Objective::To compare the analgesic effects of ibuprofen administered orally via two modes combined with a conventional, patient-controlled intravenous analgesia pump on maternal pain after cesarean section (CS).Methods::This prospective, randomized, controlled study enrolled females who underwent CS from August 2022 to August 2023 at Peking University First Hospital, Beijing, China. Participants were randomly assigned to either an as-needed ibuprofen group (300 mg orally upon request) or a scheduled ibuprofen group (300 mg every 12 hours for 48 hours). The primary outcomes assessed were postoperative pain levels using the Wong-Baker Faces Pain Scale-Revised and cumulative oxycodone consumption at multiple time points up to 48 hours post-delivery. Secondary outcomes included recovery parameters (time to first flatus, ambulation, and lactation initiation), patient satisfaction with pain control, and postpartum depression scores evaluated by the Edinburgh Postnatal Depression Scale on postoperative day 3. Normally distributed data analyzed with t-tests; non-normal data with Mann-Whitney U tests; categorical variables with chi-square or Fisher’s exact tests (SPSS 26.0, P < 0.05). Results::After excluding 61 non-eligible cases, 339 patients were included (171 as-needed vs. 168 scheduled). The scheduled group showed significantly better pain control at 12 hours (4.00 (2.00-5.50) vs. 4.00 (4.00-6.00), P < 0.001), 24 hours (4.00 (2.00-4.00) vs. 4.00 (2.00-6.00), P < 0.001), and 36 hours (2.00 (2.00-4.00) vs. 4.00 (2.00-4.00), P < 0.001), and 48 hours (2.00 (2.00-4.00) vs. 2.00 (2.00-4.00), P = 0.004) post-delivery and lower levels of oxycodone consumption at 36 hours (10.20 (8.20-13.35) vs. 11.00 (8.80-14.40), P = 0.042) and 48 hours (12.40 (10.40-15.95) vs. 13.80 (11.00-16.00), P = 0.020) postpartum compared with those in the as-needed group. Additionally, the time to the return of bowel movements was shorter in the scheduled group than in the as-needed group (23.50 (16.94, 31.47) vs. 27.00 (19.88, 35.97), P = 0.004). Differences in post-delivery ambulation, lactation initiation, satisfaction levels, and depression scores were not significantly different between the two groups. Conclusion::The results of this study promote the use of ibuprofen (scheduled oral administration) combined with a conventional, patient-controlled intravenous analgesia pump for achieving better post-CS pain control than an as-needed dosage regimen.Registration::Chinese Clinical Trial Registry, ChiCTR2400082474.

ObjectiveTo investigate the impact of dexmedetomidine-ropivacaine combination versus sufentanil-ropivacaine combination for epidural labour analgesia on neonatal and maternal outcomes and test the feasibility of a future large, randomised trial.DesignA randomised, double-blind, pilot clinical trial from 16 March 2023 to 15 June 2023.SettingA tertiary-care hospital in Beijing, China.Participants200 women aged≥18 years who had full-term single pregnancy and were scheduled for vaginal delivery with epidural analgesia.InterventionsEligible participants were randomly assigned in a 1:1 ratio to receive self-controlled epidural labour analgesia using ropivacaine supplemented with either dexmedetomidine (0.45 µg/mL for induction and 0.36 µg/mL for maintenance) or sufentanil (0.45 µg/mL for induction and 0.36 µg/mL for maintenance).Main outcomes and measuresThe primary endpoint was a composite of neonatal morbidity, including 1- or 5 min Apgar score<7, umbilical artery PH<7.1, requirement for immediate assisted ventilation and admission to neonatal ward or intensive care unit within 24 hours. Secondary and other endpoints included effect of analgesia and occurrence of adverse events. The feasibility of implementing the protocol was evaluated.ResultsAll 200 women were included in the intention-to-treat analysis. Composite neonatal morbidity occurred in 14.0% (14/100) of women with dexmedetomidine versus 17.0% (17/100) of women with sufentanil: relative risk 0.82, 95% CI 0.43 to 1.58. Women in the dexmedetomidine group had a comparable area under curve of pain intensity (median difference −2.0 point⋅h, 95% CI −9.9 to 5.9, p=0.638), required more self-controlled boluses (median difference two boluses, 95% CI 0 to 3, p=0.040) and epidural analgesics (median difference 17 mL, 95% CI 4 to 29, p=0.007), and experienced less pruritus (0.0% (0/100) vs 30.0% (30/100), p<0.001) but more lower limb weakness (13.0% (13/100) vs 1.0% (1/100), p<0.001). Recruitment rate was satisfactory (87.7%); the protocol was well accepted by anaesthesiologists and nurses.ConclusionsCompared with sufentanil-ropivacaine combination, use of dexmedetomidine-ropivacaine combination for epidural labour analgesia was associated with a 18% decrease in composite neonatal endpoint and deserve further investigation. The dexmedetomidine-ropivacaine combination provided comparable analgesia but increased mild motor block. The conduct of a large, randomised trial using same protocol requires careful re-evaluation.Trial registration numberNCT05698407.

