Inquiry-based small-class teaching is student-centered and problem-oriented. It takes group learning as the basic form, and promotes students’ knowledge construction and clinical thinking development through in-depth interactive learning in small classes. The flipped classroom relies on students’ self-study before class and high-level learning tasks in class. It has been proven effective in many disciplines, which can improve learning engagement, promote peer cooperation, enrich classroom interaction, and strengthen students’ clinical thinking. When applying the combined model of inquiry-based small-class teaching and flipped classroom in obstetrics and gynecology teaching, low student participation is a common problem. Taking the teaching practice of obstetrics and gynecology in West China Second University Hospital of Sichuan University as an example, this paper introduces the implementation process and teaching effects of the integrated teaching mode, and puts forward targeted improvement measures to solve the problem of low student participation. The results show that this combined teaching model can obviously raise students’ participation and overall ability, and it is feasible and effective in the teaching of obstetrics and gynecology. 探究式-小班化课程坚持以学生为中心、以问题为导向，以小组为基本单元，通过小规模深度互动促进知识建构与临床思维的发展。翻转课堂以课前自主学习为基础、以课中高阶任务为抓手，已在多学科教学中被证实有效，可提升学习投入，促进同伴协作，优化课堂互动，并强化临床思维。在妇产科学教学中实施探究式-小班化结合翻转课堂模式过程中，发现学生参与度偏低。基于此，本文系统梳理四川大学华西第二医院妇产科学探究式-小班化与翻转课堂融合的实践路径与教学成效，并针对学生参与度偏低的问题提出针对性改进策略。结果显示，探究式-小班化与翻转课堂融合的教学模式能够有效提升学生的参与度与综合胜任力，在妇产科学教学中具备良好的可行性与应用有效性。

BACKGROUND:Bartter syndrome (BS) is a rare autosomal recessive renal disease. There are relatively few reports on fetal Bartter syndrome, but it has been documented that the condition can increase the incidence of prematurity and hypovolemia. Umbilical vein thrombosis (UVT) is a rare obstetric complication that poses a serious threat to fetal safety, potentially leading to acute fetal distress and even intrauterine fetal death. Consequently, early identification and intervention of UVT are crucial. CASE PRESENTATION:We present a case of an emergency cesarean section prompted by ultrasound findings of intrahepatic segment of umbilical vein thrombosis and polyhydramnios. After birth, the newborn was admitted to the Department of Neonatology for observation and further treatment due to persistent, uncorrected hypokalemia. Genetic testing diagnosed the infant with Bartter syndrome type 4b. We hypothesize that the umbilical vein thrombosis and polyhydramnios in this case may be associated with fetal Bartter syndrome. CONCLUSION:This case highlights a suspected instance of umbilical vein thrombosis and polyhydramnios potentially linked to fetal Bartter syndrome. Currently, the causes of umbilical vein thrombosis primarily focus on abnormalities in umbilical cord structure or mechanical injury to the cord, with few cases involving fetal genetic conditions. The purpose of this report is to enhance medical professionals' understanding of Bartter syndrome and to consider it as a possible cause of fetal umbilical vein thrombosis and polyhydramnios. Further research should explore the link between fetal Bartter syndrome, umbilical vein thrombosis, and polyhydramnios. Additionally, strengthening case collection and analysis will help accumulate experience, optimize management strategies, and improve maternal and fetal outcomes.

