2021年 · 第03卷第03期

Objective: This survey was designed to understand the misconceptions about labor epidurals. Methods: This voluntary and anonymous online survey on wenjuan.com was conducted from September 1st, 2015 to January 1st, 2016 via mainly WeChat groups dedicated to perinatal healthcare providers in China. The questionnaire included items inquiring the knowledge and opinions about labor epidural analgesia related to maternal complications, baby safety, and effect on laboring. Incomplete surveys were excluded from the data analysis. The data was presented as percentages and a Chi-square test or Fisher’s exact test, as appreciate, was used to quantitatively compare the results. Results: A total of 1412 respondents completed surveys with 42.9% (606/1412) of them being anesthesiologists, 35.1% (495/1412) being obstetricians, 11.8% (167/1412) being midwives, 3.7% (52/1412) being labor and delivery nurses, and 6.5% (92/1412) being hospital administrators and unspecified. The study revealed a lack of knowledge in labor pain control. Although 82.4% (1164/1412) of respondents were familiar with labor epidural analgesia, 8.9% (126/1412) did not know how it works, and 1.1% (15/1412) never heard it in a multiple-choice question. The three main groups (anesthesiologists, obstetricians, and midwives/labor and delivery nurses) were chosen for comparisons. Opinions among these three groups concerning five questions in the three main concerns were evaluated using a statistical significance of P<0.05. Conclusion: The results in our survey indicated an urgent need of continuing medical education to multidisciplinary specialties to improve evidence-based medical practices as these misconceptions have existed for over 10 years in the medical professionals. Lack of public awareness fueled by misconceptions related to labor epidural analgesia may be associated with a lack of professional knowledge. Correct knowledge in professionals needs to be disseminated to the public in order to dispel possible misconceptions and rumors about labor epidural analgesia. This would not only enhance patient understanding of their care but also improve maternal, fetal, and neonatal outcomes.

Objective: To evaluate the predictive ability of neonate condition through the traditional parameters and artery umbilical cord blood gas (aUCBG). Methods: A prospective cohort study was conducted in obstetrics and gynecology department between October 2017 and August 2018 at Tongji Hospital in Wuhan, China, and 360 aUCBG samples were collected. The average age of pregnant women was (29.50±4.42) years, range from 19 to 48 years old. The gestational age range from 28+4 weeks to 41+3 weeks at admission. Logistic regression and area under the curve (AUC) from Receiver operating characteristic curves were used to identify risk factors, such as, premature rupture of membranes (PROM), high blood pressure, premature delivery (PD), low 1-minute Apgar scores (Apgar 1), low 5-minute Apgar scores (Apgar 5), pH, base excess, bicarbonate, neonatal blood sugar (NBS), and so on, to predict neonatal condition and evaluate the predictive ability of traditional and aUCBG parameters. Results: In all cases, PROM, PD, Apgar 1, Apgar 5, pH, base excess, bicarbonate, total carbon dioxide, and neonatal blood sugar were risk factors and were associated with poor condition of neonate. Apgar 1 were an independent risk factor. Combined traditional and aUCBG parameters had higher AUC of 0.895 (95% confidence interval (CI): 0.830-0.960, P<0.001). In cesarean section subgroup, high blood pressure, PD, and Apgar 1 were risk factors and were associated with poor condition of neonate. Apgar 1 and low pH were the independent risk factors. Combined traditional and aUCBG parameters had highest AUC of 0.940 (95% CI: 0.886-0.993, P<0.001). In vaginal delivery subgroup, maternal age above 35 years, PROM, PD, Apgar 1, Apgar 5, and male newborn were risk factors and were associated with poor condition of neonate. Maternal age above 35 years was an independent risk factor. Combined traditional and aUCBG parameters had highest AUC of 0.897 (95% CI: 0.828-0.965, P<0.001). For pregnant women without comorbidities and complications of pregnancy, aUCBG may not be necessary. Conclusion: In high-risk pregnancies, especially lower Apgar scores, PD, and maternal age above 35-year old, aUCBG is recommended. Traditional parameters combined with aUCBG might increase the predicting ability of neonate condition.