Abstract Background Labor represents a period of significant physical activity. Inefficient energy supply may delay labor process and even lead to cesarean delivery. Herein we investigated whether ingestion of a carbohydrate-rich beverage could reduce cesarean delivery in laboring women with epidural analgesia. Methods This multicenter randomized trial was conducted in obstetrician-led maternity units of nine tertiary hospitals in China. Primigravidae with single term cephalic pregnancy who were preparing for vaginal birth under epidural analgesia were randomized to intake a carbohydrate-rich beverage or commercially available low-carbohydrate beverages during labor. The primary outcome was the rate of cesarean delivery. Secondary outcomes included maternal feeling of hunger, assessed with an 11-point scale where 0 indicated no hunger and 10 the most severe hunger, and maternal and neonatal blood glucose after childbirth. Results Between 17 January 2018 and 20 July 2018, 2008 women were enrolled and randomized, 1953 were included in the intention-to-treat analysis. The rate of cesarean delivery did not differ between the two groups (11.3% [111/982] with carbohydrate-rich beverage vs. 10.9% [106/971] with low-carbohydrate beverages; relative risk 1.04, 95% CI 0.81 to 1.33; p = 0.79). Women in the carbohydrate-rich beverage group had lower subjective hunger score (median 3 [interquartile range 2 to 5] vs. 4 [2 to 6]; median difference − 1; 95% CI − 1 to 0; p < 0.01); their neonates had less hypoglycemia (1.0% [10/968] vs. 2.3% [22/956]; relative risk 0.45; 95% CI 0.21 to 0.94; p = 0.03) when compared with those in the low-carbohydrate beverage group. They also had higher rates of maternal hyperglycemia (6.9% [67/965] vs. 1.9% [18/953]; p < 0.01) and neonatal hyperglycemia (9.2% [89/968] vs. 5.8% [55/956]; p < 0.01), but none required special treatment. Conclusions For laboring primigravidae with epidural analgesia, ingestion of a carbohydrate-rich beverage compared with low-carbohydrate beverages did not reduce cesarean delivery, but relieved maternal hunger and reduced neonatal hypoglycemia at the expense of increased hyperglycemia of both mothers and neonates. Optimal rate of carbohydrate supplementation remains to be determined. Trial registration www.chictr.org.cn ; identifier: ChiCTR-IOR-17011994 ; registered on 14 July 2017.

BackgroundKetamine is approved for antidepressant therapy, but evidence regarding its use in women with perinatal depression is lacking. Herein, we investigated the effects of low-dose ketamine in women with prenatal depressive symptoms and tested the feasibility of a future large randomized trial.MethodsThis was a randomized, double-blind, placebo-controlled pilot trial. Sixty-six women with prenatal depressive symptoms who were scheduled for elective cesarean delivery were randomized to receive either low-dose ketamine (0.5 mg/kg) or placebo (normal saline). The study drugs were intravenously infused over a 40-minute period after clamping the umbilical cord. The primary outcome was depression score assessed with the Edinburgh Postnatal Depression Scale at 48 h postpartum. Among other and safety outcomes, occurrence of nausea or vomiting was observed, pain intensity was assessed with the numeric rating scale. The feasibility of implementing the protocol was also evaluated.ResultsA total of 64 parturients were included in the intention-to-treat analysis. The depression score at 48 h did not differ between groups: median 9 (interquartile range 6 to 13) with ketamine vs. 8 (6 to 10) with placebo; median difference 1, 95% CI −1 to 3; P = 0.608. The pain intensity at 4 h postpartum was less severe in the ketamine group (median difference −1, 95% CI −1 to 0, P = 0.002). Among safety outcomes, intraoperative nausea or vomiting was less common in patients given ketamine (0.0% [0/33] with ketamine vs. 21.2% [7/33] with placebo, P = 0.011). Recruitment was satisfactory and the protocol was acceptable to participants and clinicians.ConclusionsA single low-dose ketamine infusion did not decrease the depression score at 2 days, but reduced intraoperative nausea and vomiting and lowered pain intensity at 4 h after cesarean delivery among women with prenatal depressive symptoms. The study protocol is feasible for a large randomized trial.Clinical Trial RegistrationThe study was registered with ClinicalTrials.gov (identifier: NCT03336541; 08/11/2017).

