Epidural labor analgesia aims to provide effective medical services to alleviate labor pain in parturients, while adhering to the principles of voluntary participation and clinical safety. In 2018, Peking Union Medical College Hospital(PUMCH)became one of the first pilot units for labor analgesia in China, and has achieved satisfactory results in high-quality development of labor analgesia. This article mainly introduces the achievements and experience of labor analgesia at PUMCH, including: (1) prioritizing maternal and infant safety, arranging personnel rationally, and developing standardized treatment processes through multidisciplinary collaboration to ensure safe and comfortable childbirth; (2) leveraging the hospital's comprehensive capabilities in emergency treatment, and improving collaborative rescue plans for critically ill parturients and newborns; (3) implementing advanced teaching methods to effectively train and conduct simulated drills for labor analgesia and rescue of critically ill parturients; (4) conducting patient education and informative lectures to help parturients acquire a scientific understanding of labor analgesia. We hope that this experience can provide reference and inspiration for other hospitals.

The immune system plays an important role in the treatment of tumors. Immune checkpoint inhibitors represented by monoclonal antibodies have achieved success in the field of anti-tumor and changed the pattern of tumor treatment. In this paper, we review immune checkpoint inhibitors of cytotoxic T lymphocyte associated antigen 4 (CTLA-4), programmed cell death protein 1 (PD1/PD-L1) pathway, and new immune checkpoint targets. We also summarize the clinical applications and immune-related adverse events (irAEs) of immune checkpoint inhibitors. Key problems remain to be solved, such as how to identify the benefit population, how to manage irAEs better, and how to overcome drug resistance.

2018年国家卫生健康委员会医政医管局发布了《关于开展分娩镇痛试点工作的通知》,各省市自治区均有多家医院成为国家分娩镇痛试点医院.妇产专科医院和妇幼保健院的椎管内分娩镇痛率普遍较高,部分医疗机构高达80％以上.北京及上海等某些综合医院椎管内分娩镇痛率已超过40％ [1],但仍有其他城市大量综合医院提升有限,甚至无法突破40％的及格线.本文对中国医学科学院北京协和医院开展椎管内分娩镇痛的相关工作流程及经验进行总结,希望能有可借鉴之处,促进综合医院椎管内分娩镇痛工作的开展.

Background The objective of this systematic review was to explore the association between private health insurance and health care utilization. Methods We searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases for relevant articles since 2010. Studies were eligible if they described original empirical research on the utilization of public health care by individuals with private health insurance, compared with individuals without private insurance. A pooled measure of association between insurance status with health care utilization was assessed through meta-analysis. Results Twenty-six articles were included in the final analysis. We found that patients with private insurance did not use more public health care than people without private insurance (P < 0.05). According to the subgroup analysis, people with private insurance were more likely to be hospitalized than people with no insurance (OR 1.67; 95% CI, 1.18 to 2.36). Conclusions People with private insurance did not increase their use of health care (outpatient services), compared to those without private insurance. Private health insurance coverage may ease the financial burden on patients and on the public health insurance system.

Yolk sac tumor (YST) is a rare malignant germ cell tumor, which usually affects young males. Because of the low incidence, few studies on YST have been published. In our study, we aim to investigate the clinical characteristics, survival and risk factors of male YST patients based on the Surveillance, Epidemiology, and End Results (SEER) program. We identified 569 male YST patients from the SEER-18 database with additional treatment fields. Clinical characteristics, survival and prognostic factors were described in the study. Chi-square tests were applied to analyze categorical and continuous variables between different groups. Univariate and multivariate Cox proportional hazard model were performed to assess the relative impacts of risk factors on cancer-specific survival (CSS) in YST patients. Kaplan–Meier method and the log-rank test were used to analyze differences in survival that were significant. The major primary sites of YST were testis (74.69%), mediastinum (15.47%), retroperitoneum (2.64%) and central nervous system (1.24%). The 3-year and 5-year CSS was 70.0%, 56.5% vs. 97.2%, 96.0% for the mediastinal and testicular YST patients, respectively (p < 0.001). Primary site of mediastinum, distant SEER Summary stage were independent factors of poor prognosis (hazard ratio (HR) = 2.010 (1.094–3.695), p = 0.025; HR = 6.501 (2.294–18.424), p < 0.001, respectively). Receiving surgery was a good prognosis factor for all patients (HR = 0.495 (0.260–0.940), p = 0.032) and for the mediastinal group (p = 0.0019). Being treated with chemotherapy indicated poor outcome in all patients (HR = 3.624 (1.050–12.507), p = 0.042) and in the localized testicular YST patients (p = 0.0077). For the first time, our study revealed the primary site distribution of male YST, and summarized the clinical characteristics, survival and prognostic factors based on the SEER database, which provided important epidemiological evidence for clinical practice.

