The study utilized non-invasive myocardial work indices to investigate myocardial injury in infants born to mothers with severe preeclampsia (SPE) and to explore the duration of this myocardial damage during the neonatal period. This prospective study included 34 preterm infants born to mothers with SPE and 28 preterm infants born to mothers without severe pregnancy complications (termed “controls”). Echocardiography was performed in infants within 24 h of birth, then again at 48–72 h and 14–28 days, to obtain echocardiographic parameters. Two-dimensional speckle-tracking echocardiography (2D STE) was performed to construct a non-invasive left ventricular pressure–strain loop based on two-dimensional myocardial strain and non-invasive left ventricular systolic pressure measurements, allowing for the calculation of myocardial work indices. Within 24 h after delivery, left ventricular stroke volume (SV), cardiac output (CO), and left ventricular global work index (GWI) in newborns born of mothers with SPE were significantly reduced compared to controls, while mitral E/e′ and left ventricular longitudinal strain were increased. At 48–72 h after birth, mitral E/e′ and left ventricular global waste work (GWW) increased, and global work efficiency (GWE) was reduced in infants of mothers with SPE. During the 14–28 days of the neonatal period, left ventricular SV and CO were reduced in the offspring of mothers with SPE and mitral E peak velocity, and E/e′ and left ventricular GWW were increased. The adverse intrauterine environment caused by SPE can lead to persistent impaired left ventricular function in preterm infants during the neonatal period.

This paper reports a case of neonatal lupus syndrome manifested by metabolic disease. A male neonate was admitted to the Children's Hospital of Soochow University due to poor response and vomiting for 1 day. Based on the clinical symptoms, including the patterned skin and a full anterior fontanelle, and a result of leukocytosis, neonatal sepsis was considered. Lysinuric protein intolerance was not excluded from the genetic metabolic disorders screening. The patient was positive for lupus-related autoantibodies and antinuclear antibodies, which were also found in his mother and elder sister. He had no functional variant of the SCL7A7 gene, a gene related to lysinuric protein intolerance, thereby the diagnosis of neonatal lupus syndrome manifested by metabolic disorders was confirmed. After treatment with methylprednisolone, the patient recovered well with no specific change in blood genetic metabolism at re-examination. Monthly follow-up after discharge found decreased antibody titers.