Objective: To evaluate the ability of cervical length (CL) at 28-32 weeks of gestation to predict spontaneous preterm delivery and preterm premature rupture of membranes (PPROM). Methods: It was a retrospective cohort study that vaginal ultrasonography at approximately 28-32 weeks of gestation was performed in 14,953 women between 17-49 years old with singleton pregnancies who delivered after 28 weeks of gestation at the Peking University First Hospital from June 2008 to December 2012. The pregnancy outcomes were followed and the relationship between the CL and preterm delivery or PPROM was assessed. The relative risk was calculated to assess group differences in the likelihood of an event occurring. Results: The overall prevalence of preterm delivery was 5.7% (858/14,953); the incidence for therapeutic preterm delivery was 2.1% (318/14,953), for spontaneous preterm delivery was 0.9% (133/14,953), and for PPROM was 2.7% (407/14,953). Excluding the 318 women who had therapeutic preterm delivery, the relative risk of preterm delivery for women with a CL between 25 mm and <30 mm, between 15 mm and <25 mm, and <15 mm was 3.7, 9.3, and 30.2, respectively. The sensitivity, specificity, and positive and negative predictive values of CL ≤25 mm at 28-32 weeks of gestation as the cut-off value for predicting preterm delivery were 19.8%, 97.5%, 23.4%, and 96.9%, respectively. For preterm delivery before 35 weeks of gestation, the sensitivity, specificity, and positive and negative predictive values of a CL ≤ 25 mm at 28-32 weeks of gestation as the cut-off value were 30.0%, 97.2%, 11.8%, and 99.1%, respectively. In addition, women with PPROM (n = 407) had significantly shorter CL (31.9 ± 7.4) mm at 28-32 weeks of gestation compared that of women without PPROM (34.0 ± 8.3) mm. The incidence of PPROM in women with a CL ≤25 mm at 28-32 weeks of gestation (19.4%, 79/407) was significantly lower than that for women with a CL >25 mm (80.6%, 328/407, P < 0.05). Conclusion: CL at 28-32 weeks of gestation can predict spontaneous preterm delivery, and is valuable for predicting PPROM.

Objective: The aims of this study were to determine the differences between women with single vs. recurrent episodes of preeclampsia in term of: (1) the outcome of the first pregnancy affected by preeclampsia; and (2) the perinatal outcomes of subsequent pregnancies. Methods: This population based retrospective cohort study included all multiparous patients with a singleton gestation who delivered at Soroka University Medical Center (Beer Sheva, Israel) from January 1988 until December 2012, meeting the inclusion criteria, those who had fetuses with chromosomal or anatomical abnormalities were exclude. Our cohort included 213,558 deliveries that met the inclusion criteria, of them 208,017 had normotensive pregnancies and 5541 had preeclampsia. The latter group was further divided into those who had a single episode of preeclampsia followed by normotensive gestations (n=3879), and women who had recurrent preeclampsia (n=1662). We used parametric and non-parametric statistics as appropriate. Results: (1) Women with recurrent preeclampsia had an increased rate of early ((130/1662) 7.8% vs. (171/3879) 4.4%, P<0.001) and late ((268/1662) 16.1% vs. (438/3879) 11.3%, P<0.001) preterm deliveries than a single episode of preeclampsia; (2) of interest, the rate of chronic hypertension is higher in the first pregnancy of those with a single preeclampsia episode (P<0.001), while women with recurrent preeclampsia developed it in the subsequent gestations (P<0.001); (3) the rate of small for gestational age neonates in the index pregnancy was higher in those with recurrent rather than a single episode of preeclampsia (single episode 450/3879,11.6%, recurrent preeclampsia 244/1662, 14.7%, P=0.002); (4) patients with recurrent disease had an increased rate of cesarean deliveries in the subsequent pregnancies (P<0.001); and (5) patients who developed severe preeclampsia in the subsequent gestations had lower mean birthweight (P<0.001), a higher rate of perinatal mortality (P<0.001), and a lower Apgar score at 1 and 5 minutes (P<0.001), than those who developed mild preeclampsia in subsequent pregnancies, those with a single episode of preeclampsia and the control group. Conclusion: Recurrent preeclampsia increases the rate of pregnancy complications in the following gestations. Early onset preeclampsia at the index pregnancy of women with recurrent preeclampsia, is associated with increased risk for severe preeclampsia, placental abruption and perinatal mortality in subsequent pregnancies.

Preeclampsia is a progressive, multi-system disorder of pregnancy associated with morbidity and mortality on both the mother and the fetus. Currently, research is directed at identifying early biomarkers of preeclampsia in order to predict its occurrence. This is important because it helps understand the pathophysiology of the disease, and thus, promises new treatment modalities. Although a clear understanding of the pathogenesis of PE remains elusive, the currently most accepted theory suggests a two-stage process. The first stage results in inadequate remodeling of the spiral arteries and leads to the second stage, whereby the clinical features of the syndrome are featured. In this review, we summarize the modalities that have been studies so far to predict preeclampsia. The use of uterine artery Doppler and several other biomarkers such as vitamin D, soluble fms-like tyrosine kinase 1/placental growth factor (sFLT1/PlGF) ratio, soluble endoglin, and a subset of T-lymphocytes has shown promising results. We are still at early stages in this advance, and no clear recommendations have been made about their clinical use to date. Further studies are still needed to improve screening strategies and evaluate the cost-effectiveness of any intervention.