目的 分析"智慧医疗"在提高患者就诊体验和医疗服务质量方面的应用价值.方法 利用虚拟入院系统、智能预约平台、床位统筹调配、医保实时结算、移动电子支付等手段,为患者提供入院登记、床位调配、检查检验、费用结算、出院随访等服务.结果 推行"智慧医疗"服务模式后,在手术人次增长与手术难度提高情况下,2019年1月-6月患者平均住院时间、术前待床日分别缩短至8.10天及2.68天,平均治疗费用也有所降低;住院患者满意度提高至96.42％;形成了标准的服务流程与管理规范.结论 "智慧医疗"有利于为患者提供高效、便捷、优质的服务,改善患者就诊体验,提高医疗服务质量.

目的 探讨新生儿尿布疹评估量表汉化后的信效度.方法 经原量表作者同意,对国外已形成的新生儿尿布疹评估量表进行引进和汉化.对2019年7～11月北京市某三级甲等医院产科病房112例新生儿进行评估,通过内部一致性信度、评定者间一致性信度进行量表信度的检验,通过内容效度进行量表效度的检验.结果 新生儿尿布疹评估量表的信效度检验结果:Cronbach'sα系数为0.744,评定者间信度为0.939,内容效度为0.925.结论 中文版新生儿尿布疹评估量表具有较好的信度和效度,可用于国内新生儿尿布疹严重程度的评估,为临床干预和动态评估提供依据.

目的:探讨腹腔穿刺与腹腔输液港在卵巢癌患者腹腔化疗中的应用效果.方法:选择2017年1月至2018年12月住院行腹腔化疗的卵巢癌患者90例,其中腹腔穿刺组患者45例,腹腔输液港组患者45例.对比2组患者的治疗效果、导管相关并发症发生情况、穿刺时疼痛评分、一次性穿刺成功率以及疗程完成情况.结果:两组患者治疗效果比较差异无统计学意义(P>0.05);导管相关并发症发生情况,两组比较差异无统计学意义(P>0.05);腹腔输液港组患者穿刺疼痛评分低于腹腔穿刺组,两组M(P25,P75)评分分别为2.00(1.40,2.50)和5.33(5.00,5.67),差异具有统计学意义(P<0.05),腹腔输液港组患者有18例主诉在留置期间存在腹部异物感;腹腔穿刺组患者一次性穿刺成功率为87.44％(181/207),腹腔输液港组患者为95.04％(249/262),两组比较差异具有统计学意义(P<0.05);腹腔穿刺组患者疗程完成率为82.22％(37/45),腹腔输液港组为95.56％(43/45),差异具有统计学意义(P<0.05).结论:腹腔输液港相较于腹腔穿刺应用于腹腔化疗中,其一次性穿刺成功率更高,疗程完成度更好,故在经济条件允许且化疗周期较长、腹部穿刺困难或对疼痛不耐受的患者可考虑置入腹腔输液港.