To editor: Glanzmann thrombasthenia (GT) is a rare autosomal recessive bleeding disorder that is characterized by a quantitative and/or qualitative defect in the platelet integrin αIIbβ3 (previously known as glycoprotein (GP)IIb/IIIa), the major platelet receptor of fibrinogen. Defective αIIbβ3 can result in the absence of platelet aggregation. Pregnancy and delivery in women with GT can present specific challenges as there is a significant risk of both maternal and fetal bleeding. Cases of pregnant women with GT have rarely been reported in China; furthermore, existing reports originating from China only refer to cases involving cesarean section. In this article, we describe the case of a Chinese primipara with GT who delivered vaginally under a multidisciplinary team approach. We reviewed the patient’s pregnancy, delivery, and postpartum details and then searched the existing literature to create new insight into the clinical management of future cases during and after pregnancy when facing this challenging situation in clinical practice. The study was approved by the ethics committee of First Affiliated Hospital of Soochow University (2022-211), and informed consent was obtained from the patient. A 29-year-old gravida 1 para 0 Chinese primigravida (spontaneous pregnancy) with GT was booked into our obstetric service in the second trimester of pregnancy. The patient was diagnosed with GT because of mucocutaneous bleeding and menorrhagia at the age of 15 years. Molecular analysis showed that she had a homozygous missense mutation of the ITGA2B gene (c.2929C>T), which is known to exert serious adverse effects on the structure or function of GP IIb. Flow cytometry showed that CD61 was 4.25%. She had a negative familial history for this condition, and no consanguineous marriages were known in her family. Her partner was non-consanguineous; as such, paternal genotyping was not performed. From puberty, she experienced repeated episodes of purpura, petechiae, or abnormally easy bruising; these conditions were controllable by irregular medication treatment. During pregnancy, the patient was regularly reviewed by a multidisciplinary team. The first multidisciplinary meeting between hematology, obstetrics, and nutrition teams was arranged for 20 weeks. The team initially discussed her diagnosis, treatment, and delivery mode, and then established follow-up projects. She subsequently developed gestational diabetes but remained stable with a controlled diet. Recurrent gingival bleeding during pregnancy was managed by topical measures and tranexamic acid. She was hospitalized for hematuria during the second and third trimester and discharged after treatment with antifibrinolytics, platelet transfusion, and recombinant activated factor VII (rFVIIa). At the gestational age of 40 weeks, she was admitted to the obstetrics department to prepare for delivery. On admission, her blood pressure was 116/69 mm Hg, heart rate was 85 beats per minute, respiratory rate was 20 breaths per minute, temperature was 36.2 °C, height was 172 cm, weight was 83 kg, fundal height was appropriate for gestational age, and clinically estimated fetal weight was 3100 g. On admission, hematological workup demonstrated a normal platelet count of 119 × 109/L, a hemoglobin level of 118 g/L, a PT of 11 seconds, and an aPTT of 24 seconds; but absent platelet aggregation responses to ADP, epinephrine, and collagen, as well as a prolonged bleeding time (>15 minutes). Thrombelastography showed hypocoagulability. In addition, she was negative for platelet-specific antibodies. The entire multidisciplinary team discussed with her the plans for delivery mode, delivery risks, and postpartum risks. Following discussion, she expressed a strong will to give birth spontaneously. The team considered that there were no contraindications for vaginal and instrumental delivery. Therefore, a clear monitoring plan was established to manage delivery, including options for various potential emergencies, blood products, hemostatic therapies, and a maternal intensive care unit. In view of her unfavorable cervical status, Prostaglandin E2 (Dinoprostone Suppositories) was used for the induction of labor. A prophylactic transfusion of one unit of single donor platelets was performed after labor induction. On the day of induction, labor was initiated. At the beginning of labor, she experienced intermittent vaginal bleeding and hematuria. A vaginal examination revealed slight bleeding on the surface of her cervix. She received transfusions of blood products transfusions and other treatments. At 3-cm cervical dilation, artificial rupture of the membranes was performed yielding clear amniotic fluid. During the first stage of labor, with an estimated blood loss of 400 mL, she received three units of single donor platelets and 12 mg of rFVIIa. During the second stage of labor, however, the fetus showed severely abnormal fetal heart rate tracings. Forceps were chosen to expedite delivery to avoid fetal hypoxia and neonatal hypoxic-ischemic encephalopathy. The baby weighed 3250 g at birth and was an apparently healthy child (Apgar scores: 7–9–10). Intramuscular injections of oxytocin (20 U) and carboprost tromethamine (0.25 mg) were given to enhance contraction of the uterus and protect her from postpartum hemorrhage. At delivery and 2 hours after delivery, the total estimated blood loss, assessed by weight, was 970 mL. The administration of four units of platelets, three units of leukocytereduced red blood cells, and 12 mg of rFVIIa led to complete hemorrhage control throughout labor. The hemoglobin monitored at this time was 98 g/L and the platelet count was 181 × 109/L. However, 3 hours after delivery, she experienced hematuria and produced temporary shapeless bloody stools. On the first day postpartum, her hemoglobin level was 69 g/L and the platelet count was 90 × 109/L. The symptoms of bleeding improved with the transfusion of red blood cells, plasma, and rFVIIa, as well as oral iron and tranexamic acid. She was discharged 9 days after delivery with a hemoglobin level of 94 g/L and a platelet count in the normal range (171 × 109/L); there was no secondary postpartum hemorrhage. GT, an inherited disorder of platelet aggregation, is rare except in populations where consanguineous marriages are common. This disease presents significant challenges to women during pregnancy, delivery, and postpartum. A systematic review of the literature (in Chinese and English) was carried out using PubMed and Web of Science without time restrictions; this identified 12 cases of women with GT who delivered a viable baby vaginally1–10; the characteristics of these women are presented in SDC Table 1, https://links.lww.com/MFM/A33. All of the reported cases delivered vaginally. Our patient was induced by Prostaglandin E2 and delivered by forceps; this is unusual and has not been reported in China. Moreover, our patient was diagnosed and treated by a multidisciplinary team during pregnancy, delivery, and postpartum, thus resulting in good pregnancy outcomes. In particular, our patient received a multidisciplinary approach with regard to