Objective:To explore the effect applying the blended teaching mode based on the outcome-based education (OBE) and multi-assessment in the practice teaching of obstetrics.Methods:The experimental control method was used. Ninety five-year program students majoring in clinical medicine of Sun Yat-sen University who practiced in Department of Obstetrics, Third Hospital Affiliated to Sun Yat-sen University from August 2021 to August 2022 were selected as the research objects. They were divided into an experimental group and a control group by the envelope random method, with 45 in each group. There were 27 males and 18 females in the experimental group; they were (22.24±0.57) years old. There were 25 males and 20 females in the control group; they were (22.24±0.88) years old. The control group adopted the traditional offline practice teaching method of teacher teaching and ward practice. The experimental group adopted the blended teaching mode based on OBE concept, offline teaching combined with WeChat Rain classroom online teaching. In the mid-term evaluation of practice, the two groups' students were evaluated by the Mini-Clinical Evaluation Exercise (Mini-CEX), Direct Observation of Procedure Skills (DOPS), and Clinical Communication Skill Scale. At the end of practice, they were finally evaluated by the comprehensive assessment. The teaching effects of the two groups were compared. The measurement data were analyzed by t test, and the count data by χ 2 test or the Fisher's exact probability method. Results:In the mid-term evaluation of practice, the excellent rate of Mini-CEX in the experimental group was higher than that in the control group[15.6% (7/45) vs. 0; P<0.05]; the score of Clinical Communication Skill Scale in the experimental group was higher than that in the control group [(91.93±3.60) vs. (85.13±3.62); t=-8.938, P<0.001]. In the final evaluation, the score of the comprehensive examination in the experimental group was higher than that in the control group [(82.15±4.14) vs. (80.18±4.46); t=-2.177, P<0.05]. Conclusion:In the practice teaching of obstetrics, the application of the blended teaching mode based on OBE concept and multi-assessment has a good teaching effect on the training of clinical diagnosis and treatment thinking ability and communication ability.

Objective:To investigate the association between body fat percentage (PBF), fat mass index (FMI) and lipid profile in the first trimester with gestational diabetes mellitus (GDM).Methods:The retrospective analysis was performed on 1 578 pregnant women who received prenatal care in the Third Affiliated Hospital of Sun Yat-sen University from May 2020 to May 2021. All subjects were measured by bioelectrical impedance analysis in the first trimester to obtain PBF and fat mass, height and weight, and at the same time plasma fasting blood glucose (FPG), total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) were measured. 75 g oral glucose tolerance test (OGTT) was conducted between 24 and 28 weeks, FPG, 1 h plasma glucose (1hPG) and 2 h plasma glucose (2hPG) were detected, and the subjects were divided into GDM group (318 cases) and control group (1 260 cases) according to OGTT results. Independent sample t-test, Mann-Whitney U and χ2 test were used for comparison between groups, logistic regression model was used to analyze the association between observation index and GDM. Results:The prevalence of GDM was 20.15% (318/1 578). The age, BMI, PBF, FMI, FPG, TC, TG, LDL-C, 75 g OGTT-FPG, 1hPG and 2hPG, the proportion of gravidity≥3 times in the GDM group were higher than those in the control group ( P<0.05). The risk of GDM in those aged≥25 years increased 183.2% (OR=2.832, 95%CI 1.414-5.672, P<0.05), BMI≥24.0 kg/m 2 was 123.9% (OR=2.239, 95%CI 1.674-2.997, P<0.001), and PBF≥25% was 91.2% (OR=1.912, 95%CI 1.462-2.501, P<0.001). The pregnant women were grouped according to the quartile of FMI, FPG, TC, TG, HDL-C and LDL-C ( Q1, Q2, Q3 and Q4 group). The Q4 group of FMI increased the risk of GDM by 97.7% compared with the Q1 group ( P<0.05); the Q3 group and Q4 group of TC increased the risk of GDM by 63.3% and 55.7% compared with the Q1 group ( P<0.05); the Q4 group of TG increased the risk of GDM by 54.8% compared with the Q1 group ( P<0.05). Conclusions:Age≥25 years, BMI≥24.0 kg/m 2 and PBF≥25% are closely related to the incidence of GDM. The levels of PBF, FMI, TC and TG in the first trimester can provide a reference for early prediction of GDM.

