Recommendations for the diagnosis and treatment of maternal SARS-CoV-2 infection / 中华围产医学杂志

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has spread worldwide and threatened human's health. With the passing of time, the epidemiology of coronavirus disease 2019 evolves and the knowledge of SARS-CoV-2 infection accumu-lates. To further improve the scientific and standardized diagnosis and treatment of maternal SARS-CoV-2 infection in China, the Chinese Society of Perinatal Medicine of Chinese Medical Association commissioned leading experts to develop the Recommendations for the Diagnosis and Treatment of Maternal SARS-CoV-2 Infection under the guidance of the Maternal and Child Health Department of the National Health Commission. This recommendations includes the epidemiology, diagnosis, management, maternal care, medication treatment, care of birth and newborns, and psychological support associated with maternal SARS-CoV-2 infection. It is hoped that the recommendations will effectively help the clinical management of maternal SARS-CoV-2 infection.

Fetoscopic laser coagulation for placental chorioangioma: a report of three cases and literature review / 中华围产医学杂志

Objective:To evaluate the outcome of laser coagulation under fetoscope for placental chorioangioma (CA).Methods:The clinical data of three pregnant women with giant CA treated by laser coagulation under fetoscope in Peking University Third Hospital from January 2018 to December 2020 were analyzed retrospectively. Relevant articles up to September 2022 were retrieved from Wanfang Database, China National Knowledge Infrastructure and PubMed, and the clinical data of all patients were retrospectively summarized. Indications and intervention effects of fetoscopic laser therapy were analyzed. Descriptive statistics was used to describe the data.Results:Thirteen patients were involved in this study including 10 cases retrieved from the databases. The average age of the pregnant women was (30.3±6.2) years old. There were 12 cases of single pregnancy and one case of twin pregnancy (monochorionic diamnionic twin pregnancy). Except for cases for which data were not available in the literatures, at the diagnosis of CA, the average gestational age was (19.9±4.5) weeks ( n=7) and the average maximum diameter of the mass was (6.1±4.1) cm ( n=6). The patients underwent fetoscopic laser therapy at an average gestational age of (25.0±2.0) weeks ( n=13) with the average maximum tumor diameter of (7.6±2.8) cm ( n=9). After treatment, the amniotic fluid volume of three cases decreased to normal. In one case, the amniotic fluid volume decreased but was still above the upper limit of the normal range. Moreover, the maximum tumor diameter decreased in four cases; the peak systolic velocity of the fetal middle cerebral artery decreased to normal in one case; fetal heart function became normal in two cases and fetal edema was relieved in one case. Among the three patients treated in our hospital, the blood supply of CA disappeared after treatment. Intrauterine fetal death occurred in two cases. The other 11 patients gave birth to live babies at the gestational age of (36.6±3.8) weeks with five through cesarean section (5/11), five through vaginal delivery (4/11) and two not reported. The birth weight of the neonates was (2 712±1 023) g and all of them survived. The gender of five neonates were reported and all were females, two of them were monochorionic diamnionic twins. No abnormality was found in the three neonates delivered in our hospital during a six-month follow-up. No abnormality was reported in the other neonates during ten days to six months of follow-up. Conclusions:Fetoscopic laser coagulation may help reduce the size of CA, decrease complications and improve pregnancy outcomes.

Incidence of maternal sepsis in ICUs of hospitals in Beijing: a multicenter cohort study / 中华危重病急救医学

