivery. The third group included the pregnant women who were given corticosteroids. The forth group was a control group formed by those pregnant women (and their premature born children) whose amniotic fluid did not efflux long and those who weren't given corticosteroids during pregnancy. In all groups of pregnant women we observed: median age of pregnant women, the duration of pregnancy and mode of delivery (vaginal or cesarean section). In groups of premature born children we also observed: newborn birth weight, Apgar score in the first minute after delivery, Apgar score in the fifth minute after delivery, pH of the blood of umbilical cord, L/S ratio of amniotic fluid (lecithin-sphingomyelin ratio), RDS (neonatologist valuation in any degree of RDS developed et newborn child). Symptoms of RDS include tachypnoea, chest wall retraction and cyanosis and a zground glass' appearance of the chest on X-ray. Histopatological examinations of placentas compared the frequency of inflammatory or noninflammatory changes, also in all groups. No significant difference was found among groups of pregnant women for the following factors: the age of pregnant women, the duration of pregnancy and mode of delivery. No significant difference was found among the groups of children for the following factors: newborn birth weight, Apgar score in the fifth minute after delivery, blood pH of umbilical cord, L/S ratio of amniotic fluid. Significant difference was found among groups for the following factors: Apgar score in the first minute after delivery, the frequency of RDS and hystology of placentas. The prevention of premature delivery is the most important. All the pregnant women with symptoms of the premature delivery must be transported to the centers with the well developed unites of intensive neonatal care ("transport in utero").     

Limited Relationship between Cervico-Vaginal Fluid Cytokine Profiles and Cervical Shortening in Women at High Risk of Spontaneous Preterm Birth

Objective

To determine the relationship between high vaginal pro-inflammatory cytokines and cervical shortening in women at high risk of spontaneous preterm labor and to assess the influence of cervical cerclage and vaginal progesterone on this relationship.

Methods

This prospective longitudinal observational study assessed 112 women with at least one previous preterm delivery between 16 and 34 weeks’ gestation. Transvaginal cervical length was measured and cervico-vaginal fluid sampled every two weeks until 28 weeks. If the cervix shortened (<25 mm) before 24 weeks’ gestation, women (cases) were randomly assigned to cerclage or progesterone and sampled weekly. Cytokine concentrations were measured in a subset of cervico-vaginal fluid samples (n = 477 from 78 women) by 11-plex fluid-phase immunoassay.

Results

All 11 inflammatory cytokines investigated were detected in cervico-vaginal fluid from women at high risk of preterm birth, irrespective of later cervical shortening. At less than 24 weeks’ gestation and prior to intervention, women destined to develop a short cervix (n = 36) exhibited higher cervico-vaginal concentrations than controls (n = 42) of granulocyte-macrophage colony-stimulating factor [(GM-CSF) 16.2 fold increase, confidence interval (CI) 1.8–147; p = 0.01] and monocyte chemotactic protein-1 [(MCP-1) 4.8, CI 1.0–23.0; p = 0.05]. Other cytokines were similar between cases and controls. Progesterone treatment did not suppress cytokine concentrations. Interleukin (IL)-6, IL-8, granulocyte colony-stimulating factor (G-CSF), interferon (IFN)-γ and tumour necrosis factor (TNF)-α concentrations were higher following randomization to cerclage versus progesterone (p<0.05). Cerclage, but not progesterone treatment, was followed by a significant increase in cervical length [mean 11.4 mm, CI 5.0–17.7; p<0.001].

Conclusions

Although GM-CSF and MCP-1 cervico-vaginal fluid concentrations were raised, the majority of cervico-vaginal cytokines did not increase in association with cervical shortening. Progesterone treatment showed no significant anti-inflammation action on cytokine concentrations. Cerclage insertion was associated with an increase in the majority of inflammatory markers and cervical length.     

早产病因及发病机制的研究现状

早产在妇产科临床上比较常见,其作为围生医学当中的一类重要而复杂的妊娠并发症,对早产儿的预后具有较大危害,严重时可能直接导致早产儿死亡。通常而言,早产患者的临床表现主要是子宫收缩,初期表现为不规律的宫缩,并伴有少量的阴道出血亦或是血性分泌物,进而发展成规律性的宫缩,此过程中宫颈管先发生消退,而后扩张。早产儿的体重大多数低于2500 g,且头围小于33 cm,部分胎儿的器官功能及适应能力与足月儿相比明显较差,常需给予特殊的处理。因此,及时梳理导致早产的原因并分析其发病机制,有利于早期掌握防治早产的基础要点。本文就此展开综述,以期为改善母婴妊娠结局提供理论支持。     

Preterm Birth Prevention Post-Conization: A Model of Cervical Length Screening with Targeted Cerclage