为了预防全身麻醉下行急诊剖宫产时,产妇可能出现的反流误吸,临床上对拟行自然分娩产妇在分娩期间的饮食加以限制,以液体为主.美国麻醉医师协会(American society of anesthesiologists, ASA)及美国妇产科医师协会(the American college of obstetricians and gynecologists,ACOG)均建议对无严重产科并发症的低危产妇在分娩期间口服适量清亮液体(如清水、黑咖啡及运动饮料等),但需要避免固体食物 [1-2].

OBJECTIVE:To analyze the predictive value of umbilical arterial cord pH on complications of hospitalized neonates after cesarean section.METHODS:This was a retrospective cohort study and carried out in Peking University First Hospital from January 1, 2017 to June 30, 2017. Neonates who were delivered by cesarean section were enrolled. The primary endpoint was the incidence of complications during in-hospital stay (including infection, aspiration pneumonia, myocardial damage, etc.). The subjects were divided into two groups:with or without complication. The umbilical arterial cord pH values were compared between the two groups. Perinatal baseline characteristics of maternal and neonatal data were recorded. The ROC curve was used to analyze the value of umbilical arterial cord pH in predicting neonatal complications during hospitalization. Multivariate Logistic regression was employed to analyze the potential risk factors of neonatal complications.RESULTS:In the study, 872 neonates were included in the final analysis (541 in elective surgery and 331 in emergency surgery). The overall incidence of neonatal complications during hospitalization was 14.1%. The first three higher incidences were infection, aspiration pneumonia and myocardial damage. The average pH value in neonates without complication was 7.31 while 7.29 in neonates with complication. There was statistical significance between the two groups (P<0.001). The overall incidence of pH≤7.20 was 3.1% (27/872). The patients in neonates without complication had higher incidence of pH≤7.20 than those in neonates with complication (1.6% vs. 12.2%, P<0.001). Multivariate Logistic regression showed 6 risk factors of neonatal hospitalized complications including preterm delivery (OR=8.224, 95%CI: 4.910-13.777, P<0.001), pregnancy-induced hypertension (OR=1.886, 95%CI: 1.004-3.546, P=0.049), intrauterine growth restriction (OR=4.429, 95%CI: 1.280-15.330, P=0.019), emergency cesarean section (OR=2.711, 95%CI: 1.682-4.369, P<0.001), umbilical arterial blood gas pH≤7.20 (OR=7.420, 95%CI: 2.951-18.655, P<0.001) and 5-minute Apgar score <10 scores (OR=11.849, 95%CI: 3.977-35.128, P<0.001). The areas under the ROC curve of umbilical arterial blood gas pH in all neonatal, elective and emergency cesarean section were 0.570 (95%CI: 0.508-0.633, P=0.012), 0.559 (95%CI: 0.465-0.652, P=0.189) and 0.617 (95%CI: 0.538-0.697, P=0.002), respectively.CONCLUSION:Umbilical arterial cord pH≤7.20 was related with increased incidence of neonatal complications after cesarean section,but ROC curve analysis showed a lower predictive value.