Objective To evaluate the effect of intravenous dexmedetomidine on intraoperative sedation and adverse events in parturients undergoing Cesarean section using combined spinal-epidural anesthesia . Methods Fifty singleton parturients at term scheduled for Cesarean section under combined spinal -epidural anes-thesia were allocated to two groups using random numbers:dexmedetomidine group (study group, n=25) and nor-mal saline group (control group, n=25).All the parturients received 0.5%hyperbaric bupivacaine 8 mg intrathe-cally following subarachnoid puncture .After delivery of the baby , the study group received dexmedetomidine 1μg/kg intravenous bolus infusion for 10 minutes followed by 0.5μg/(kg? h) continuous infusion until the end of surgery , whereas the control group was infused with equivalent amount of normal saline .Ramsay scores were recor-ded every 30 minutes during the surgery .The incidence of intraoperative adverse events and adverse drug reactions were also recorded , as well as 1-minute and 5-minute Apgar scores of the newborns .Results Ramsay score of the study group was significantly higher than that of the control group (3.4 ±0.7 vs.2.2 ±0.4, P=0.001).Inci-dences of shivering (0 vs.16%, P=0.001), nausea and vomiting (8%vs.36%, P=0.019), abdominal dis-comfort upon surgical traction (12%vs.48%, P=0.006) in the study group were all significantly lower than those in the control group .In terms of adverse drug reactions , incidence of bradycardia in the study group was higher than that in the control group (24%vs.0, P=0.011) , while incidences of hypotension , oversedation , and respiratory depression showed no significant difference between the two groups .Apgar scores of the two groups also showed no significant difference .Conclusions Intravenous dexmedetomidine could improve intraoperative sedative effect in parturients undergoing Cesarean section under combined spinal -epidural anesthesia and reduce the incidence of intraoperative adverse events with little adverse reaction and no influence on neonates .

A 38-year-old woman was pregnant with a history of panhypopituitarism. In 2006, she underwent transsphenoidal pituitary adenoma resection with a diagnosis of pituitary adenoma. The adenoma was not totally resected due to its location wrapping around the left internal carotid artery. The pathological diagnosis was growth hormone adenoma. In 2006, she was treated with γ system radiosurgery and Somatostatin. Secondary glucose intolerance was diagnosed in 2007. In 2008, she received the single nostril expanded transsphenoidal pituitary GH invasive macroadenomas resection and the sellar floor reconstruction. After the surgery, she suffered from visual field damage, polyuria and the hormonal testing revealed panhypopituitarism. She was treated with levothyroxine, artificial menstrual cycle (Climen), desmopressin acetate tablets and prednisone. Her husband's semen analysis showed oligospermia and asthenospermia. With a desire of having a baby, she was treated with in vitro fertilization and embryo transfer (IVF-ET) and intracyto plasmic sperm injection (ICSI) in 2011. Her last menstrual period was on November 1, 2011. Eight sinus follicles were seen on November 2 (d2). She was treated with FSH 150 U and HMG 150 U daily for 10 days from November 2 (d2-d11). Then she was given FSH 150 U, HMG 150 U and LH 75 U on November 12 (d12). FSH 75 U, HMG 150 U and LH 75 U were given on November 13 (d13). On November 14 (d14), 3 follicles were measured more than 18 mm in diameter and the level of E2 was 1 495 pg/ml. The rHCG 250 U was given intramuscularly at 8 p.m. Ova harvest performed at 8 a.m. and ICSI performed at 1 p.m. November 16 (d16). Progesterone 40 mg was given twice a day after ova harvest. An intrauterine insemination performed 36 hours later. The progesterone dosage was decreased after December 1. At 6 weeks and 4 days, an ultrasound revealed one fetal heart rate, the progesterone was stopped. She was treated with levothyroxine, desmopressin acetate tablets, growth hormone and prednisone during her pregnancy. Her antenatal period was eventful. Her thyroid function, blood pressure and blood glucose level were with normal range during the pregnancy and no recurrence of the adenoma was found. Caesarean section was performed at 38 weeks of gestation. The surgery was successful. The blood pressure was stable. A healthy male baby was delivered. The patient was transported to the intensive care unit for the first 24 hours. She was treated with hydrocortisone succinate 100 mg at the day of surgery and 50 mg at the first day after the surgery. Then the dosage of prednisone was the same as it was during the pregnancy. The dosage of levothyroxine was reduced one third after the first day of surgery. The patient went home 3 days after the surgery. No recurrence of the adenoma after delivery and breastfeeding. The baby was 1 years old and healty. Panhypopituitarism is a rare disease. The patient with panhypopituitarism is usually secondary to some other disease such as pituitary adenoma, apoplexy, lymphocytic hypophysitis and the Sheehan's syndrome.1,2 Women with hypopituitarism are known to have lower pregnancy rates. To make the pregnancy of a woman with panhypopituitarism smooth is challenging. There was one report that the response of patients with hypogonadotropic hypogonadism to hMG alone was poor and did not result in ovulation. The study reported that adjuvant GH has been used in women with hypogonadotropic hypogonadism and GH deficiency to reduce the amount of gonadotropins required for ovulation induction with mixed results.3 With GH treatment there is a reported risk of glucose intolerance and the potential of pituitary tumor recurrence and cancer. The blood glucose level should be monitored and the adjustment of antidiabetic medicine might be needed. Patient with panhypopituitarism should be more carefully monitored during her pregnancy and should be followed up by both the obstetricians and endocrinologist. Our experience gives a ray of hope for women with panhypopituitarism to be pregnant and have a healthy baby.