the choice of delivery mode. Combined with her strong desire to have a vaginal delivery, the team discussed possible situations and countermeasures, such as whether the trial of labor and/or instrumental delivery were potential contraindications for her condition. The team also discussed emergency measures for cesarean section during the vaginal trial. After discussion, the team concluded that GT itself was not a contraindication for spontaneous vaginal delivery and instrumental delivery. Women with GT are often diagnosed at a young age with epistaxis and menorrhagia being common symptoms. These women often need to take anti-fibrinolytics and/or contraceptives, and sometimes need blood transfusions or treatment with rFVIIa to stop bleeding.11 Pregnancy is a particular challenge in women with GT. The risks of peripartum and postpartum hemorrhage are high.12 Thus, the primary goal of treatment is to control bleeding episodes. Platelet transfusion is the standard first-line therapy. However, antibodies to integrin αIIbβ3 and/or HLA antigens can be observed in pregnant women who have received platelet transfusions, thus resulting in refractoriness to such transfusions. Moreover, antibodies are capable of crossing the placenta and may cause intrauterine fetal bleeding and/or neonatal thrombocytopenia and hemorrhage.13 In a previous article, Léticée et al.14 reported a case of intrauterine death due to intracranial hemorrhage in a mother with GT and positive antibodies at 31 weeks of gestation. In another study, Barg et al.15 reported that three out of nine newborns had severe thrombocytopenia, and all three babies were delivered by mothers with positive antibodies. Studies show that large doses of uterine contractions prevent PPH. Plasmapheresis is also used for the prevention and treatment of intrapartum and postpartum bleeding as this reduces the number of antiplatelet antibodies, thus making transfusions effective.8 rFVIIa is increasingly being used to correct PPH, especially in women whose platelet transfusions have failed to arrest the hemorrhage; this is because of antiplatelet antibodies and/or patients who are refractory to platelet transfusions.16 Published data suggest that rFVIIa represents a safe and effective agent for the management of bleeding and for surgical prophylaxis. Generally, the normal dose of rFVIIa is ≥80 μg/kg every ≤2.5 hours for non-surgical bleeds and 90 to 140 μg/kg every ≤2.5 hours for more than two doses for minor surgery with additional doses for major surgery until hemostasis is secured.17 The prophylactic administration of a uterotonic agent immediately after delivery is recommended for all women with GT to prevent blood loss. Oral antifibrinolytic drugs, hormones, and prednisolone have also been used to treat secondary PPH in some centers. Sometimes, some form of hemostatic agent is also given for prophylaxis at delivery. However, a previous study by Civaschi et al.18 showed that this prophylactic therapy appears to be limited, as more than half of women with GT who had received prophylactic platelet transfusions experienced excessive bleeding requiring blood transfusion, thus suggesting that better preventive treatments are required. The optimal mode of delivery (vaginal vs. cesarean) for pregnant women with GT remains controversial. The mode of delivery does not appear to be associated with PPH. Symptomatic and asymptomatic intracranial hemorrhage of newborns have been reported in all delivery modes; higher rates have been reported after prolonged labor and instrumental delivery.19 However, during the second stage of labor, when a fetus has an abnormal fetal heart rate, it is necessary to deliver rapidly to avoid fetal hypoxia and neonatal hypoxic-ischemic encephalopathy. In such a difficult situation, instrumental delivery should be performed as this may be more beneficial to both the mother and the neonate than cesarean delivery. Vacuum extraction carries the highest risk and should be avoided. Compared with forceps, vacuum extraction increases the risk of cephalhematomas, diffuse subcutaneous hematomas of the scalp, and intracranial hemorrhage. For this reason, forceps are the better choice for instrumental delivery.10 Epidural analgesia is contraindicated because of the potential risk of epidural or spinal hematoma during insertion and removal of the catheter. Therefore, current best practice is to decide the most appropriate mode of delivery based on the specific situation of the mother and the fetus. Maternal and fetal risks and benefits must be considered in a multidisciplinary team approach and the pregnant woman and her family should be enrolled in the discussion. A prospective and individualized management plan should be established for delivery and postpartum monitoring, and should involve obstetric, hematology, neonatology, and anesthetic input. In the current case, our patient with GT received multidisciplinary management during pregnancy. She had two episodes of hematuria with no apparent cause during the second and third trimester. In her first episode of hematuria, there were no urinary tract infections, urinary tract tumors, or kidney stones. Therefore, the team considered that the hematuria was caused by GT and the bleeding was controlled by platelet transfusions. In the second episode of hematuria, the combination of platelet transfusion and antifibrinolytic drugs was not effective. First, we checked for infection. The same form of bacteriuria was found in two consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts of ≥105 colony-forming units/mL. Therefore, the patient underwent asymptomatic management for bacteriuria. This included antibiotic therapy tailored to culture results and follow-up cultures to confirm sterilization of the urine. Furthermore, following consultation with a hematologist, rFVIIa was administered and this symptom was relieved. This suggests that asymptomatic bacteriuria should be excluded in the presence of hematuria. This experience also suggests that rFVIIa may be an effective treatment for bleeding, especially when platelet transfusions are refractory. During the peripartum period, the patient also received a multidisciplinary approach. An individualized delivery plan was established to ensure optimal maternal and fetal outcomes. Finally, because of abnormal fetal heart rate tracings, we performed forceps-assisted delivery. The patient received multiple hemostatic therapies, such as platelet transfusions, red-cell transfusions, rFVIIa, uterine tonics, antifibrinolytic drugs, and uterine urination; bleeding was well controlled throughout labor and postpartum. These data emphasize the need for multidisciplinary management and antenatal delivery planning for pregnant females with GT. In conclusion, GT is a rare autosomal recessive bleeding disorder. Pregnancy and delivery represent a particular challenge for women with GT. It is important to stress the need for a multidisciplinary approach for managing these patients, and for the newborn infants, including pre-pregnancy counseling, and an individualized plan for pregnancy, delivery, and postpartum monitoring.