DOI:10.12089 / jca.2019.10.003 作者单位:100034 北京大学第一医院麻醉科 通信作者:曲元,Email:quyuanbj@hotmail.com 【摘要】 目的 比较两种硬膜外镇痛模式对肥胖产妇镇痛效果和分娩方式的影响。 方法 回顾 性分析 2013—2016 年本院肥胖产妇 586 例,年龄 21~43 岁,BMI 30~41 kg / m,ASAII或III级,按照镇痛 模式分为两组,每组 105 例:连续硬膜外输注组(CEI 组)和间歇脉冲硬膜外输注组(IEB 组)。 两组均 事先配置硬膜外注射混合液 0􀆰 08%罗哌卡因+0􀆰 45 μg / ml 舒芬太尼 200 ml。 CEI 组:背景剂量 6 ml / h, PCEA 剂量 6 ml,注药速率为 60 ml / h,锁定时间 30 min;IEB 组:脉冲频率每小时 1 次,剂量 6 ml,注药速 率 400 ml / h,PCEA 剂量 6 ml,锁定时间 30 min。 应用 SPSS 22􀆰 0 中倾向性评分匹配(PSM)模块,采用 1 ∶1最近邻匹配法、设定卡钳值为 0􀆰 01 进行倾向性匹配分析。 记录镇痛前、镇痛后 10、30 min 和宫口开 全时 NRS 评分;记录产程时间、分娩方式;记录镇痛药物总量、PCEA 追加次数、PCEA 有效次数和新生 儿 1、5 min Apgar 评分;记录镇痛期间不良反应的发生情况。 结果 宫口开全时 IEB 组 NRS 评分明显 低于 CEI 组[(3􀆰 8±0􀆰 7) 分 vs (4􀆰 2±0􀆰 7) 分, P<0􀆰 05]。 IEB 组三个产程时间明显长于 CEI 组(P< 0􀆰 05),PCEA 追加次数及 PCEA 有效次数明显少于 CEI 组(P<0􀆰 05)。 两组分娩方式、镇痛药物总量、 新生儿 Apgar 评分和不良反应发生率差异无统计学意义。 结论 IEB 模式为肥胖产妇提供良好的镇痛 效果,不影响分娩方式,可安全有效地用于肥胖产妇联合 PCEA 进行分娩镇痛。 【关键词】 硬膜外分娩镇痛;分娩方式;肥胖产妇;镇痛效果

Rationale: Postoperative delirium is extremely rare in young women and in minimally invasive endoscopic surgeries in gynecology and obstetrics. It greatly affects both physicians and patients. This report presents a special case of postoperative delirium after hysteroscopy in a young woman and a literature review of the associated etiology, diagnosis, and treatment. Patient concerns: A 39-year-old woman was admitted to the gynecology ward following irregular vaginal bleeding for 3 months and an intrauterine space-occupying lesion for 1 week. Hysteroscopy, endometrial polypectomy, and fractional curettage procedures were successfully performed; however, the patient became unresponsive after surgery. Diagnosis: Postoperative delirium. Interventions: Sedatives and vasoactive medicines, such as dexmedetomidine, midazolam, and dopamine were administered for maintenance treatment. Outcomes: The patients gradually regained consciousness. Lessons: Physicians should attach importance and improvise effective clinical management strategies for postoperative delirium based on clinical specialty characteristics and related guidelines.

As one of the most effective and commonly used analgesic methods during labor and delivery,epidural analgesia has been widely accepted in terms of its safety.Neurological complications following childbirth,which are most related to pregnancy and childbirth factors rather than labor analgesia,has not been well studied or recognized in China.Therefore,there are some confusions and misunderstandings of reasons for these neurological complications,and,to a certain extent,have affected the clinical implementation of epidural labor analgesia.This review analyzed the etiology and prognosis of this problem in order to help the clinicians in identifying the risk factors and causes and also to improve clinical awareness,prevention,and management for these conditions.