Postpartum hemorrhage is an obstetrical emergency, and it is a major cause of maternal morbidity.Since the unified diagnostic criteria of postpartum hemorrhage is lacking, the incidence rate of postpartum hemorrhage varies widely in various regions.The most common cause of postpartum hemorrhage is uterine atony.Every pregnant woman has the possibility of postpartum hemorrhage.In recent years, the incidence of refractory severe postpartum hemorrhage caused by placenta disease is increasing, the clinicians should pay attention to it.

早产是产科常见的并发症,占全球分娩总数的12％左右,是影响新生儿发病率、死亡率的重要因素,并影响新生儿预后.早产根据病因可分为自发性早产和医源性早产.由于分娩的动因不清,自发性早产的发病机制尚不明确,一般认为是由多因素造成的.基质金属蛋白酶(matrix metalloproteinases,MMPs)在细胞外基质降解中发挥重要作用.MMPs可裂解胶原、弹性蛋白、明胶和酪蛋白等,在胚胎发育、形态学及组织吸收与重建中起重要作用,参与关节炎、肿瘤、心血管及神经系统疾病的病理生理过程.近年的研究提示,其可能同样参与自发性早产的发生.本文对MMPs与自发性早产的关系进行综述.

Objective:To investigate the relationship between placenta previa and postpartum hemorrhage,and reveal the clinical character of the patients with postpartum hemmorrahge. Methods:The data of the patients with placenta previa in Peking Union Medical College Hospital were analyzed retrospectively. Results:A total of 9,086patients were delivered in Peking Union Medical College Hospital from Jan 2009to Jun 2012.Placenta previa occurred in 222patients(2.4%).Among them,174patients were suffered with marginal placenta previa,34patients with complete placenta previa,and 14patients with incomplete placenta previa.Thirty seven patients with marginal placenta previa delivered vaginally,while others underwent ceserean section.Postpartum hemorrahge occurred in 39patients(17.6%).All patients with postpartum hemorrhage were treated successfully.Twelve patients were treated with medicine and massage to enhance uterine contraction.Four patients were treated with local suture after enhancing uterine contraction.Other 23patients were treated with some other procedure addition to the enhancement of uterine contraction.Among them,6patients were treated with intrauterine packing,5patients with Bakriintrauterine packing,8patients with B-Lynch suture,2patients with uterine artery embolism and 2patients with hysterectomy.No severe complications occurred.Among 39patients with postpartum hemorrhage, 15patients were suffered with complete placenta previa(38.5%),13patients with placenta implantation or adhesion(33.3%),and 5patients with history of cesearen section(12.8%). Conclusions: Complete placenta previa,history of cesearen section and placenta implantation or adhesion were risk factors of postpartum hemorrahge.Enhancement of uterine contraction,local suture, intrauterine packing,B-lynch suture,uterine embolism and hysterectomy were staged treatment of postpartum hemorrahge.

产后出血(postpartum hemorrhage)是导致孕产妇死亡的首要原因.引起产后出血的原因分别为子宫收缩乏力、胎盘因素、软产道裂伤及凝血功能障碍.产后出血的病因治疗是最根本的治疗,是产后出血救治成功的关键.产后出血的药物治疗主要是针对子宫收缩乏力宫缩剂的治疗.缩宫素为一线用药,当单独手法按摩子宫和缩宫素不能达到止血目的时,可以考虑使用卡贝缩宫素、卡前列素氨丁三醇或卡前列酸栓.在没有注射用宫缩剂或注射用宫缩剂使用禁忌时可以考虑使用米索前列醇.当药物加强宫缩治疗无效时应注意不同药物的起效时间及持续时间.此外,一方面要重新核对有无合并其他原因所致产后出血;另一方面应及时采用必要的进一步治疗如宫腔填塞或子宫动脉栓塞等.