目的 探讨阴道助产对初产妇产后早期盆底功能的影响.方法 收集345例阴道分娩初产妇的临床资料,根据分娩方式分为自然分娩组170例、胎头吸引器助产组130例、产钳助产组45例,在产妇产后6～12周进行盆底肌力和盆底三维超声检查.比较3组产妇的盆底肌力异常率、膀胱颈移动度增大率、膀胱膨出率、肛提肌裂孔面积增大率、肛提肌损伤率及肛门括约肌损伤率.结果 3组产妇的年龄、BMI、孕期增重、孕周、新生儿出生体质量比较差异均无统计学意义(P均>0.05).产钳助产组盆底肌力的异常率高于自然分娩组(P<0.017),其余两两比较差异均无统计学意义(P均>0.017).产钳助产组的肛提肌损伤发生率高于自然分娩组及吸引器助产组(P均<0.017),吸引器助产组的肛提肌损伤发生率高于自然分娩组(P<0.001).3组产妇的膀胱颈移动度增大、膀胱膨出、肛提肌裂孔面积增大及肛门括约肌损伤发生率比较差异均无统计学意义(P均>0.05).盆底超声提示盆底肌肉损伤的52例产妇中,产后盆底肌力筛查示正常9例,2种检查方法的一致性检测结果为Kappa=0.061,P=0.029.结论 与自然分娩的产妇相比,产钳助产对盆底肌力的损伤最大,接受产钳助产者的肛提肌损伤发生率最高;2种产后盆底肌力检查方法相互独立,盆底超声能清晰显示盆底肌损伤状况,在产后盆底筛查中起重要作用.

患者38岁,孕4产2,因"孕27+3周,双下肢水肿3周,发现血压升高1 d"于2019年6月24日急诊收入中山大学附属第三医院产科.患者末次月经不详,根据超声推算预产期2019年9月18日.孕期未进行规律产科检查,未监测血压.

例1 患者31 岁,孕2产0,因"停经39 +3周,下腹阵痛6 h"于2014年8月8 日收入中山大学附属第三医院产科.患者孕期定期产前检查,妊娠期血常规提示血红蛋白波动在100～110 g/L,其余各项检查均正常,否认既往高血压、糖尿病、心脏病、癫痫等病史.入院诊断:(1 )妊娠39 +3周,先兆临产;(2)轻度贫血.入院后患者生命体征平稳顺利进入产程,第一产程14小时零5 分钟,患者无不适,第二产程指导用力15 min后患者突然出现抽搐,呼之不应,口吐白沫,呼吸困难和低氧血症.立即启动多学科[神经内科、神经外科、心血管内科、麻醉科、新生儿科、重症监护病房(intensive care unit,ICU)]急会诊,怀疑羊水栓塞,按照羊水栓塞抢救并气管插管,抢救期间血压最高148/86 mmHg,检测尿蛋白(-),胎心率100～110 次/min,钳产助产娩出一足月女婴,出生体重4000 g,Apgar评分9-10-10分,因代谢性酸中毒转新生儿科.分娩后患者行头颅CT平扫(图1 A)、计算机断层扫描动脉造影(computed tomography angiography,CTA)及计算机断层扫描静脉造影(computed tomography venography, CTV)检查,左侧大脑中动脉M1 段可见一球状突起,大小约24 mm ×22 mm,左侧大脑中动脉M1段动脉瘤破裂伴广泛蛛网膜下腔出血,双侧侧脑室后角及第四脑室积血(图1B,C).产后24 h阴道出血约300 ml.产后患者处于轻度昏迷,呼吸机辅助呼吸,格拉斯哥昏迷指数评分(Glasgow Coma Scale,GCS)为7分(唤醒能睁眼、伴呻吟、对外界刺激四肢可屈曲有反应),Hunt-Hess分级属于Ⅳ级.因患者浅昏迷伴肺部感染、广泛的蛛网膜下腔出血和脑水肿,动脉瘤2. 5 cm开颅手术难度较大,死亡率极高,全院大会诊和与患者家属沟通后,家属考虑手术风险,强烈要求保守治疗.