Objective To explore the effects of whole-stage labor analgesia on maternal and neonatal outcomes after the implementation of the new partogram.Methods A retrospective cohort study was performed in Peking University First Hospital.From June to December 2016,907 nulliparae with full-term singleton cephalic pregnancies that were expected to deliver vaginally and adhered to the new partogram were selected as the study group,and 982 cases that adhered to the old partogram (Friedman standard) from June to December 2012 were selected as the control group.Maternal basic characteristics and analgesic,obstetric and neonatal data were collected.Maternal and neonatal outcomes between the two groups were analyzed with independent sample t-test,rank sum test or Chi-square test (Fisher's exact test).Results (1) Maternal age and the proportion of gravidas of advanced maternal age in the study group were both higher than those in the control group [(30.2±3.0) vs (29.64-2.9) years,t=3.823;8.2％ (74/907) vs 4.2％ (41/982),x2=13.087;both P＜0.001].No statistically significant difference in the other basic characteristics was found between the two groups.(2) Women in the study group had significantly smaller cervical dilatation [M(P25-P75)] than that in the control group when analgesia was commenced [2(1-2) vs 2(1-3) cm,Z=-3.752].The intensity of pain quantified with numerical rating scale (NRS) before analgesia,and during the second stage of labor in the study group were less than that in the control group [8(8-9) vs 8(8-10) points,Z=-14.441;5(4-5) vs 6(5-7) points,Z=-16.495].The study group had longer median duration of analgesia than the control group [520(340-750) vs 300(200-453) min,Z=-17.801,P＜0.001].The overall dose of analgesics in injection pump in the study group was significantly higher compared with that used in the control group [68 (35-84) vs 30 (18-48) ml,Z=-18.004,P＜0.001].However,there was no significant difference in the incidence of analgesia-related complications (hypotension,accidental dura puncture,lower extremity numbness,pruritus and urinary retention) between the two groups.(3) The study group showed a higher percentage of spontaneous vaginal delivery,and a lower rate of converted cesarean section compared with the control group [71.8％ (651/907) vs 63.2％ (621/982),x2=15.623;13.6％ (123/907) vs 20.5％ (201/982),~=18.831;both P＜0.001].The study group had lower forceps-assisted vaginal delivery rate than the control group without statistically significant difference [14.8％ (133/907) vs 15.3％ (150/982),x2=0.093,P=0.797].The duration of the first,second and third stage of labor in the study group were all significantly longer than that of the control group [680 (470-900) vs 480 (360-660) min,Z=-12.490;56 (31-89) vs 37 (24-58) min,Z=-9.964;7 (5-10) vs 6 (5-8) min,Z=-6.673;all P＜0.001].Women in the study group had a lower rate of artificial rupture of membranes when comparing with the control group [55.2％ (501/907) vs 63.2％ (621/982),x2=12.516,P＜0.001].The incidence of fever,pathologically confirmed infection and postpartum hemorrhage were significantly higher in the study group than that in the control group [10.8％ (98/907) vs 6.4％ (63/982),x2=11.652;9.6％ (87/907) vs 3.7％ (36/982),x2=27.201;12.6％ (114/907) vs 5.7％ (56/982),x2=27.144;all P＜0.05].There was no significant difference in the rate of oxytocin use during labor or blood transfusion between the two groups.(4) Compared with the control group,the proportion of cesarean section due to arrested active stage of labor in the study group was significantly lower [5.7％ (7/123) vs 50.2％ (101/201),x2=68.173,P＜0.05],but the incidences of cesarean section due to intrauterine infection and relative cephalopelvic disproportion were higher in the study group [61.0％ (75/123) vs 30.8％ (62/201),x2=2.680;20.3％ (25/123) vs 8.0％ (16/201),x2=10.555;both P＜0.05].There was no significant difference in the proportion of fetal distress or other indications for cesarean section between the two groups.(5) There was no significant difference between the two groups in birth weight,macrosomia,fetal distress,neonatal asphyxia,or the proportion of neonatal intensive care unit admission.Conclusions After the implementation of the new partogram,analgesic pain relief covering the whole labor prolongs the average analgesic time and reduces the rate of cesarean section due to arrested active stage of labor.Although the risk of postpartum hemorrhage is slightly increased,analgesia itself does not pose additional risks on forceps-assisted delivery,maternal blood transfusion and neonatal asphyxia.