BACKGROUND: Although guidelines suggest administering antibiotics 12 to 18 hours after the rupture of membranes in women with term premature rupture of membranes, in practice, clinicians tend to initiate prophylactic antibiotics as soon as possible to avoid risk of infection. OBJECTIVE: This study aimed to assess whether early administration of prophylactic antibiotics for term premature rupture of membranes reduces the incidence of maternal and neonatal infections. STUDY DESIGN: This multicenter prospective cohort study included women with term premature rupture of membranes. The participants were divided into early and late administration groups according to the duration between rupture of membranes and antibiotic use. The effectiveness outcomes included the incidence of puerperal infection, the incidence of total maternal infection, and the rate of neonatal sepsis, whereas the safety outcomes included the incidence of adverse reactions. Antibiotic use density was used to assess antibiotic consumption. The propensity score matching method was used to control for confounding factors. RESULTS: A total of 1099 women with term premature rupture of membranes were enrolled: 459 in the early 6-hour group (antibiotic administration within 6 hours) and 640 in the late 6-hour group (antibiotic administration after 6 hours) and 707 in the early 12-hour group (antibiotic administration within 12 hours) and 392 in the late 12-hour group (antibiotics administration after 12 hours). After propensity score matching, there were 300 women in each 6-hour group and 230 women in each 12-hour group. The baseline characteristics showed no significant difference between the matched groups (P>.05). The early 6-hour and 12-hour groups had lower maternal C-reactive protein levels than the late 6hour and 12-hour groups (P<.05). However, no significant difference was observed in other maternal and neonatal outcomes (P<.05). Adverse reactions showed no statistically significant difference between the early and late treatment groups (P=1.000). Antibiotic use density was higher in the early treatment groups by 10.1 defined daily doses (6-hour groups) and 11.7 defined daily doses (12-hour groups). CONCLUSION: There was no substantial difference in the efficacy and safety of antibiotics administered within 6 to 12 hours after rupture of membranes compared with that administered after 6 to 12 hours in women with term premature rupture of membranes. Delayed antibiotic use substantially reduced antibiotic consumption.

OBJECTIVE:To investigate the prognostic significance of molecular classification on treatment outcomes of fertility-sparing treatment (FST) in early-stage endometrial cancer (EC), and its potential in optimizing fertility-sparing management. METHODS:Patients with early-stage EC who received FST with ProMisE classification were investigated. Oncological and reproductive outcomes were compared across four molecular subtypes. Factors influencing complete response (CR) were analyzed. RESULTS:Among 116 molecularly classified patients, 80 were evaluated for therapeutic effects, including 64 (80.0 %) p53wt, 7 (8.7 %) MMR-D, 5 (6.3 %) POLE EDM, and 4 (5.0 %) p53abn. Overall CR rates were comparable across four molecular subtypes, with 92.2 % of p53wt, 71.4 % of MMR-D, 100.0 % of POLE EDM, and 75.0 % of p53abn (P = 0.145). MMR-D patients needed the longest median treatment time to achieve CR (7.9 months, range 3.5-15.9), while POLE EDM required the shortest (3.0 months, range 2.8-6.4), followed by p53abn (3.5 months, range 3.0-3.7) and p53wt (3.7 months, range 2.2-22.8) (P = 0.049). Among 14 p53wt patients with superficial myometrial invasion (MI) or G2 histology, 13 (92.9 %) achieved CR, and of 8 who attempted to conceive,4 delivered. Multivariable analysis identified MMR-D, superficial MI and insulin resistance negatively predicted CR, while POLE EDM was a positive factor. CONCLUSIONS:Molecular classification of EC may serve as a tool for predicting response to FST and assist in identifying candidates for FST. POLE EDM patients tended to obtain promising outcomes. MMR-D cases should be cautiously administrated for FST with close surveillance. Patients with p53wt demonstrated favorable outcomes, including those with superficial MI or G2 EC. Patients with endometrium-confined p53abn tumors may benefit from FST. However, given the small sample sizes of certain subtypes, further investigation is necessary to validate these findings.

Antiphospholipid syndrome (APS) is an acquired autoimmune disorder characterized by recurrent venous and/or arterial thrombosis and/or pregnancy complications, in the presence of elevated antiphospholipid (aPL) antibodies. APS in pregnant women is referred to as "obstetrical" APS (OAPS). The diagnosis of definite OAPS requires the presence of one or more typical clinical criteria and persistent aPL antibodies at least 12 weeks apart. However, the classification criteria for OAPS have generated wide discussion, with a growing impression that certain patients not fully meeting these criteria might be inappropriately excluded from the classification, which is known as "non-criteria" OAPS. We present here two unique cases of potentially lethal "non-criteria" OAPS, complicating severe preeclampsia, fetal growth restriction (FGR), liver rupture, preterm birth, refractory recurrent miscarriages, or even stillbirth. We further share our diagnostic search and analysis, treatment adjustment, and prognosis for this unusual antenatal event. We will also present a short review of an advanced understanding of the pathogenetic mechanisms of this disease, heterogeneous clinical features, and potential significance.

