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

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.

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.

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 investigate the influence of two labor analgesia methods on pregnancy outcomes and incidence of adverse events during analgesia. Methods The study retrospectively investigated 121 healthy parturient women as the control group who received EA+PCEA analgesia from November 2013 to March 2014 and had full-term, single fetal head fetus without obstetric pathological conditions such as cephalopelvic disproportion or pregnancy with internal diseases. The observation group included 110 healthy parturient women who received EA + PCEA within background mode from November 2014 to March 2015. Numeric rating scale ( NRS) was used to evaluate the pain at 10 min, 30 min, and 1 h after the delivery. Meanwhile, adverse pregnancy outcome and incidence of adverse events were compared between two groups. Results 1 h NRS score and urinary catheterization times had statistical differences (P <0. 01). But the differences of duration of labor, postpartum hemorrhage, delivery mode and neonatal outcome between two groups had no statistical significance (P>0. 05). Conclusions EA+PCEA within background mode performs better in effective and lasting analgesia, but has no influence on postpartum hemorrhage, delivery mode and neonatal outcome.

Objective To investigate the influence of biological rhythm on labor pain,epidural analgesia and delivery mode in parturients.Methods In this retrospective cohort study,3 571 Chinese nulliparas with term singleton cephalic pregnancy who were preparing to deliver vaginally and receive epidural analgesia,were included.Parturients were divided into four groups according to the beginning time of analgesia,i.e.,morning group (7:01 to 13:00,n=955),afternoon group (13:01 to 19:00,n=1 159),evening group (19:01 to 1:00,n=763),and night group (1:00 to 7:00,n=694).Pain scores were assessed using a numeric rating scale (NRS) before and after epidural analgesia.Delivery mode,incidence of adverse events and neonatal outcomes were also compared among the four groups with monovariance analysis,LSD,Chi-square test or Fisher's exact test,Bonferroni,General Linear Model (GLM) and Logistic regression analysis.Results (1) The NRS pain scores of morning,afternoon,evening and night groups before analgesia were 8.6± 1.0,8.8± 1.0,8.9± 1.0 and 8.7± 1.0,respectively.After adjusted by GLM,the NRS pain scores of the four groups were 8.6±0.0,8.8 ± 0.0,8.9±0.0 and 8.7±0.0,respectively.Univariate and multivariable analyses showed that pain scores before analgesia were higher in afternoon group than in morning group (P＜0.01),and they were significantly higher in evening group than in morning and night groups (all P＜0.05).(2) At 10 and 30 minutes after epidural analgesia,the NRS pain scores of the four groups were 4.3± 1.0 and 1.8±0.9,4.8± 1.0 and 2.1 ±0.9,4.9± 1.1 and 2.2± 1.0,and 4.4± l.l and 1.8± 1.0,respectively,which were also significantly higher in afternoon and evening groups than in morning and night groups (all P ＜ 0.01 or 0.05) ; and the proportions of analgesia satisfaction (NRS pain score ≤ 3) were 19.7％ (188/955) vs 97.4％ (930/955),11.6％ (134/1 159) vs96.0％ (1 113/1 159),11.3％ (84/743) vs95.2％ (707/743),18.7％ (130/694) vs 95.6％ (670/694),respectively,which were significantly lower in afternoon and evening groups than in morning and night groups (all P＜0.01 or 0.05).(3) Delivery mode,incidence of adverse events and neonatal outcomes were similar among the four groups.Conclusions More severe labor pain before analgesia occur in parturients who receive epidural analgesia in the afternoon and at night,and less efficient analgesia and a lower rate of satisfaction are observed at 10 and 30 minutes after analgesia.However,delivery mode,neonatal outcomes and incidence of adverse events are not influenced by biological rhythm.

目的 观察0.5％等比重罗哌卡因腰麻在剖宫产手术中的麻醉效果及并发症.方法 选择100例ASA Ⅰ～Ⅱ拟行剖宫产手术产妇,均采用腰麻-硬膜外联合麻醉(CSEA).随机分为两组,分别向蛛网膜下腔注射0.5％(比重1.008)布比卡因和罗哌卡因.布比卡因组给予7～10mg,罗哌卡因组给予11～ 15mg.腰麻平面不足T6者,硬膜外腔追加2％利多卡因.结果 两组均于蛛网膜下腔注药后20分钟达到最高平面,均为T4(T6 ～T2).运动阻滞分级在注药60分钟时出现显著性差异(P＜0.05),罗哌卡因组运动阻滞均可在150分钟内恢复.结论 0.5％罗哌卡因可以达到与0.5％布比卡因同样的阻滞麻醉效果,产生相对较少的麻醉并发症及更轻程度的运动阻滞.0.5％罗哌卡因可以作为布比卡因的替代药物.

目的通过调查了解我院大学生对急救复苏这门课的认识以及对急救知识的掌握程度,为进一步加强急救知识的教育、教学提供科学的依据。方法采用自行设计的问卷对我院三年级的医学类与非医学类各240名大学生进行调查,了解他们对急救知识的了解程度及对开设这门课的认识。结果对医学生的调查显示,97.5%的大学生认为应该尽早开设这门重要的课程,但有2.5%的医学生认为急救复苏知识在大学仅可作为了解内容,真正的学习可以在工作的过程中进行;而对非医学生的调查显示,3%的大学生认为自己没必要学习这门课程。另外,从所有被调查学生对急救复苏知识的掌握程度看,许多学生对其掌握有一定的欠缺。结论应大力加强普及大学生急救复苏知识的教育;并对教学方法给以改进。