Objective:To investigate the epidemiological data of maternal sepsis in intensive care unit (ICU), analyze the common causes, outcomes of maternal sepsis, and the risk factors of multi-drug resistant (MDR) bacteria.Methods:A retrospective cohort study. Maternal sepsis cases admitted to ICUs of Peking University Third Hospital, Beijing Chao-Yang Hospital Affiliated to Capital Medical University, and Beijing Friendship Hospital Affiliated to Capital Medical University from January 2008 to September 2022 were enrolled. The following data were recorded: demographic characteristics, sequential organ failure assessment (SOFA) during infection, infection time, infection sites, invasive intervention measures before infection, microbial culture results, blood routine test during infection, body temperature, and clinical outcomes caused by infection. According to the time of sepsis occurrence, the patients were divided into pre-ICU sepsis group and ICU sepsis group, and the causes of sepsis in the two groups were analyzed. According to whether MDR occurred, the patients were divided into MDR group and non-MDR group, and clinical outcomes were analyzed. Multivariate Logistic regression was used to analyze the risk factors of MDR bacteria infection in obstetrics with sepsis.Results:160 patients were enrolled, among which 104 cases of sepsis happened before ICU and 56 cases of sepsis happened during ICU, 53 cases were with MDR bacteria and 107 cases were without MDR bacteria. The median age of the patients was 30.5 (28.0, 34.0) years old, the median temperature was 38.8 (38.2, 39.5) ℃, and the median white blood cell count (WBC) was 17.2 (13.2, 21.3)×10 9/L, the median SOFA score was 5.0 (3.0, 8.0), and 130 cases (81.2%) were referred from other hospitals. The main infection sites were uterine cavity in 64 cases (40.0%), lung in 48 cases (30.0%), abdominal and pelvic cavity in 30 cases (18.8%), urinary system in 27 cases (16.9%). Sepsis led to hysterectomy in 6 cases (3.8%), stillbirth in 8 cases (5.0%), and neonatal death in 2 cases (1.3%). The main surgical intervention measures were cesarean section (44 cases, accounting for 27.5%), followed by exploratory laparotomy (19 cases, 11.9%). The median length of ICU stay was 5.0 (3.0, 10.0) days, and the median hospital length was 14.0 (10.0, 20.8) days. Intrauterine infection was the primary cause of sepsis happened during ICU, accounting for 50.0% (28/56), of which postpartum hemorrhage accounted for 85.7% (24/28). The proportion of diabetes [28.3% (15/53) vs. 14.0% (15/107)], intrauterine operation [41.5% (22/53) vs. 23.4% (25/107)], intrauterine infection [50.9% (27/53) vs. 34.6% (37/107)] and bacteremia [18.9% (10/53) vs. 2.8% (3/107)] in the MDR group were significantly higher than those in the non-MDR group (all P < 0.05). Multivariate Logistic regression analysis showed that diabetes [odds ratio ( OR) = 2.348, 95% confidence interval (95% CI) was 1.006-5.480, P = 0.048] and intrauterine operation ( OR = 2.541, 95% CI was 1.137-5.678, P = 0.023) were independent risk factors for MDR bacterial infection in obstetrics with sepsis. Conclusions:Intrauterine infection is the common cause of maternal sepsis in ICU, and postpartum hemorrhage is the common cause of secondary intrauterine infection in ICU. MDR bacteria can lead to serious clinical outcomes. Diabetes and intrauterine operation are independent risk factors for MDR bacteria' infection.

Comparison of four-coagulation-tests values in normal pregnant women during early and late pregnancy and the influence of age / 中华妇产科杂志

Objective:To explore and compare the reference ranges of four coagulation tests in normal pregnant women during early and late pregnancy and the influence of age.Methods:Values of four coagulation tests from 4 974 pregnant women, who gave single birth at Peking University First Hospital, Obstetrics and Gynecology Hospital of Fudan University, West China Second University Hospital, Peking University Third Hospital and Shengjing Hospital of China Medical University from February 2017 to July 2020, were measured and analyzed in this study, including prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (Fib) and thrombin time (TT). The four normal reference ranges of coagulation during early and late pregnancy phases were expressed as P2.5- P97.5. The difference of two pregnancy phases was compared by non-parametric test of two related samples. And the difference between pregnant women of advanced and non-advanced age in the same pregnancy phase was compared by independent sample non-parametric test. Chi-square test was used to compare the incidence of pregnancy complications in different coagulation reference ranges. Results:The reference ranges of PT of normal pregnant women′s early and late pregnancy were 10.0-13.9 s and 9.6-12.3 s, the reference ranges of APTT were 22.6-35.3 s and 22.4-30.9 s, the reference ranges of Fib were 2.4-5.0 g/L and 3.0-5.7 g/L, the reference ranges of TT were 12.0-19.0 s and 11.5-18.4 s. Compared with early pregnancy, PT, APTT and TT shortened significantly, while the Fib significantly increased in late pregnancy (all P<0.001). PT, APTT and TT of advanced and non-advanced age pregnant women were significantly different (all P<0.01). Compared with the ranges of non-pregnant population, more pregnant women were included in the normal pregnant reference ranges of PT in early pregnancy and APTT in the early and late pregnancy, while the incidence of pregnancy complications had no significant differences (all P>0.05). The incidence of fetal distress was higher and the incidence of preterm birth was lower in the reference range of PT in late pregnancy. The incidence of gestational diabetes mellitus was higher in the early and late gestational Fib reference ranges, and the incidence of hypertensive disorders in pregnancy was higher in the late gestational Fib reference range (all P<0.05). Conclusions:The coagulation function of pregnant women increases significantly with the growth of pregnancy, and there is a significant difference between advanced significantly and non-advanced age pregnant women. The recommended ranges of normal pregnant women′s early and late pregnancy PT are 10.0-13.9 s and 9.6-12.3 s, the recommended ranges of APTT are 22.6-35.3 s and 22.4-30.9 s, the recommended ranges of TT are 12.0-19.0 s and 11.5-18.4 s. The appropriate ranges of normal pregnant women′s early and late pregnancy Fib still need further exploration.