Objective To demonstrate that cesarean section with a transverse incision at the lower posterior wall of the uterus is suitable for some special obstetric cases.Case report A 35-year-old primigravida with a previous surgical history of laparoscopic myomectomy underwent elective cesarean section at 39 weeks and 2 days of gestation. During surgery, there were severe pelvic adhesions and engorged vessels on the anterior wall. Considering safety, we rotated the uterus 180 degrees and made a lower transverse incision on the posterior wall. The infant was healthy and the patient had no complications.Conclusions A low transverse incision in the posterior uterine wall is safe and effective when the incision of the anterior wall encounters a dilemma, especially in patients with severe pelvic adhesions. We recommended this approach should be done in selected cases.

1 主持人 四川大学华西第二医院产科邢爱耘主任医师 2 病例汇报人 四川大学华西第二医院产科张今成医师 3 病例摘要 患者刘某,31 岁, G6 P1 +4 (见下页表1 ).因"停经27 +4周,发现胎儿脐动脉( umbilical artery,UA)血流频谱异常3周"于2022-03-01入院.患者孕早期于成都市某生殖专科医院就诊,予"丙种球蛋白、集落刺激因子、重组人II型肿瘤坏死因子受体-抗体融合蛋白、培塞丽珠单抗、地屈孕酮、环孢素、赛能、美卓乐、安卓、依诺肝素、阿司匹林"等保胎治疗.孕15+4周于四川大学华西第二医院产科建卡规律产检.调整用药为口服赛能每日2 次,每次200 mg;美卓乐每日1次,每次4 mg;阿司匹林肠溶片每日1次,每次50 mg;优甲乐每日1 次,每次75 ug;皮下注射依诺肝素每日2 次,每次6000 IU;以及补充钙剂、铁剂、维生素D、叶酸等.孕16 +3周、21 周、22 +3周、23 +1周分别行产科超声检查未见异常.孕24 +4周胎儿彩超示UA舒张末期血流间歇性缺失,胎儿肠管回声稍增强,胎儿生长测值正常;孕期查抗核抗体1:100 , ENA谱、经典抗磷脂抗体、血栓组套、血浆D2 聚体、肝肾功能、无创产前检查、甲状腺功能、口服葡萄糖耐量试验、TORCH、胎儿心脏彩色多普勒超声检查未见明显异常.

目的 本文主要探讨了"网络教学"在妇产科教学中的具体运用.方法 网络教学结合翻转课堂,借助各类APP构建妇产科学教学网络平台,与本科生(包括外国留学生)进行课程指导、互动,将授课分为课前自学、课中答疑、课后测试与评估三阶段.课程结束后,学生在网络平台填写"教学反馈评价表"及"线上教学调查表",对教师的网络教学效果进行评估,即时反馈学生的建议和意见,不断完善网络教学.结果 学生可从网络资源中获取更多医学知识,通过各种音频、视频将抽象的重点、难点知识形象化、具体化和直观化,在学习过程中可以将自己的学习心得和问题及时向老师反馈,增加了自主学习的兴趣和积极性.结论 网络混合式教学不仅可行,而且具有传统课堂所不具备的优势.

对妇产科学教学开展课程思政的必要性与可行性进行分析,并通过探索性研究,论证在专业课程教学中融入医德医风等思政教育是必要且可行的,找到课程思政的切入点与方法 ,证实课程思政对学生积极正面价值观的形成具有显著作用.