国内外对宫角妊娠定义不一,诊断较为困难,一次检查结果可能不足以诊断,有时也会存在一定的误导.所以动态监测对于宫角妊娠诊断以及后续患者的管理十分重要,而超声检查相比于盆腔MRI或腹腔镜检查具有更经济、方便、省时、操作性强等优势.本文报道了1例继续妊娠意愿非常强烈的宫角妊娠患者.利用超声技术对患者进行动态监测,观察其孕囊的大小、位置、与子宫内膜的关联、宫角部肌层的厚度等,后期随访超声检查均提示为偏心的宫内妊娠,最终患者成功足月分娩.本病例提示可以利用超声对这类患者进行动态监测,但应由经验丰富的医师进行标准化检查以尽早明确诊断,必要时还可采用三维超声、盆腔MRI及腹腔镜检查协助诊断.宫角妊娠需建立多学科、全方位、全程规范化的患者管理方案,以改善母婴结局.

Background A prediction algorithm to identify women with high risk of an emergency cesarean could help reduce morbidity and mortality associated with labor. The objective of the present study was to derive and validate a simple model to predict intrapartum cesarean delivery for low-risk nulliparous women in Chinese population.Methods We conducted a retrospective cohort study of low-risk nulliparous women with singleton, term, cephalic pregnancies. A predictive model for cesarean delivery was derived using univariate and multivariable logistic regression from the hospital of the First Affiliated Hospital of Soochow University. External validation of the prediction model was then performed using the data from Sihong county People’s Hospital. A new nomogram was established based on the development cohort to predict the cesarean. The ROC curve, calibration plot and decision curve analysis were used to assess the predictive performance.Results The intrapartum cesarean delivery rates in the development cohort and the external validation cohort were 8.79% (576/6,551) and 7.82% (599/7,657). Multivariable logistic regression analysis showed that maternal age, height, BMI, weight gained during pregnancy, gestational age, induction method, meconium-stained amniotic fluid and neonatal sex were independent factors affecting cesarean outcome. We had established two prediction models according to fetal sex was involved or not. The AUC was 0.782 and 0.774, respectively. The two prediction models were well-calibrated with Hosmer-Lemeshow test P=0.263 and P=0.817, respectively. Decision curve analysis demonstrated that two models had clinical application value, and they provided greatest net benefit between threshold probabilities of 4% to 60%. And internal validation using Bootstrap method demonstrated similar discriminatory ability. We external validated the model involving fetal sex, for which the AUC was 0.775, while the slope and intercept of the calibration plot were 0.979 and 0.004, respectively. On the external validation set, another model had an AUC of 0.775 and a calibration slope of 1.007. The online web server was constructed based on the nomogram for convenient clinical use.Conclusions Both two models established by these factors have good prediction efficiency and high accuracy, which can provide the reference for clinicians to guide pregnant women to choose an appropriate delivery mode.

目的 探讨低风险初产妇在分娩过程中合理的静脉入量管理方法.方法 对 2018 年 7 月至2020 年12 月苏州大学附属第一医院收治的180 例足月低风险初产妇进行研究,随机数字表法分成3 组,每组60 例.在活跃期(宫口≥5 cm)后指导口服清流质的同时开通静脉通路,分别以250 mL/hr的速度输注 5%葡萄糖氯化钠溶液(GNS组)、乳酸钠林格氏液(林格组)以及 0.9%氯化钠溶液(NS组),对比 3 组产妇总产程、第一产程、活跃期、第二及第三产程时间、分娩方式、产后出血量以及新生儿出生 1 min和 5 min Apgar评分.结果 GNS组、林格组和NS组分别有57 例、58 例和57 例经阴道分娩.3 组孕妇在总产程、第一产程、活跃期和第三产程、缩宫素使用的差异具有统计学意义(P＜0.05).GNS组与NS组比较,GNS组显著降低总产程、第一产程、活跃期和第三产程时间,降低了缩宫素的使用率(26.3%vs 61.4%).GNS组相较于林格组,两者在总产程、第一产程时长和缩宫素的使用率上无统计学差异,但GNS组显著缩短了活跃期和第三产程时间.林格组与NS组在各产程时长和缩宫素使用率的差异无统计学意义.但 3 组分娩方式、产后出血量及新生儿出生Apgar评分无统计学差异(P＞0.05).结论 GNS比单纯给予NS更有助于产妇缩短总产程、第一产程、活跃期时间,减少缩宫素的使用率,更值得临床推广应用.