Objective To investigate the role of Bakri balloon insertion following unsuccessful medical management of postpartum haemorrhage (PPH).Methods The clinical features of patients with PPH managed with Bakri balloon in our department between January and July 2012 were retrospectively reviewed.The therapeutic role of Bakri balloon was analyzed.Results Eight cases were managed with Bakri balloon during the study period.Caesarean section (CS) was performed in all these cases,among whom seven were due to placenta previa.Two cases had disseminated intravascular coagulation (DIC).Three cases needed a second procedure to stop the bleeding,among whom two had placenta previa,previous CS,and placenta accreta.No patient experienced postpartum abdominal pain or fever.Conclusions Bakri balloon tamponade is effective and safe in the management of PPH unresponsive to standard management.Patients should be carefully monitored after the placement of Bakri balloon.Central placenta previa with a history of CS,placenta accreta or placenta adherence may impact the success of Bakri balloon placement.

目的 分析妊娠合并甲状腺功能减退症(甲减)或亚临床甲减者经过激素替代治疗的妊娠结局. 方法 回顾性分析2010年1月至2011年9月在本院妇产科分娩的单胎妊娠合并临床甲减(64例)或亚临床甲减(65例)共129例(病例组)患者,均在我院产科和内分泌科定期随诊,其中121例患者孕期甲功控制在正常范围.选取同期正规产检并分娩的无甲状腺疾病合并症产妇2,355例作为对照.比较病例组与对照组的一般情况和妊娠结局,并进一步分析病例组中甲状腺球蛋白抗体(TG-Ab)和抗甲状腺过氧化物酶抗体(TPO-Ab)对妊娠结局的影响. 结果 (1)临床甲减组妊娠期高血压疾病(子痫前期+妊娠期高血压)的发病率(7.7％)高于对照组(2.3％,P＜0.05),新生儿结局(新生儿孕周及出生体重)及其它妊娠并发症[胎心率不可靠(nonassuring fetal heart rate)、妊娠期糖尿病、羊水过少、胎膜早破、新生儿窒息、早产等并发症]的发生率在三组间没有统计学差异(P＞0.05).(2)病例组中,99例患者进行了抗体的检查,TPO-Ab阳性率为48.5％,TG-Ab的阳性率为40.4％,抗体异常与无异常的患者、新生儿结局及妊娠合并症发生率均无显著性差异(P＞0.05). 结论 本研究纳入病例中,除妊娠期高血压疾病的发生率在临床甲减的孕妇组中有升高以外,孕期临床甲减或亚临床甲减患者经过激素替代治疗控制甲功在正常范围内,妊娠不良结局的发生率较对照组无明显增加,也没有观察到甲状腺自身抗体对妊娠结局的不良影响.

与其他的妊娠期合并症相比,妊娠合并肿瘤并不常见.但随着人们对于孕期保健的重视和肿瘤诊断水平的提高,妊娠合并肿瘤的相关问题越来越受到产科医师和肿瘤科医师的关注.妊娠本身对于肿瘤的影响如何,而肿瘤又将如何影响母婴的安全,一旦发现肿瘤就立即积极处理还是与肿瘤"和平共处"直到胎儿成熟……越来越多的问题在医师与患者之间、医师与医师之间讨论着.在这些宏观问题与细节中,无不渗透着规范化与个体化的原则.本文通过对近年国内外关于妊娠与肿瘤的相关研究进行综述,希望能起到抛砖引玉的作用,为更多的患者和医师带来帮助.

过敏反应是一种急性、可能威胁生命的累及多系统的综合征,围产期的过敏反应比较少见,但是如果一旦发生,而临床医生没有快速识别、恰当处理,会导致母亲的低血压和低血氧,严重的并发症及新生儿后遗症,甚至母胎死亡,产科医护人员都要了解围产期过敏的识别与处理,引起重视.本文介绍两例围产期过敏性休克的病例,并复习文献进行探讨.