Background To examine the association between the Apgar score and neonatal mortality over gestational age in China and to explore whether this association changed when Apgar scores were combined at 1 and 5 min. Methods Data for all singleton live births collected from 438 hospitals between 2012 and 2016 were used in this study. Poisson regression with a robust variance estimator adjusted for a complete set of confounders was used to describe the strength of the association between the Apgar score and neonatal mortality. Results The relative risks of neonatal death-associated intermediate Apgar score at 5 min peaked at 39–40 weeks of gestation and subsequently decreased if the gestational age increased to 42 weeks or above, in contrast to the low Apgar score. Among both preterm and term new-borns with Apgar scores at 5 min, new-borns that were not small for gestational age had a lower mortality rate than those that were small for gestational age. The association between Apgar score and the neonatal mortality was even stronger when scores at 1 and 5 min were combined. Conclusions Apgar score is not only meaningful for preterm new-borns but also useful for term new-borns, especially term new-borns that are not small for gestational age. Once the baby’s Apgar score worsens, timely intervention is needed. There is still a gap between China and high-income countries in terms of sustained treatment of new-borns with low Apgar scores.

Cesarean section is a common obstetric operation and an important method for saving the lives of mothers and their neonates in dangerous situations. Nevertheless, cesarean section has a higher risk and might have more complications compared with natural delivery. A reasonable choice of delivery method is important for maternal and neonatal health. The incidence of complications after cesarean section for mothers and neonates during the second stage of labor significantly increases compared with planned cesarean section. During the second stage of labor, the fetal head is deep in the pelvic cavity. If a cesarean section is performed at this stage, it is prone to causing complications, including difficult delivery of the fetal head, delayed uterine incision, and massive hemorrhage, which seriously threaten the health of the mother and her neonate. For the first time, we report a case of cesarean section after complete opening of the uterine orifice, which led to almost mistakenly suturing the cervix to the uterus. This report will hopefully help surgeons anticipate such incidents during cesarean section in the future.

1 病例报告 患者,36岁,因体外受精-胚胎移植(IVF-ET)术后妊娠19周,阴道流液5天,下腹坠胀7+小时,于2019年3月就诊于四川大学华西第二医院产科.2018年11月因原发不孕于外院行IVF-ET术,移植术后10+天,查血人绒毛膜促性腺激素(hCG)阳性提示受孕,孕8+周行B超检查提示宫内双绒毛膜双羊膜囊双活胎.孕16+6周于我院建卡并定期产前检查.地中海贫血基因检测提示孕妇为β-地中海贫血基因携带者,孕17周无创产前检测提示低风险.5天前患者出现少许阴道流液,7+小时前出现不规律下腹发紧收入我院.既往史:否认内外科疾病史及家族遗传病史,无妊娠、生育史.体格检查:生命体征平稳,心肺查体未见异常,腹膨隆,未见明显宫缩,窥阴器窥视阴道:阴道后穹隆未见积液,子宫颈管消退100％,宫口未开.辅助检查:胎儿彩超检查提示宫内双活胎,横位/枕右前位,双顶径(BPD):4.00/4.08 cm,股骨长(FL):2.46/2.37 cm,胎盘1:附着于子宫前壁,厚2.0 cm,0级;胎盘2:附着于子宫后壁,厚2.4 cm,0级.羊水1∶5.2 cm,羊水2∶4.2 cm.经阴道彩超检查提示:几乎未见闭合子宫颈管回声,子宫颈内口呈开放状态,开放约0.8 cm,可见前羊水囊嵌入其中,深约3.0～3.8 cm,几乎达子宫颈外口.