Objective: To evaluate the accuracy of sonography-estimated fetal weight (EFW) and to determine the potential factors influencing EFW accuracy in the Chinese population. Methods: Eleven widely used formulae were chosen to evaluate the accuracy of EFW in 7016 cases in a retrospective cohort study. Nine potential factors (prenatal body mass index [BMI], gestational age [GA], birth weight [BW], fetal sex, fetal presentation, amniotic fluid volume [AFV], seniority of sonographers, the time interval between ultrasonic measurement and delivery, and diabetes mellitus) were analyzed by binary logistic regression to determine whether they influenced sonography-EFW. Results: All 11 models had high correlation coefficients between EFW and BW ( r = 0.819–0.843). Model 3 was the most accurate formula for the Chinese population. Compared to fetuses with EFW of 2500–3999 g, the accuracy of EFW decreased by 69.10% ( P <0.001) for fetuses less than 2500 g, and decreased by 54.10% ( P <0.001) for fetuses larger than 4000 g. The accuracy of EFW in female fetuses decreased by 12.70% compared with male fetuses ( P = 0.021). Compared to the EFW calculated 1-3 days before delivery, the accuracy of the EFW performed 4–7 days before delivery showed a significant decrease ( P = 0.014). The accuracy of EFW was influenced by the individual measurement accuracy of the sonographers. Maternal BMI, DM, GA, fetal presentation, and AFV did not influence the accuracy of EFW after adjustment. Conclusion: Model 3 was the most accurate model for the Chinese population. The BW, fetal sex, time interval, and technique of the sonographers had different influences on the accuracy of EFW.

Objective: This study aimed to quantitatively assess myocardial strain in preterm children aged 5 to 8 years of pregnancy complicated by severe preeclampsia (PE) by two-dimensional (2D) speckle tracking echocardiography. Method: A cohort study of 23 preterm children delivered by severe PE pregnant women from 2010 to 2012 in the First Affiliated Hospital of Soochow University was carried out. 23 preterm children from uneventful pregnancies in the same period served as controls. Myocardial functions including left ventricular longitudinal strain, radial strain, circumferential strain, and right ventricular longitudinal strain were evaluated by conventional Doppler, tissue Doppler imaging, and 2D speckle-tracking echocardiography (2D STE). All examinations were performed by an experienced ultrasonographer using the VIVID E9 (GE Healthcare) machine, according to standard techniques. Results: Children aged 5-8 years delivered from severe PE presented less weight (24.41 vs. 20.89 kg, P < 0.05), shorter height (124.1 vs 115.6 cm, P < 0.05) and faster heart rates (84 vs. 93 bpm, P < 0.05) compared to offspring of normotensive women. There were no significant differences in global left ventricular longitudinal strain, radial strain, circumferential strain, and right ventricular longitudinal strain between the children in the experimental group and the control group (P > 0.05). Conclusion: Exposure to the intrauterine environment of severe PE during the fetal period did not have a significant impact on cardiac structure in premature children at 5-8 years old, but they had a higher resting heart rate which may be associated with cardiovascular disease in the long run.

OBJECTIVES:To evaluate myocardial injury in neonates born to pregnant women with pregnancy complicated by severe preeclampsia by myocardial work indices.METHODS:A prospective cohort study was performed on 25 preterm infants born to the pregnant women with severe preeclampsia from June 2020 to April 2021 (severe preeclampsia group), and 25 preterm infants born to the pregnant women without severe complications in pregnancy were enrolled as the control group. Echocardiography was performed within 24 hours and at 48-72 hours and 14-28 days after birth to measure conventional parameters. Two-dimensional speckle-tracking echocardiography was performed to construct a noninvasive left ventricular pressure-strain loop based on two-dimensional myocardial strain and left ventricular systolic pressure noninvasively measured, so as to calculate myocardial work indices.RESULTS:Compared with the control group, the severe preeclampsia group had significant reductions in left ventricular global work index and global constructive work within 24 hours after birth (P<0.05), a significant reduction in left ventricular global work efficiency and a significant increase in global waste work at 48-72 hours after birth (P<0.05), and a significant reduction in left ventricular global work efficiency at 14-28 days after birth (P<0.05).CONCLUSIONS:Subclinical myocardial injury persists in the neonatal period in preterm infants born to pregnant women with severe preeclampsia.