Moyamoya disease complicated with subarachnoid hemorrhage is a life-threatening condition in perinatal women. Perioperative anesthetic management of patients with this condition is critical to the health of mothers and neonates.Here we reported a case of this kind.The patient received cesarean section under general anesthesia.The general principle of anesthetic management of this patient is to maintain normal cerebral blood flow and cerebral perfusion while avoiding of the increase of intracranial pressure and cerebral oxygen consumption. During operation under intensive multi-indicator monitoring, we used propofol and remifentanil for sedation and anesthesia, and applied mechanical ventilation for maintenance of respiration. This case showed subarachnoid hemorrhage, the efforts were made to prevent spasm of cerebral vasculature, to reduce intracranial pressure, and to control systolic blood pressure in normal range after operation. The patient eventually recovered, and was discharged with a healthy neonate from hospital.We provided detailed information about the comprehensive treatment for the reference in the field.

Objective To investigate the effects of anesthesia management on maternal and neonatal prognosis in patients complicated with different types of placenta implantation. Methods A retrospective case review of the patients with placenta implantation from January 2009 to May 2017 at the department of Obstetrics in Peking University First Hospital was conducted. Patients with either natural or artificial abortion were excluded,and a total of 82 cases were enrolled into this study.According to the degree of placenta implantation,the cases were divided into 3 groups:accreta group(groupA,n=41),increta group(group I,n=20),and percreta group(group P,n=21).We analyzed the anesthesia management,and maternal and neonatal prognosis. Results Anesthetic paradigms among three groups were significantly different(P<0.05).In the accreta group,34 cases(82.9%)underwent spinal anesthesia, 6 cases(14.6%)underwent general anesthesia,and only 1 case(2.4%)was eventually switched to general anesthesia from initial spinal anesthesia (mixed anesthesia) during the operation. In the increta group, spinal, general, and mixed anesthesia were respectively performed in 11 (55.0%),6 cases (30.0%),and 3 (15.0%)cases,in the percreta group,2 (9.5%),12 (57.1%),and 7 (33.3%)cases underwent spinal, general, and mixed anesthesia, correspondingly. Patients with greater degree of placental implantation bled more and had higher rates of hysterectomy, and their neonates exhibited lower Apgar score 1 min after birth. Conclusions Spinal anesthesia can be used as the first choice of cesarean section complicated with placenta accrete, while general anesthesia should be considered in placenta percreta,especially those carrying abdominal aortic balloon catheters.

目的 观察口服碳水化合物对接受硬膜外分娩镇痛产妇产程中舒适度的影响.方法 选择接受硬膜外分娩镇痛的单胎、头位、足月初产妇90例,年龄24～39岁,BMI 21～39kg/m2,ASAⅡ级,随机分为两组:口服碳水化合物组(CHO组,n=46)和对照组(C组,n=44).在接受分娩镇痛后,CHO组饮用术能,C组饮用无渣液体,第三产程后两组均停止饮用液体.记录两组饮用时长、液体总量,计算两组液体供能;记录产程时长、分娩方式、PCEA镇痛泵按压次数、药物总量和产程中呕吐的发生情况;记录分娩镇痛后即刻以及第三产程结束即刻饥饿、口渴、疲劳程度NRS评分.结果 CHO组饮用液体总量少于C组,但差异无统计学意义[(129.5±28.8) ml vs(142.4±53.3)ml,P=0.15],CHO组液体供能明显多于C组[(312.2±69.5)kJ/h vs (153.9±96.7)kJ/h,P＜0.01].两组液体饮用时长、产程时长、分娩方式、镇痛泵药物总量差异无统计学意义.CHO组镇痛泵按压次数明显少于C组[0.6(0～11.6)次vs 2(0～8.6)次,P=0.03].CHO组产程中呕吐的比例明显低于C组[3例(6.5％) vs 10例(22.7％),P=0.03].第三产程后即刻CHO组饥饿NRS评分[2(0～9)分vs 6(0～10)分,P＜0.01]、疲劳程度[3(2～8)分vs 4(1～7)分,P=0.04]明显低于C组.两组口渴NRS评分差异无统计学意义.结论 口服碳水化合物作为接受硬膜外分娩镇痛产妇产程中的能量补充饮品可以降低产妇的饥饿疲劳程度,可降低产程中呕吐发生率,增加产妇的分娩舒适度.