多胎妊娠延迟分娩(DID)是指多胎中的一胎(胎儿1)在中孕期,特别是胎龄≤24周时发生流产或早产后,孕妇子宫收缩逐渐减弱,宫口逐渐回缩,甚至宫颈管闭合,若及时采取措施,则可使宫内留存胎儿在宫腔内继续妊娠数天,甚至数周,待其各器官进一步成熟后再娩出.目前,随着女性受孕年龄增加及辅助生殖技术的应用,多胎妊娠发生率逐年上升,多胎妊娠发生胎儿1流产或早产后,对宫内留存胎儿实施DID的成功率也逐渐增高.多胎妊娠DID的适应证包括胎儿1于胎龄≤24周时分娩后,母体宫缩消退,不伴胎膜早破(PROM)、绒毛膜羊膜炎、严重阴道流血、可疑胎盘早剥及其他严重内科与外科合并症,宫内留存胎儿无胎儿宫内窘迫、先天畸形等.目前,DID临床处理措施包括:高位结扎胎儿1脐带,采取宫缩抑制剂抑制母体宫缩、抗菌药物预防母胎感染、宫颈环扎术及对母胎进行严密监护,必要时使用糖皮质激素促胎肺成熟.对宫内留存胎儿实施DID后,分娩时机掌握,非常重要.笔者拟就多胎妊娠胎儿1于胎龄≤24周时分娩后,对宫内留存胎儿实施DID的必要性、适用人群、临床管理、临床处理流程及多胎妊娠DID胎儿妊娠结局等最新研究进展进行阐述,旨在为相关临床研究提供参考.

1病历摘要 患者,26岁,G2P0,因孕37周,发现血压升高1 +月,头痛1周,恶心、呕吐1天,于2020年7月11日2时30分入院.孕妇于2019年12月20日至当地某三甲医院建卡,后旅居西藏,未做任何产前检查,2020年5月返回当地不定期产前检查.未行唐氏筛查、胎儿系统超声及胎儿心脏超声筛查.孕晚期行口服葡萄糖耐量试验(OGTT),因空腹血糖5.34 mmol/L,考虑诊断为妊娠期糖尿病,行糖尿病饮食及运动指导,血糖监测正常.

1 主持人: 四川大学华西第二医院姚强教授 2 病例汇报人:四川大学华西第二医院吕斌医师3 病例摘要患者,31 岁, G3 P0 .因孕 31 周,胎动减少半天,于2017 年4 月10 日急诊入院,患者孕期定期产检未见异常,半天前开始无明显诱因出现胎动减少,无应激试验(non－stress test,NST)无反应型,收入院.患者孕期精神食欲正常,大小便无明显异常,体重增加7 kg.给予地塞米松6 mg 肌注1 次促胎肺成熟,经宫内复苏后(左侧卧位、吸氧) ,复查 NST 仍为无反应型,胎儿生物物理评分6 分( NST 0 分,胎动0 分,羊水2 分,呼吸2 分,肌张力2 分) ,此时患者胎膜自然破裂,羊水Ⅰ度,考虑胎儿宫内窘迫,充分告知患者及家属病情及相关风险后,其选择行急诊剖宫产.术中见后羊水Ⅲ度,新生儿评分(Apgar)8 －9 －10 分,新生儿脐血 pH 7.19,出生体重1 430 g,新生儿气管插管吸羊水及气管内注入固尔苏240 mg,转新生儿科治疗.术中预防性使用抗生素头孢替唑钠.

目的 研究探究式——小班化教学模式下情景模拟教学法在妇产科见习教学中的应用价值.方法 选取四川大学华西临床医学院2015级临床医学专业学生228名,随机分为试验组和对照组,每组114人,每组分为6批次小班化开展教学.实验组在见习中采用情景模拟教学法,对照组采用传统见习教学法.通过阶段考试、期末考试以及教学反馈调查来评价教学效果.采用SPSS进行独立样本t检验和卡方分析.结果 试验组阶段考试成绩显著高于对照组(P＜0.05),期末考试成绩比对照组高,但差异无统计学意义(P＞0.05).课后反馈调查显示试验组认为情景模拟教学手段灵活(95.6％),教学内容丰富(90％),传授的知识点印象深刻(94.7％),能够激发学习兴趣(85％),提升综合能力(团队协作、沟通、分析)(97.3％),均显著高于对照组的传统教学法(P＜0.05).结论 探究式一小班化情景模拟教学可以提高妇产科见习教学效果,提升学生的综合能力.