Preeclampsia (PE) is a principal cause of maternal and newborn mortality that poses financial and physical burdens to tens of thousands of families each year. Unfortunately, there is no effective management to arrest the progression of this disease unless delivery. Therefore, standardized management or preventive treatments are needed urgently. PE is closely associated with placental hypoxia, which increases the secretion of soluble fms-like tyrosine kinase 1 (sFlt-1) as well as soluble endoglin (sEng) into the maternal circulation. Metformin has been found to inhibit those anti-angiogenic factors so it might be a candidate to prevent or treat PE. Women who are diagnosed with gestational diabetes mellitus (GDM) are more likely to have complications of hypertension or PE, so this review aims to demonstrate that the application of metformin in GDM might prevent the onset or progression of PE complicated with GDM.

This paper provides ethical guidance for the professionally responsible clinical investigation of maternal-fetal investigation for fetal or neonatal benefit and its transition into clinical practice. We present an ethical framework based on the ethical principles of beneficence, respect for autonomy, and justice, the professional virtue of integrity, and the ethical concept of the fetus as a patient. We identify the implications of this ethical framework for the qualifications that centers for maternal-fetal intervention should satisfy. These centers have the ethical obligation to provide prospective review and oversight of both innovation (an experiment undertaken to benefit an individual patient) and research (an experiment undertaken to create generalizable knowledge). We describe ethically justified criteria for innovation and early-phase research, for randomized clinical trials, and for the responsible transition into clinical practice. We also identify the elements of the informed consent process, including measures to prevent therapeutic misconception by pregnant patients during the informed consent process. The scientific, clinical, and ethical requirements of maternal-fetal investigation are demanding. However, the commitment to safety and quality requires that they be met. Fulfilling this commitment will result in well-documented professionally responsible investigation of maternal-fetal intervention for fetal and neonatal benefit.

Pregnancy is rare and difficult in Sheehan syndrome patients. With the help of assisted reproductive technology, the patients even with panhypopituitarism can get pregnant again. Moreover, women with hypopituitarism have increased risk of pregnancy complications. Here we report a patient who suffered acute and severe Sheehan syndrome with panhypopituitarism and central diabetes insipidus got pregnant again by in vitro fertilization and embryo transfer. A regular and careful antenatal care was given by the cooperation between obstetricians and endocrinologists. Finally, she delivered a healthy female baby at 37+6weeks of gestation with Apgar scores of 10 and 10 at 1 and 5 minutes, respectively. The patient and her baby were doing well at postpartum follow-up. The related articles were also reviewed. This case report is aimed to help clinical practitioners to make better decisions on the management of Sheehan syndrome or other type of hypopituitarism during pregnancy.

A 32-year-old lady presented to us at 6 months of gestation with acute pancreatitis due to parathyroid hormone-dependent hypercalcemia and with insulin-dependent hypoglycemia, owing to parathyroid adenoma and possibly insulinoma, respectively. The parathyroid adenoma was localized on the magnetic resonance imaging of the neck; however, imaging for the insulinoma could not be done due to the gravid state. Due to the simultaneous occurrence of tumours in two endocrine glands, namely, parathyroid gland and pancreatic islet cells, a diagnosis of MEN-1 (multiple endocrine neoplasia) was considered, which is very rarely seen in pregnancy. Her hypercalcemia was effectively managed with cinacalcet and alcohol ablation of the parathyroid adenoma while her hypoglycemic episodes were managed with short and long-acting octreotide injections during the antenatal period. She had a full-term cesarean delivery, with no maternal or neonatal complications, except for transient neonatal hypoglycemia. The patient was followed up for 1 year after her delivery with no further episodes of hypercalcemia and hypoglycemia, on medical management. Tc99m sestamibi scan was done after delivery which confirmed the presence of a left inferior parathyroid adenoma. MEN-1 with pregnancy thus poses a diagnostic and therapeutic challenge and our case highlights the role of multimodal medical therapy for successful management.

Choledochal cysts is a rare congenital cystic dilatation of common biliary duct. The most common prenatal diagnosed form type- I (85%-90%), consists of fusiform dilation of the common bile duct. There is communication between the bile duct and the cyst. In antenatal period diagnosis may be made by the presence of a cyst in the upper right side of the fetal abdomen on ultrasound. To differentiate it with other cystic lesions prenatal ultrasonography (USG), three-dimensional USG and magnetic resonance imaging may be helpful. By early diagnosis and prompt removal of cyst in postnatal period long term complications like development of biliary cirrhosis, portal hypertension, calculi formation or adenocarcinoma can be avoided in later life. The operative mortality is about 10%. We are reporting a case of antenatal diagnosis type I congenital choledochal cysts at 21 weeks, its follow up and successful postnatal management.