Background: Some models predicting cesarean section (CS) have been proposed, with Tolcher, Levine, and Burke model well acknowledged. Tolcher model targets nulliparous women with term labor induction; Levine model targets women with term labor induction with intact membranes and an unfavorable cervix. Burke model targets term nulliparous woman with an uncomplicated pregnancy. Our objective was to assess the predictive performance of these three models, and to disclose the variables which may predict the risk of CS in Chinese population. Methods: A retrospective study was conducted on women with singleton, term, cephalic pregnancies at a tertiary academic center (2011–2017). A predicted probability for CS was calculated for women in the dataset by the algorithm of each model. The performance of the model was evaluated for discrimination. Univariate analysis was used to screen out the factors that may increase the risk of CS. Results: The three models predicted CS as following (expressed by an area under the receiver operating characteristic curve [AUC ROC]) (in the population defined/employed by each model): Tolcher model with AUC ROC of 0.659; Levine model with 0.697; and Burke model as 0.623. Different interventional measures or characteristics of labor were also evaluated; the nulliparous and multiparous were analyzed separately. Still, most of the results were unsatisfactory (AUC ROC <0.7). Univariate analyses on the clinical parameters that may affect the incidence of CS were performed. The followings affected the incidence/probability of CS: maternal age, height, body mass index (BMI), weight gain during pregnancy, gestational age, mode of labor induction, meconium-stained amniotic fluid, presence of complications, neonatal weight/gender. Conclusion: These three models may not be suitable for predicting CS for Chinese population. Some maternal and fetal characteristics increased the risk of CS, which should be taken into account in creating some appropriate models for predicting CS in Chinese population.

目的 探讨国外阴道试产失败中转剖宫产预测模型在国内的适用性,并初步探索影响中转剖宫产的危险因素.方法 回顾性分析2011年1月—2017年8月本院妇产科所有单胎头位足月妊娠初产妇的病例资料.利用Tolcher、Levine、Burke模型分别进行预测风险计算及分析,并比较预测值及实际值.结果 利用本院初产妇对Tolcher、Levine、Burke模型进行验证,其AUC ROC分别为0.659(95％CI 0.635-0.682),0.697(95％CI 0.656-0.738),0.623(95％CI 0.500-0.746).上述三种模型在Hosmer-Lemeshow goodness-of-fit检验中显示其校准能力均良好(P>0.05).对可能影响阴道试产中转剖宫产的临床参数进行单因素分析发现,当最佳临界值即孕妇年龄>26岁、身高≤160 cm、分娩孕周>40周、孕前BMI>21.3 kg/m2、孕期增重>13 kg、合并疾病、羊水粪染及男性胎儿时初产妇中转剖的风险显著增加.结论 上述三种模型均不适用于我院人群.在本研究中,产妇年龄、身高、BMI、孕期增重、孕周、引产方式、是否有羊水粪染、有无合并及并发症、新生儿体重、新生儿性别等影响了分娩方式.

Objective To explore the application value of six prediction models reported at home and abroad for adverse outcomes of hypertensive disorders of pregnancy(HDP) in eastern and western China. Methods For all patients who delivered in the First Affiliated Hospital of Soochow University and Sichuan Provincial Maternal and Child Health Care Hospital from May 1, 2011 to April 30, 2019 and were diagnosed with HDP, their clinical data were retrospectively analyzed. Six models, fullPIERS, miniPIERS, Zwertbroek, PREP, Ngwenya, and Ma Guojun, were used to predict the risk of adverse outcomes for the patients. The predictive performance of the models was evaluated in terms of discrimination and calibration. Results A total of 2978 patients were eligible. Combined adverse outcomes occurred in 13.6% (405/2978) of women within 48 h of admission, and 22.0% (655/2978) at any time during admission. The delivery < 34 weeks (49.4%, 200/405), need for blood product transfusion (43.5%, 176/405), and placental abruption (23.5%, 95/405) were the most common adverse outcomes within 48 hours of admission. The area under of the curve of the six models for predicting adverse outcomes in the patients with HDP within 48 hours of admission/during hospitalization ranged from 0.600 to 0.897, the sensitivity ranged from 57.1% to 69.5%, and the specificity ranged from 60.1% to 76.6%. The Hosmer-Lemeshow test showed that except for the PREP model (which had a small validation population and was not evaluated for calibration), the P-values of all the other 5 models were less than 0.05. Conclusions The six prediction models have certain application value in the prediction of adverse outcomes of HDP patients in the eastern and western regions of China, but the fitting is poor. The predictors involved in some models are not routine inspection indicators, and the feasibility of large-scale model application is still open to question. It is still necessary to establish a better prognostic model suitable for local areas based on Chinese characteristics.

