2019年 · 第01卷第01期

We are proud and honored to launch the inaugural issue ofMaternal-Fetal Medicine(MFM), a new publication of the Chinese Medical Association. On behalf of the editorial team, we would like to extend a very warm welcome to the readership ofMFM. We also take the opportunity to thank our authors, editors, and reviewers, all of whom have contributed tremendously to the successful launch of this journal.

In the past 9 years, several externally blinded validation and implementation studies have shown that it is now possible, through analysis of cell-free (cf) DNA in maternal blood, to effectively detect a high proportion of fetuses affected by trisomies 21, 18, and 13 at a much lower false positive rate than all other existing screening methods. This article aims to review the technical and clinical considerations for implementing cfDNA testing in routine practice, including methods of analysis, performance of the test, models for clinical implementation, and interpretation of results.

Cesarean section rates are rising worldwide, and in many countries the rate is much higher than medical indicated.¹Huge variation between countries and regions is observed.²Underuse leads to maternal and perinatal mortality and morbidity. Conversely, overuse of cesarean section has not shown benefits and can create harm.³In rural area of sub-Saharan Africa, cesarean rates are 1%–2%, but in Egypt and Greece, the frequency is more than 50%. High cesarean section use is observed among low-risk births, especially among more educated women in, for example, Brazil and China.²Maternal request is one cause of high cesarean rates, but also intrapartum cesarean section rates are much higher than medically indicated. In China the cesarean section rate is 45%⁴; close to 2/3 of urban women give birth by cesarean section and 25% in rural areas. A marked reduction in cesarean section rates was observed in an urban tertiary care center in Shanghai as a result of efforts to reduce the high rate of caesarean delivery. No notable differences in neonatal outcomes were observed.⁵Cesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates.⁶Cesarean section is associated with an increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth in subsequent pregnancies.⁷Avoiding the first cesarean influences delivery mode in subsequent deliveries. WHO recommends that every effort should be made to provide cesarean sections to women in need, rather than striving to achieve a specific rate.⁸Efforts to lower cesarean section rates are multiple, including policy change, patient education, and physician training.

To evaluate the effectiveness of the use of a modified Zhukovsky double (vaginal and uterine) balloon to improve the results of treatment in women with obstetric hemorrhage.

We conducted an observational controlled study including 701 puerperas, which were divided into two groups: The main group consisted of 508 women, who underwent a combined management, that is, traditional (transfusion of fresh frozen plasma, erythrocyte mass, uterotonics, hemostatic agents), surgical hemostasis in cases of caesarean section, and insertion of a double Zhukovsky balloon; while the comparison group included 193 patients, who were managed traditionally. The main group and the comparison group were divided into subgroups according to the main etiology of obstetric hemorrhage: IA and IB—postpartum; IIA and IIB—placenta accreta; IIIA and IIIB-postpartum hysterectomy.

The most frequent causes of massive obstetric hemorrhage were atony of the uterus (39.2%), placenta previa (29.1 %), and placental abruption (11.5%). Of the 508 balloon insertions, 345 (70.7%) were inserted for hemorrhage during cesarean section and 148 (29.3%) for obstetric hemorrhage after spontaneous delivery. Among the obstetric hemorrhage at caesarean section, lower segment bleeding prevailed (78.1%), caused mainly by placenta previa, placenta accreta, placental abruption, polyhydramnios, and uterine scar defects. Combined management, including surgical hemostasis and insertion of vaginal and uterine balloon of Zhukovsky, reduced blood loss by 1.5 times and the number of hysterectomies by 6.72 times compared to controls.

The use of a modified Zhukovsky double balloon in the management of obstetric hemorrhage may reduce the number of hysterectomies and the amount of blood loss.

To investigate whether a precise circular resection of the uterine tissue at the placental attachment part is effective in cases with placenta previa complicated with placenta percreta (PPWPP).

Patients diagnosed with PPWPP were assessed for pregnancy termination at 34–36 weeks of gestation. During the operation, we performed circular resection of the uterine tissue at the placental attachment part. Then the characteristics of the operation and the follow-ups were recorded.

During the operation, the vital signs were stable. The mean intraoperative blood loss, packed red blood cells units transfusion, fresh frozen plasma transfusion, and operation time were 2140 mL, 6 U, 440 mL, and 179.8 minutes, respectively. There was no bowel, ureter, or bladder injury. And there was no patient transferred to the ICU after operation. The mean postoperative blood loss was 458.6 mL. There was no fever, infection, intestinal obstruction, or other complications after operation during the hospitalization. The shape and the blood flow of the uterus were normal. After the patients were discharged, one had developed cesarean scar diverticulum. The mean lochia duration was 30 days. The menstrual cycle and volume were as before. The shape and the blood flow of the uterus and the ovarian were normal.