Women with a history of excisional treatment (conization) for cervical intra-epithelial neoplasia (CIN) are at increased risk of preterm birth, perinatal morbidity and mortality in subsequent pregnancy. We aimed to develop a screening model to effectively differentiate pregnancies post-conization into low- and high-risk for preterm birth, and to evaluate the impact of suture material on the efficacy of ultrasound indicated cervical cerclage. We analysed longitudinal cervical length (CL) data from 725 pregnant women post-conization attending preterm surveillance clinics at three London university Hospitals over a ten year period (2004–2014). Rates of preterm birth <37 weeks after targeted cerclage for CL<25mm were compared with local and national background rates and expected rates for this cohort. Rates for cerclage using monofilament or braided suture material were also compared. Of 725 women post-conization 13.5% (98/725) received an ultrasound indicated cerclage and 9.7% (70/725) delivered prematurely, <37weeks; 24.5% (24/98) of these despite insertion of cerclage. The preterm birth rate was lower for those that had monofilament (9/60, 15%) versus braided (15/38, 40%) cerclage (RR 0.7, 95% CI 0.54 to 0.94, P = 0.008). Accuracy parameters of interval reduction in CL between longitudinal second trimester screenings were calculated to identify women at low risk of preterm birth, who could safely discontinue surveillance. A reduction of CL <10% between screening timepoints predicts term birth, >37weeks. Our triage model enables timely discharge of low risk women, eliminating 36% of unnecessary follow-up CL scans. We demonstrate that preterm birth in women post-conization may be reduced by targeted cervical cerclage. Cerclage efficacy is however suture material-dependant: monofilament is preferable to braided suture. The introduction of triage prediction models has the potential to reduce the number of unnecessary CL scan for women at low risk of preterm birth.     

胚胎移植前的阴道微生态对辅助生殖患者妊娠结局的影响

探讨辅助生殖治疗患者在胚胎移植前的阴道微生态对妊娠结局的影响。

选取1 420例在北部战区总医院生殖医学科经体外受精/卵胞浆内单精子注射(IVF/ICSI)治疗并接受冻融胚胎移植的不孕患者。在胚胎移植前取阴道分泌物涂片、革兰染色、显微镜镜检检查阴道微生态情况, 回顾性分析阴道微生态对辅助生殖患者妊娠结局的影响。

微生态失衡患者的HCG阳性率、临床妊娠率、胚胎种植率、流产率和早产率与微生态正常患者相比差异无统计学意义(P > 0.05)。708例微生态失衡患者中, 菌群正常功能下降335例、菌群抑制141例、白细胞异常127例、BV中间型52例、BV 30例、VVC 23例。BV患者的流产率与其他几种微生态失衡情况相比, 差异有统计学意义(P < 0.01)。

微生态失衡对辅助生殖患者的妊娠率影响有限; BV患者在胚胎移植后可能有流产的风险, 建议调整阴道微生态的平衡防止流产发生。

     

羊膜腔内感染微生物分布及相关影响因素分析

研究剖宫产术中产妇的感染症状、羊水微生物分布情况及相关影响因素,为该类患者的治疗提供帮助。

采集本院2020年6月至2023年2月于剖宫产术中提取的羊水498份进行细菌培养,根据羊水微生物分布情况和相关因素,综合分析产妇临床感染症状。

498份送检羊水标本中有147份标本检出微生物,总检出率为29.5%（147/498）。498例产妇中有100例术前出现感染症状,检出微生物78株;51例术后出现感染症状,检出微生物34株;8例术后切口感染,检出微生物7株。339例没有临床感染症状的产妇检出微生物28株。羊水微生物的检出率与胎膜早破或试产后人工破膜、产妇自身阴道菌群分布、术前出现感染症状呈显著相关（均P＜0.05）。

对胎膜早破、阴道菌群失调等高危产妇及时送检标本查找病原体,对羊膜腔内感染的早期预防和针对性治疗具有显著意义。

     

妊娠合并甲状腺功能减退症26例妊娠结局分析

目的：对妊娠合并甲状腺功能减退症进行分析,探讨其对母儿的影响,及孕期筛查甲状腺功能有无意义。方法：对我院26例妊娠合并甲减的临床资料进行回顾性统计分析。结果：26例妊娠合并甲减病例中有1例早产（孕33周）,其余25例患者维持至足月妊娠,其中剖宫产17例（65.38%）,合并妊娠期高血压疾病5例（19.23%）,妊娠期糖尿病3例（11.53%）,羊水胎粪污染3例（11.54%）,新生儿无先天性甲减。经过治疗后甲状腺功能减退孕妇的剖宫产率,糖尿病发生率、高血压疾病发生率、羊水粪染的发生率较对照组增加;但两组妊娠结局差异无统计学意义（P〉0.05）。结论：妊娠合并甲状腺功能减退症孕妇多种妊娠并发症的发病率高于正常孕妇,应加强对妊娠甲减的早期筛查及治疗,可有效降低不良妊娠结局,减少先天性甲低的出生。     

78例胎盘早剥临床分析

目的：探讨胎盘早剥的诱发因素、手术方式和临床处理方法。方法：采用回顾性病例分析的方法,对2010年6月至2012年1月在我院妇产科接受治疗的78例胎盘早剥患者的临床资料进行统计,分析胎盘早剥的诱因、临床分度及处置原则。结果：诱发因素：妊娠期高血压病占第1位,胎膜早破为第2位,妊娠期合并糖尿病为第3位。此外,羊水过多、妊娠合并子宫肌瘤、外伤等也是引起胎盘早剥的因素。在78例胎盘早剥患者中,重度的有18例,中度的有32例,这50例患者全用采取剖宫产进行处置。另有28例为轻度胎盘早剥,其中6例采用阴道分娩。结论：胎盘早剥以妊娠期高血压、胎膜早破、妊娠期糖尿病为主要发病诱因,中重度胎盘早剥一般用剖宫产终止妊娠,轻度胎盘早剥可部分用阴道分娩。