Objective:To explore the effects of gestational diabetes mellitus (GDM) on the perinatal outcomes in twin pregnancies, and analyze the risk factors of twin pregnancies complicated with GDM.Methods:Retrospective analysis was performed on 757 patients of twin pregnancies who had delivered in the Third Affiliated Hospital of Sun Yat-sen University during January 2015 to June 2020. According to the results of 75 g oral glucose tolerance test (OGTT), 196 cases were in the GDM group, and 561 cases were inthe non-GDM group. The clinical characteristics of the subjects were recorded, the perinatal outcomes of the two groups were compared by using t test, Mann-Whitney U test, χ 2 test or Fisher exact probability method;the risk factors related to GDM were analyzed by multivariate-logistic stepwise regression. Results:Compared with the non-GDM group, 75 g OGTT-fasting plasma glucose (FPG), 1 h plasma glucose (PG), 2 h PG in GDM group were higher, gestational weeks and birth weight of newborn in GDM group were lower, the rate of preterm birth(<37 weeks) was higher. The incidence of neonatal respiratory distress syndrome, infection and anemia in the GDM group was higher than that in the non-GDM group (all P<0.05). There were statistically significant differences in age, pre-pregnancy body mess index (pre-BMI), gravidity, parity, proportion of in vitro fertilization and embryo transfer (IVF-ET), chorionicity, polycystic ovary syndrome (PCOS) history and family history of diabetes (all P<0.05). Risk factors were analyzed by multivariate-logistic stepwise regression, age ≥35 years (OR=2.335), pre-BMI ≥24.0 kg/m 2 (OR=2.356), PCOS history (OR=1.932) and family history of diabetes (OR=3.127) were independent risk factors for GDM in twin pregnancies (all P<0.05). Conclusions:GDM increased the incidence of preterm birth less than 37 weeks, neonatal respiratory distress syndrome, infection and anemia in twin pregnancies. Age ≥35 years, pre-BMI ≥24.0 kg/m 2, PCOS history and family history of diabetes were independent risk factors for GDM in twin pregnancies.

Objective:To explore whether thyroid stimulating hormone (TSH) treat-to-target during early pregnancy had an impact on the incidence of gestational diabetes mellitus (GDM) in women with hypothyroidism.Methods:A retrospective analysis was performed on naturally conceived singleton pregnant women who had accepted routinely prenatal services at the Third Affiliated Hospital of Sun Yat-sen University from January 2015 to December 2018. The gestational weeks of the first obstetric examination were before 13 weeks and 6 days of gestation. Data of 6 978 subjects were analyzed, including 186 cases in the hypothyroidism group and 6 792 cases in the normal group. In the hypothyroidism group, according to whether TSH levels were<2.5 mU/L in the first prenatal examination, 124 cases were in the under control group and 62 cases in the non-control group. Basic information was collected at first visit, and laboratory tests were performed with fasting samples, including thyroid function [TSH, free thyroxine (FT4), thyroid peroxidase antibody (TPOAb)] and fasting plasma glucose (FPG). The 75-gram oral glucose tolerance test (OGTT) was performed at 24 to 28 weeks. The incidence of GDM and the impact of TSH levels on it between the hypothyroidism group and the normal group were explored by using χ2 test. The risk factors of GDM were analyzed by logistic regression. Results:The incidence of GDM in the hypothyroidism group was higher than that in the under-control group [21.5% (40/186) vs. 13.7% (929/6 792), P=0.002]. The incidences of GDM in the under-control group [20.2% (25/124)] and the non-control group [24.2% (15/62)] were higher than that of the control group (all P<0.05). Multivariate logistic regression analysis for risk factors of incidence of GDM was performed, and finally age, pregestational body mass index, history of hypothyroidism, FPG, positive TPOAb, and triglyceride were considered to be independent risk factors for incidence of GDM ( P<0.05). Whether TSH met the standard was ruled out from the equation. Conclusion:Compared with women with normal thyroid function, women with hypothyroidism still are at higher risk of developing GDM, whether TSH levels are under control or not.