The circular resection following end-to-end anastomosis is an effective precision surgical approach for PPWPP. It can achieve the purpose of hemostasis while maximizing the protection of organ function and reducing surgical trauma.

Preeclampsia (PE) is a multisystem disorder of pregnancy classically characterized by hypertension with significant proteinuria after 20 weeks’ gestation. This disorder is one of the leading causes of maternal and perinatal morbidity and mortality. PE can be subdivided into preterm PE (with delivery at <37 weeks’ gestation) and term PE (with delivery at ≥37 weeks’ gestation). Preterm PE is associated with a higher risk of adverse maternal and perinatal outcomes than term PE. Traditional method of screening as recommended by professional guidelines has limited predictive performance and therefore should be updated to reflect recent scientific evidence that the target of screening should be preterm PE, the best way to identify the high-risk group is the Bayes-based method that combines maternal risk factors and biomarkers, the threshold should be set at screen positive rate of 10%, aspirin should be started before 16 weeks’ gestation, and the daily dose should be higher than 100 mg.

Gestational diabetes mellitus (GDM) is one of the most common complications during pregnancy. Despite extensive research in the past 50 years, the universal approach to diagnose GDM continues to be debated around the world and clinical practices vary from country to country and unit to unit within the same country. As new evidence emerges, the diagnostic criteria of GDM has continuously evolved since the 1990s. In 2011, after the announcement of the landmark International Association of Diabetes and Pregnancy Study Groups diagnostic criteria, many international organizations have accepted and advocated its use. However, there are differences in glucose metabolism among different ethnic groups, and the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) Study lacked data from mainland China. Whether the criteria developed based on the HAPO study are applicable to China remains to be further validated. In this current review, we will discuss the evolution of GDM diagnostic criteria and guidelines in China, and compare them to that in western countries to figure out the proper recommendations on the diagnosis of GDM among Chinese women.

Antiphospholipid antibody syndrome is an autoimmune disorder that primarily affects reproductive age women and poses significant obstetric complications. Here we review the pathogenesis, diagnosis, obstetric complications, and management in women with antiphospholipid antibody syndrome.

Mother-to-infant transmission of hepatitis B virus (HBV) is a main cause of chronic HBV infection. Maternal high HBV DNA level or positive hepatitis B e antigen (HBeAg) is the major risk factor for the transmission. With recommended passive and active immunoprophylaxis, the transmission occurs in nearly 0 and 4–12% of infants born to HBV-infected mothers with negative and positive HBeAg, respectively. Therefore, pregnant women with negative HBeAg appear not requiring antiviral therapy to prevent mother-to-infant transmission of HBV. Recent studies demonstrated that oral antivirals (lamivudine, telbivudine, or tenofovir) in pregnant women with high viral load or positive HBeAg, starting from 28–32 weeks of gestation, together with neonatal immunoprophylaxis, can almost completely prevent the transmission, indicating that it does not require antiviral therapy before 28 weeks of gestation. Accumulated evidence showed that the antivirals may be stopped upon delivery, and the infants may receive breast feeding after birth. However, these issues, as well as HBV DNA threshold for antiviral therapy during pregnancy, optimal timing for start and discontinuation of antivirals, and the drug safety of fetuses/infants, require further investigations to optimize the antiviral therapy during pregnancy. The proof of safety of fetal exposure to antivirals needs more evidence, which can be achieved from the real-world data analysis.

There are many ways to perform cesarean section, with many methods developing from local traditions. Following a 3-year study process, a modified, evidence-based method has been developed, which is now in use in many countries.

The abdomen incision is based on the Joel-Cohen incision, the peritoneum is opened by repeated stretching, and the uterus is opened transversely after pushing the bladder down.

After delivery the uterus is sutured with one layer using a large needle, and the abdomen is closed with only two layers, fascia and skin.

This method was subject to scores of studies, with all upholding its superiority over traditional methods. As a result, the "Stark (Misgav Ladach) method" is recommended to become a standard procedure across China.

To editor:

Where required, abstracts are limited to 500 words, which is excluded from the overall manuscript word count. The abstract is unstructured and should briefly describe: (1) the problem being addressed in the study, (2) how the study was performed, (3) the salient results, and (4) what the authors conclude from the results.