Objective:To develop and validate a predictive model for adverse outcomes in women with hypertensive disorders of pregnancy (HDP).Methods:We retrospectively analyzed the clinical data of patients diagnosed with HDP and delivered at the First Affiliated Hospital of Soochow University or Sichuan Provincial Maternity and Child Health Care Hospital between May 1, 2011, and April 30, 2019. These patients were categorized as the adverse outcome group or the control group with adverse outcomes within 48 h after admission. Univariate analysis, least absolute shrinkage, selection operator (LASSO), and multivariable logistic regression were employed to analyze factors influencing the adverse outcomes and develop a predictive model. The receiver operating characteristic (ROC) curve and calibration plot was used to assess the predictive performance. Bootstrapping was used for the internal validation and the retrospective dataset of patients with HDP from the First Affiliated Hospital of Soochow University from May 1, 2019, to April 30, 2020, for the external validation. A graphic nomogram was created through R software based on the model.Results:(1) Of the 2 978 HDP patients who were included in the development set, 356 were in the adverse outcome group, accounting for 12.0%; of the 233 patients who were included in the external validation set, 40 presented with adverse outcomes within 48 h after admission, accounting for 17.2%. (2) Nine optimal predictors were identified based on the LASSO regression analysis and multivariable logistic regression, consisting of gestational age on admission, routine prenatal care, number of symptoms, mean arterial pressure, platelet count, fibrinogen, albumin, serum urea, and serum creatinine, based on which the logistic predictive model was established. (3) The ROC curve for this predictive model achieved an area under the curve (AUC) of 0.878 (95% CI: 0.858-0.897), and the ideal cut-off value for predicted probability was 0.136, with a sensitivity of 0.778 (95% CI: 0.731-0.820) and specificity of 0.848(95% CI: 0.834-0.862). The model was well-calibrated as the Hosmer-Lemeshow test showed that P>0.05. The calibration plot of the model had a slope of 1 and an intercept of 0. (4) The model showed good consistency in the internal validation and had an AUC of 0.872 (95% CI: 0.807-0.937) in the external validation. The Hosmer-Lemeshow test showed that the P value was >0.05, and the calibration slope was 1.001. (5) A nomogram was constructed for convenient clinical use. Conclusion:A relatively accurate prediction model for adverse outcomes in HDP patients was established, which could be used as a valuable quantitative tool for assessing HDP-related complications.

Objectives: Preeclampsia is a common complication of pregnancy that causes health problems for both the mother and her fetus. This study aimed to develop and externally validate a model to predict adverse outcomes in preeclampsia in a trans-regional two-center retrospective cohort of Chinese women. Study design: To generate a model for the risk of women with adverse outcomes, we incorporated candidate variables in the development set in univariate, least absolute shrinkage and selection operator analysis and multivariable logistic regression. The performance of the model was evaluated for the receiver operating char-acteristic (ROC) curve, calibration and decision curve analysis. Further, we externally validated the model in an independent dataset. Main outcome measures: Composite adverse outcomes within 48 h of admission. Results: There were 1 783 and 116 preeclampsia women in the development and validation set, respectively. The model included 10 predictors: gestational age at admission, irregular prenatal care, number of symptoms, mean arterial pressure, hematocrit, platelet count, fibrinogen, albumin, total bilirubin, and serum urea. The area under the ROC curve of the model was 0.867 in the development set and 0.841 in the external validation set. The calibration plots for the probability of adverse outcomes demonstrated a good correlation. Decision curve analysis further showed that our model had clinical application value. The nomogram and a software-based calculator (https://sdfyyfck.shinyapps.io/preeclampsia/) were constructed for convenient clinical use. Conclusions: Such a model could be used as a useful tool for the assessment of hypertensive-related complications in Chinese preeclampsia patients.

随着我国“二孩”政策的实施,各地迎来生育高峰,产科工作者面临工作量增大和保障母婴安全的双重考验.探讨生物节律和排班模式与分娩结局的关系,可指导产科工作的合理安排,对提高工作效率和保障围产保健质量有着重要的现实意义.因此,本文就不同分娩时间对分娩结局影响的相关研究予以综述,得出分娩时间对分娩结局可能存在影响,以期为孕产妇选择恰当的分娩时间和改善母婴结局提供理论依据.