Clinical features and perinatal outcomes of twin pregnancies with complete placenta previa / 中华围产医学杂志

Objective:To investigate the clinical features and perinatal outcomes of twin pregnancies with complete placenta previa (CPP).Methods:We conducted a retrospective study on 266 women with CPP, including 62 twin pregnancies (twins group) and 204 singleton pregnancies (singleton group), who gave birth in Peking University Third Hospital from January 2012 to December 2020. T-test, nonparametric test and Chi-square test were adopted for univariate analysis. Differences between the two groups regarding clinical features and perinatal outcomes were compared using multivariate logistic regression or multivariate linear regression. Results:The incidence of twin pregnancy with CPP was 2.11% (62/2 937). Placenta accreta spectrum disorders (PAS) accounted for 48.4% (30/62) and 53.9% (110/204) in the twin and singleton group, respectively, but the difference was not statistically significant ( χ 2=0.58, P>0.05). In terms of antepartum hemorrhage, the proportion of women affected, those with first onset <29 weeks, amount of bleeding ≥200 ml, and the number of episodes of bleeding ≥3 were significantly higher in the twin group than those in the singletons [56.5% (35/62) vs 39.7% (81/204); 35.5% (22/62) vs 12.7% (26/204); 17.7% (11/62) vs 4.9% (10/204); and 21.0% (13/62) vs 10.3% (21/204), χ 2=5.42, 16.62, 10.78, and 4.86, respectively, all P<0.05]. Multivariate Logistic regression analysis showed that compared with the singleton group, the twin group was at higher risk of antepartum hemorrhage volume >200 ml, the number of antepartum hemorrhage episodes ≥3, preterm delivery before 34 weeks and 32 weeks, emergency cesarean section, and emergency cesarean section caused by antepartum hemorrhage [a OR(95% CI)=4.36(1.17-16.30), 3.15(1.01-9.79), 17.24(5.36-55.46), 9.85(2.32-41.77), 3.98(1.72-9.20), and 3.10(1.22-7.85), respectively, all P<0.05]. Multivariate linear regression analysis showed that the gestational week at the emergency cesarean section in the twins group was about 2.22 weeks (0.17-4.27 weeks) earlier than that in the singletons. The postpartum hemorrhage amount and the risk of postpartum hemorrhage after cesarean section, infusion of red blood cells, and hysterectomy did not differ significantly between the two groups. Conclusions:Compared with singleton pregnancies, the proportion of preterm delivery, cesarean sections, especially those caused by antepartum hemorrhage, is significantly higher among twin pregnancies combined with CPP. Accordingly, preterm delivery should be actively prevented, and the timing of cesarean section should be individualized according to the condition of the mothers and babies, and early delivery may be considered.

Clinical value of noninvasive prenatal testing in vanishing twin pregnancies / 中华围产医学杂志

Objective:To analyze the clinical value of noninvasive prenatal testing (NIPT) in vanishing twin (VT) pregnancies.Methods:A total of 164 VT pregnancies that underwent NIPT in Peking University Third Hospital from January 2017 to December 2020 were enrolled. Gestational age at onset of vanishing, results of NIPT and invasive prenatal diagnosis, blood sampling time points, and pregnancy outcomes were retrospectively analyzed using two independent samples t test and Chi-square test. Results:(1) Of the 164 cases, six had positive results for NIPT, but negative results for karyotype analysis or single nucleotide polymorphism genotyping, with a false positive rate of 3.7% (6/164) for NIPT and all of them were delivered at term. Four pregnancies terminated in the second trimester, including two fetal malformation cases and one unexplained intrauterine death whose single nucleotide polymorphisms results are all normal and one inevitable abortion case due to premature rupture of membrane who refused amniocentesis. The other 154 women all gave birth to normal phenotype babies including 12 preterm ones. (2) The false-positive rate of NIPT was lower in VT pregnancies diagnosed at less than eight gestational weeks than those diagnosed after [1.5% (2/134) vs 13.3% (4/30), χ2=6.68, P=0.010]. The false-positive rate was 6.9% (4/58) in women diagnosed at or below eight weeks between the occurrence of VT and blood sampling and was 1.9% (2/106) in those with interval more than eight weeks, but without significant difference ( χ2=1.44, P=0.231). Conclusions:Although VT pregnancies exist false-positive results in NIPT, screening is still recommended based on fully informed consent to reduce unnecessary invasive prenatal diagnosis. The earlier the onset of VT, the lower the NIPT false positive rate, but whether extending the sampling interval would reduce the risk of false-positive needs further study.