Objective To compare the difference between intermittent epidural bolus(IEB) combined with patient controlled epidural analgesia(PCEA)and continuous epidural infusion(CEI)combined with PCEA mode in labor analgesia. Methods It was a retrospective cohort study ,which subjects were assigned to CEI+PCEA and IEB + PCEA group. Correlated data were collected to compare the effect of the two analgesic mode on perinatal events. Results There were less consumption of ropivacaine and sufentanil per hour ,less PCEA request and actual bolus in IEB + PCEA group. There were no significant difference between the delivery mode and the percentage of low Apgar score in neonates. Conclusion IEB+PCEA mode has better analgesic effect ,meanwhile doesn't disturb the delivery mode has no effect on the neonate outcome.

充分认识妊娠期生理改变对循环的影响及先天性心脏病的病理生理过程,有助于提高妊娠期及围产期的安全性.本文回顾2例妊娠合并先天性心脏病及肺动脉高压的患者并结合文献分析麻醉管理的要点.

近年来,妊娠及产褥期静脉血栓形成性疾病,尤其是深静脉血栓疾病已经引起了重视,但对颅内静脉血栓形成尚缺乏关注。研究表明,颅内静脉血栓形成是危及妊娠和产褥期女性生命的严重并发症[1]。颅内静脉血栓形成的临床症状复杂多样,不具备特异性,易被误诊,尤其是硬脊膜穿破后头痛(post dural puncture headache,PDPH)的患者。我院遇到2例产褥期 PDPH 合并颅内静脉血栓形成的患者,现报道如下。

Objective To observe the influence of epidural labor analgesia on the maternal and neonatal outcomes of trial of labor after cesarean section (TOLAC). Methods In this retrospective study, one hundred and three parturients who chose TOLAC at the Peking University First Hospital from August 2010 to May 2017 were enrolled. The perinatal information including age, BMI, prenatal diagnosis, past history, prenatal hemoglobin, mode of delivery, duration of delivery, ammiotomy, fever, use of oxytocin during labor, neonatal Apgar score, and the incidence of fetal distress was collected. The independent sample t-test was used to compare the differences in age, BMI, time after last birth, gestational age, prediction of fetal weight in 36 weeks prior to birth, neonatal length, neonatal weight, and prenatal hemoglobin between the two groups of subjects who underwent repeated cesarean section (RCS) or not. The t-test was used to compare the differences in duration of first and second stage of delivery between the two groups of subjects who accepted epidural labor analgesia or not. The rank sum test was used to compare the difference in gravidity between the two groups of subjects who undertaken RCS or not, and the Apgar score between the two groups of subjects who accepted epidural labor analgesia or not. The chi-square test was used to compare the difference in combined internal, gynecological, obstetrical diseases, oxytocin, fever, ammiotomy, and epidural labor analgesia between the two groups of subjects who undertaken RCS or not, and the incidence of forceps assisted delivery, neonatal distress, and admission to NICU between the subjects who accepted epidural labor analgesia or not. Multivariate logistic regression analysis was applied to investigate the relationship between perinatal factors including epidural labor analgesia and delivery mode of TOLAC. Results Among the 103 parturients who chose TOLAC, 23 (22.3%) underwent RCS. Between the two groups of subjects who undertaken RCS or not, BMI [(29±5) kg/m2vs (27±3) kg/m2, t=2.55, P=0.01], past gynecological diseases (13.0% vs 11.3%, χ2=4.82, P=0.03), and the rate of acceptance of epidural labor analgesia (13.0% vs45.0%, χ2=7.75, P 0.05). BMI was identified to be an independent risk factor of RCS (β=0.164, P=0.03) while acceptance of epidural labor analgesia was an independent protective factor for RCS (β=-1.600, P=0.02). Conclusion Epidural labor analgesia can decrease the rate of RCS in women who have an earlier cesarean section but is accompanied by the prolonged first stage of labor. Using epidural labor analgesia has no obvious influence on the incidence of neonatal distress. Key words: Labor analgesia, epidural; Trial of labor after cesarean section; Virginal birth after cesarean section; Repeated cesarean section; Fetal distress