Objective:To establish a model for predicting cesarean delivery after failure of trial of labor among low-risk term primipara.Methods:This study retrospectively analyzed the clinical data of low-risk primiparas, with singleton cephalic full-term fetus, who delivered in the Department of Obstetrics and Gynecology of the First Affiliated Hospital of Soochow University from January 1, 2011 to August 31, 2017. Women experienced cesarean delivery(CS) following failed trial of labor were grouped as CS group, while those successfully delivered normally as vaginal delivery group(VD group). Chi-square test, t-test and multivariate logistic regression analysis were used for statistical analysis. Influencing factors of CS after a failed trial of labor were screened to establish the prediction model. The area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow goodness-of-fit test were used to assess the performance of the model. A nomogram was established using R programming language based on the predictive model. Results:(1) This study recruited 6 551 subjects and among them, 576 (8.8%) women experienced CS after a failed trial of labor and the rest 5 975(91.2%) delivered vaginally. (2) The women in CS group were older [(27.5±3.1) vs (26.8±3.0) years, t=-4.963, P<0.01] and shorter in height [(159.5±4.2) vs (161.7±4.6) cm, t=11.548, P<0.01] , had higher pre-pregnancy body mass index (BMI) [(21.5±2.6) vs (20.8±2.5) kg/m 2, t=-6.743, P<0.01] and higher weight gain during pregnancy [(14.8±4.2) vs (14.1±4.2) kg, t=-3.446, P<0.01] and delivered later [(282±7) vs (278±7) d, t=-10.499, P<0.01] compared with those in VD group. The incidence of premature rupture of membranes (PROM) [26.4% (152/576) vs 20.7% (1 238/5 975) , χ2=10.101, P<0.01], labor induction [oxytocin: 26.4% (152/576) vs 16.3% (976/5 975), artificial rupture of membranes: 46.5% (268/576) vs 36.6% (2 189/5 975), application of cervical dilator balloon: 2.6% (15/576) vs 1.1% (65/5 975) and Propess: 4.7% (27/576) vs 2.5% (149/5 975), χ2=134.918, P<0.01], and the proportion of cases with meconium-stained amniotic fluid [ Ⅰ: 5.2% (30/576) vs 3.5% (209/5 975), Ⅱ: 5.7% (33/576) vs 2.5% (150/5 975), Ⅲ/bloody: 13.7% (79/576) vs 1.8% (105/5 975), χ2=307.664, P<0.01] were all higher in CS group than in VD group. There were more male infants [58.0% (334/576) vs 49.1% (2 934/5 975), χ2=16.576, P<0.01] and higher neonatal birth weight [(3 528±389) vs (3 344±368) g, t=-11.431, P<0.01] in the CS group as well. (3) Multivariate logistic regression analysis showed that maternal age and height, pre-pregnancy BMI, weight gain during pregnancy, gestational age at delivery, PROM, labor induction with oxytocin, artificial rupture of membrane, application of cervical dilator balloon and Propess, meconium-stained amniotic fluid, and fetal gender were all independent factors for CS. Two prediction models and nomograms were established according to fetal gender was involved or not. (4) The AUC of the prediction model not involving fetal gender was 0.774 (95% CI: 0.763-0.784) and the cut-off value was >8.7% with the sensitivity and specificity of 0.707 and 0.706, while that involving fetal gender was 0.782 (95% CI: 0.771-0.791) with the sensitivity and specificity of 0.785 and 0.645, respectively, when the cut-off value was >7.4%. The Hosmer-Lemeshow goodness-of-fit test showed that the two models fitted well (both P>0.05). Results of the internal validation using Bootstrap method indicated that the CS rates predicted by both models were consistent with the real data. Conclusions:The established models could effectively and accurately predict CS in term, singleton, cephalic, and low-risk primipara after failure of trial of labor, which might be a tool for clinicians to inform pregnant women to choose an appropriate delivery mode, thus improving maternal and infant outcomes.

乳腺癌是女性常见的恶性肿瘤之一.该病的全身治疗会对子宫内膜及卵巢功能产生影响,如排卵障碍导致的子宫内膜异常增生、异常子宫出血等疾病.如果不考虑患者合并乳腺癌,则可使用孕激素类药物进行止血、调经及对内膜进行保护治疗.但该药在乳腺癌患者中应用的安全性尚不明确.该文从基础及临床研究角度出发,就孕激素类药物用于该类患者的安全性作一综述.目前而言,在乳腺癌患者中应用孕激素类药物是否增加风险可能与孕激素的种类、剂量和使用方法等有关,同时与所患疾病类型也有一定关联.基于现有数据,在乳腺癌患者中短期谨慎使用天然孕激素或地屈孕酮较为安全,其他方式途径还需更多研究评估.

妊娠期高血压疾病可造成孕产妇和围产儿不良预后,严重威胁母儿健康.用简单有效的方式去预测不良结局的发生可以帮助管理和改善妊娠结局.近年来国内外有很多学者致力于预测不良结局发生的研究,联合多指标建立了预测模型,如fullPIERS、miniPIERS、late preterm预后模型、PREP模型、风险因子预测、风险预警等,这些模型有一定的预测价值,可作为一种辅助工具对该类患者进行评估管理,但还需得到更多大样本多中心的临床数据进一步外部验证.