[目的]探讨产后腹直肌分离的相关危险因素.[方法]回顾性分析2019年6月至2020年10月在中山大学附属第三医院岭南医院产检并分娩,且产后3个月内使用高频超声探头测量腹直肌的孕妇共2394例,根据腹直肌是否分离,分为非DRA组321例和DRA组2073例.收集两组孕期的一般临床特点和分娩结局,包括:年龄、身高、产次、体质量指数、是否合并糖尿病、分娩孕周、分娩方式和新生儿出生体质量等.对比分析两组之间的临床特点差异,通过Logistic回归分析方法分析DRA发生的危险因素.[结果]①产后3个月内DRA以脐部分离为主,发生率为86.6％.其中轻度DRA发生率32.1％,中度DRA发生率48.2％,重度DRA发生率6.3％.②与非DRA组相比较,DRA组的产妇年龄、孕前BMI、分娩前BMI和新生儿出生体质量更大(P<0.001),DRA组中多产和剖宫产的比例更高(48.2％vs.26.8％和41.3％vs.19.6％,P<0.001).③高龄、多产和剖宫产均为产后DRA发生的独立危险因素[OR=4.137,95％CI为(2.655,6.448);OR=2.892,95％CI为(2.198,3.805)和OR=3.217,95％CI为(2.379,4.350),P<0.05].[结论]高龄、多产和剖宫产均为产妇产后DRA发生的独立危险因素.

[目的]探讨双胎妊娠期糖尿病(GDM)早孕期的相关危险因素,以寻找早孕期预测双胎GDM的有效指标.[方法]回顾性分析2015年1月至2019年6月在中山大学附属第三医院规律产检并分娩,且病例资料完整的双胎妊娠孕妇共318例,根据75克口服葡萄糖耐量试验(OGTT)结果,将其分为双胎GDM组84例,正常双胎组(双胎未合并GDM)234例,收集记录研究对象的临床特征,包括年龄、孕前体质量指数、孕产次、既往病史、此次受孕方式、双胎绒毛膜性质;早孕期(11～13+6周)的空腹血糖(FPG)、总胆固醇(TC)、甘油三酯(TG)、高密度脂蛋白(HDL)、低密度脂蛋白(LDL)及早孕期唐氏筛查生物学标记物妊娠相关血浆蛋白A(PAPP-A)和人绒毛膜促性腺激素β亚单位(Freeβ-HCG)的检测结果,通过多因素Logistic逐步回归分析法分析双胎GDM的早孕期相关危险因素,采用受试者工作特征曲线评价双胎GDM的早期预测.[结果]①两组比较,双胎GDM组的年龄、孕前体质量指数高于正常双胎组(P<0.001),双胎GDM组合并多囊卵巢综合征病史的比例高于正常双胎组(P<0.05);②双胎GDM组早孕期FPG、TG高于双胎正常组(P<0.05),而两组TC、HDL、LDL及PAPP-A MOM值及Freeβ-HCG MOM值差异无统计学意义(P>0.05);③年龄、孕前体质量指数、PCOS病史、早孕FPG水平均为双胎GDM发生的独立危险因素(P<0.05);④早孕期FPG预测双胎GDM的ROC曲线下面积(AUC)为0.617(95％CI:0.547～0.688),FPG为4.495 mmo/L时,约登指数为0.223,敏感度、特异度分别为65.5％、56.8％;早孕期TG预测双胎GDM的AUC为0.65(95％CI:0.584～0.716),TG为1.195 mmo/L时,约登指数为0.24,敏感度、特异度分别为77.4％、46.6％;而早孕期FPG、TG结合孕妇年龄、孕前体质量指数、PCOS病史预测双胎GDM的AUC为0.751(95％CI:0.693～0.810),敏感度、特异度分别为73.8％、70.1％.[结论]孕妇年龄、孕前体质量指数、PCOS病史、早孕FPG水平均为双胎GDM发生的独立危险因素;早孕期FPG、TG可作为早期预测双胎GDM发生的指标,结合临床特征可以增加早期预测价值.