Objective To investigate the effect of the different phases of menstrual cycle on the incidence of post-operative nausea and vomiting (PONV)after laparoscopic gynecological surger-ies.Methods A total of 228 women undergoing laparoscopic gynecological surgeries were enrolled from Mar 2016 to Feb 2017 in our hospital.They were classified into three groups according to the different phases of menstrual cycle at the time of surgeries:group follicular phase (n =98),group o-vulatory phase (n =79),and group luteal phase (n =59).The incidence of PONV and the use of res-cue antiemetic drugs were recorded within 0-2 h,0-24 h periods after surgeries.Multivariate Logistic regression analysis was applied to identify independent risk factors of PONV.Results The incidence of 0-2 h PONV and 0-24 h PONV were 23.2% (53/228)and 54.8% (125/228)respectively.Univa-riate analysis showed that the incidence of PONV in the different phases of menstrual cycle was not statistically significant,as well as 0-24 h.Multivariate logistic regression analysis showed that the risk of 0-2 h PONV in group luteal phase might be higher than that in group follicular phase,however, the difference was not statistically significant (OR =2.289,95%CI 0.979-5.355,P =0.056).And two independent risk factors of 0-2 h PONV were identified:duration of operation > 1 h (OR =3.176,95% CI 1.567-6.436,P = 0.001 )and history of PONV (OR = 5.711,95% CI 1.710-19.080,P =0.005).Three independent risk factors of 0-24 h PONV were identified:duration of op-eration>1 h (OR = 2.714,95%CI 1.525-4.829,P = 0.001 ),postoperative PCA (OR = 2.717, 95%CI 1.233-5.986,P = 0.013 )and application of metronidazole (OR = 3.926,95%CI 1.808-8.527,P =0.001).Conclusion There was no significant effect of different phases of menstrual cycle on the incidence of nausea and vomiting after gynecologic laparoscopic surgeries.

肾移植后妊娠是高危妊娠,较为罕见.了解肾移植术后的治疗和管理,有助于做出更好的临床决策,保证母婴安全. 患者,女,31岁,因"孕30+1周,胸闷、浮肿半月"急诊入院.孕24周时,BP150/100mmHg,加用硝苯地平缓释片30mg,后改为氨氯地平5mg,孕28周时,BP160/100mmHg,自觉胸闷、浮肿,于当地医院测得BP180/120mmHg,尿蛋白+++,血清肌酐(Scr)240μmol/L,白蛋白(ALB)26.9g/L,脑钠肽(BNP)232pg/ml.患者2005年体检时发现血尿、蛋白尿,未治疗.2006年孕期BP升高至180/110mmHg,Scr360μmol/L,顺娩后Scr升高至800μmol/L,后于2008年行肾移植术.2011年因BP不高自行停用降压药,目前口服甲强龙、吗替麦考酚酯和他克莫司.

Objective To investigate the efficacy of intermittent epidural bolus ( IEB) for patient?controlled epidural analgesia ( PCEA) during delivery. Methods Eighty?five parturients requesting epi?dural analgesia, who were at full term ( 37-42 weeks of gestation) with a singleton fetus in vertex presenta?tion, of American Society of Anesthesiologists physical statusⅠorⅡ, with body mass index< 35 kg∕m2 , were divided into either IEB group ( n=42) or continuous epidural infusion ( CEI) group ( n=43) using a random number table. The analgesia solution contained 0.08% ropivacaine and 0.4μg∕ml sufentanil in both groups . IEB settings were a 6 ml bolus every hour at the rate of 400 ml∕h with a bolus dose 6 ml and lockout interval 30 min. CEI settings were background infusion 6 ml∕h with a bolus dose 6 ml and lockout interval 30 min. Numeric rating scale score was maintained≤5, and if the efficacy was not satisfactory, a bolus of pump solution 5-10 ml was added. The consumption of analgesics per hour, initial PCA time, and occur?rence of lower extremity numbness, motor block, nausea and vomiting, and pruritus were recorded. Pa?tients′satisfaction with analgesia was scored, and the duration of labor and mode of delivery were recorded. Results Compared with group CEI, the initial PCA time was significantly prolonged, the satisfaction score was significantly increased, the incidence of lower extremity numbness was significantly decreased ( P<0.05) , and no significant change was found in the consumption of analgesics per hour, incidence of motor block, nausea and vomiting, and pruritus, constituent ratio of mode of delivery, and duration of la?bor in group IEB ( P>0.05) . Conclusion IEB can be safely and effectively used for PCEA during deliver?y, and the efficacy is better than that of CEI in the parturients.