Background Many foreign students have difficulty taking histories from Chinese patients, especially in clinical context of the Department of Obstetrics and Gynaecology. The efficacy of using standardized patients to prepare foreign students for communicating with Chinese patients and taking their histories was evaluated in this study. Methods Ninety-four four-year foreign students were assigned to one of three clinical sub-departments (gynaecology, obstetrics, and reproductive endocrinology) to practice history-taking; after practicing in one sub-department, the students were then crossed over to a different department. The histories were taken from real patients in the sub-departments of obstetrics and reproductive endocrinology and from standardized patients in the sub-department of gynaecology. Prior to contact with real patients in the sub-department of reproductive endocrinology, the students practised with standardized patients. The quality levels of the case reports generated in the three departments were compared by repeated measures ANOVA. The attitudes, satisfaction and suggestions of the students were also investigated through a questionnaire. Results The local Chinese language spoken by the patients was thought to be the most common difficulty students (76.7%) encountered while taking patient histories. Two-thirds and one-third of the students were interested in taking histories from standardized and real patients, respectively. Most students (94.2%) thought that working with standardized patients was useful for practising communication skills with Chinese patients. The total scores of the case reports were significantly different among the three groups ( P < 0.001), and compared with case reports collected from real patients, case reports collected from standardized patients were of better quality. However, the quality of the case reports taken from real patients was better when the case reports were generated by students who had previous practice with standardized patients than when they were generated by students lacking such experience ( P < 0.001). Conclusions Standardized patient training for practising history-taking can be included as part of the clinical training curriculum for foreign medical undergraduates in the Department of Obstetrics and Gynaecology in China.

1生物物理评分 生物物理评分(biophysical profile,BPP)是一个无创,易掌握、实施的产前胎儿监护手段.1980年Manning等提出将五个胎儿生物物理指标结合起来评估胎儿宫内状况比单一指标更准确,自此,BBP已广泛应用于产科临床实践.构成BPP的五个生物物理指标分别为:胎儿电子监护无应激试验(NST)和超声监护下的胎儿呼吸样运动(FBM)、胎动(FM)、胎儿肌张力(FT)及羊水量(AFV);每个指标依据表1的标准给予2分或0分.

OBJECTIVE:To investigate the expression of miRNA-148b-3p and its target gene in the placenta between normal pregnant women and pregnant women with intrahepatic cholestasis of pregnancy (ICP) and to explore the possible mechanism of glucose metabolism of offspring with maternal cholestasis.METHODS:There were 30 cases of normal pregnant women and 30 cases of pregnant women with ICP recruited in the study, all of whom underwent cesarean delivery from Mar. 2017 to Jan. 2018. Placenta tissues, maternal blood and cord blood were collected in each case. Maternal blood and cord blood were sent for biochemical detection. miRNA of placenta tissues was extracted and qRT-PCR was used to measure the expression of miR-148b-3p in the placenta. Normal HTR-8 cells were transfected with miR-148b-3p inhibitor/mimics wrapped with lipofectaine3000. qRT-PCR was used to measure the expression of miR-148b-3p, and Western blot was used to measure the expression of glucose transporter 1 (GLUT1) after transfection.RESULTS:Maternal fasting blood glucose (FPG) and its fetal cord blood insulin levels in the ICP group were significantly higher than those of control. The expression of miR-148b-3p in the placenta of ICP group was lower than that of control group ( P<0.05). Compared with inhibitor control group, the expression of miR-148b-3p was decreased in HTR-8 cells transfected with miR-148b-3p inhibitor ( P<0.05), while the expression of GLUT1 was increased ( P<0.05). Compared with mimics control group, the expression of miR-148b-3p was increased in HTR-8 cells transfected with miR-148b-3p mimics ( P<0.05), while the expression of GLUT1 was decreased ( P<0.05).CONCLUSION:miR-148b-3p might participate in glucose metabolism of offspring with maternal cholestasis through the negative regulation of GLUT1 expression in placental trophoblast cells.