目的 探讨不同分娩方式对产后早期盆底解剖结构和功能的影响.方法 收集2015年4月～2016年7月在中山大学附属第三医院岭南医院分娩,并在产后6～12周复查的产妇共469例,按照分娩方式分为会阴侧切组187例、会阴裂伤组195例和选择性剖宫产组87例.应用盆底肌电生理仪和3D会阴超声两种评价方式评估三组产妇产后产后盆底Ⅰ类Ⅱ类肌纤维肌力异常率、膀胱颈位置、膀胱移动度、Valsalva动作后肛提肌裂孔面积、膀胱后角的开放率及尿道内口漏斗形成率差异.结果 产后盆底Ⅰ类和Ⅱ类肌纤维肌力的异常率分别为85.92％,84.86％,其中裂伤组的异常率89.74％,88.21％,高于剖宫产组的78.16％,74.71％,差异有统计学意义(P<0.05).其余组间比较,差异无统计学意义(P>0.05);三组间静息状态下膀胱颈的位置比较,差异无统计学意义(P>0.05);裂伤组及侧切组的膀胱移动度及Valsalva动作后肛提肌裂孔面积大于剖宫产组,差异有统计学意义(P<0.05),而侧切组与裂伤组比较,差异无统计学意义(P>0.05);侧切组及裂伤组的膀胱后角的开放率及尿道内口漏斗形成率高于剖宫产组,差异有统计学意义(P<0.05),侧切组与裂伤组比较,差异无统计学意义(P>0.05).结论 选择性剖宫产对盆底功能有一定的保护作用.阴道分娩的女性产后盆底组织结构变化较选择性剖宫产的更明显,会阴侧切对产后早期盆底的结构及功能影响无明显差异.

Our study aims to evaluate the correlations between thyroid hormone levels in early pregnancy and the incidence of gestational diabetes mellitus (GDM). A total of 2112 pregnant women were recruited from our hospital, Guangzhou, China, from June 2016 to June 2017. Fasting plasma glucose (FPG), Thyrotropin (TSH), free T4 (FT4), and thyroid peroxydase antibody (TPO-Ab) were measured at 9-14 weeks’ gestation (first trimester) and 75-g OGTT (24-28 weeks’ gestation) were performed in each subject. Diagnosis of GDM was made by the IADPSG guideline (2010). All subjects had median age of 30 years (interquartile range:27-34 years). Two hundred and twenty four subjects (10.6%) were diagnosed as GDM. GDM women had older age and higher FPG(P<0.05). The level of free T4 (FT4) in GDM women was similar than that in non-GDM women (16.45±3.42pmol/L and 16.80±3.46 pmol/L, respectively, P=0.152). No difference was observed in the levels of TSH and TPO-Ab between GDM women and non-GDM women (all P>0.05). The prevalence of GDM in subjects among different quartiles of FT4 levels were 11.9%, 11.5%, 9.5% and 9.5% from the first to fourth quartile (P=0.429,χ2=2.766). By using logistic regression, FT4 in the first trimester odds ratios for GDM were not significant: OR 0.970 [95% CI 0.931-1.011] (unadjusted) and 0.960[95% CI 0.920-1.002] (adjusted for age, TSH, TPO-Ab). Our results indicated the level of FT4 in the first trimester may not have strong correlation with incidence of GDM. Disclosure P. Li: None. S. Lin: None. L. Li: None. L. Ouyang: None. J. Fan: None.