Application status and suggestions of obstetric intelligent medical service system / 中华医院管理杂志

By leveraging information technologies such as the internet, the internet of things and artificial intelligence, the data-driven intelligent medical service system for obstetrics is an important means to alleviate the uneven distribution of obstetric medical resources, improve service efficiency and reduce medical costs. In recent years, the application advantages of the obstetric intelligent medical service system in maternal health monitoring, health education and remote consultation had gradually emerged, which could effectively improve pregnancy outcomes and improve the utilization of medical resources. Given the significant advantages of the system in convenience, accessibility and interactivity, it is also challenged in such aspects as imperfect application system, poor information security, imperfect policy system and uneven smartness among regions. Therefore it is necessary to further protect maternal and infant safety, promote system upgrading, improve the policy system, promote regional layout balance, and improve medical insurance payment system.

Neonatal and long-term outcomes of selective fetal growth restricted fetuses / 中华围产医学杂志

Objective:To investigate the short- and long-term outcomes of fetuses with selective fetal growth restriction (sFGR).Methods:A retrospective study was conducted on monochorionic diamniotic (MCDA) twins with sFGR admitted to the Neonatal Intensive Care Unit of Peking University Third Hospital from September 2017 to December 2019. MCDA neonates delivered during the same period without significant complications were selected as the control group. MCDA twins with sFGR were divided into type Ⅰ, Ⅱ, and Ⅲ groups and then further divided into the larger and the smaller fetus subgroups according to the birth weight. These children were followed up by telephone at 2-3 years old. Height-for-age and weight-for-age Z-scores were calculated. Ages and Stages Questionnaire-Third Edition (ASQ-3) was used to determine comprehensive development. Independent sample t-test, one-way analysis of variance, non-parameter test, and Chi-square test (or rank-sum test) were used for statistical analysis. Results:(1) A total of 116 pregnant women with sFGR (232 neonates) were enrolled in this study. There were 43, 40, and 33 mothers and 86, 80, and 66 newborns in type Ⅰ, Ⅱ, and Ⅲ groups, respectively. The control group included 31 pregnant women and 62 neonates. The gestational age at onset of sFGR was younger in the type Ⅱ and Ⅲ groups than in type Ⅰ group [(23.8±4.8) and (24.1±3.1) vs (27.0±6.1) weeks, F=5.19, P<0.05; all P<0.017 during pairwise comparisons]. (2) The incidence of sepsis and treatment abandonment/death in neonates in type Ⅱ and Ⅲ groups were higher than those in type Ⅰ and control groups [neonatal sepsis: 11.3% (9/80) and 6.1% (4/66) vs 2.3% (2/86) and 0.0% (0/62), χ2=6.30, P=0.001; death or treatment abandonment rate:13.8% (11/80) and 10.6% (7/66) vs 3.5% (3/86) and 0.0% (0/62), χ2=4.68, P=0.003; all P<0.017 during pairwise comparisons]. In cases with type Ⅱ or type Ⅲ sFGR, the risk of digestive system diseases was significantly higher in the smaller fetus group than in the larger fetus group [type Ⅱ: 46.2% (37/80) vs 38.7% (31/80), χ2=16.72; type Ⅲ: 47.0% (31/66) vs 34.8% (23/66), χ2=39.69; both P<0.001], while the rate of respiratory system diseases was lower in the smaller fetus group [type Ⅱ: 35.0% (28/80) vs 45.0% (36/80), χ2=36.85; type Ⅲ: 37.9% (25/66) vs 45.4% (30/66), χ2=12.55; both P<0.001]. The incidence of neonatal sepsis in smaller fetuses was higher than that in larger ones in type Ⅱ sFGR [7.5% (6/80) vs 3.7% (3/80), χ2=4.68, P=0.034]. The incidence of neurological complications in larger fetuses was higher than that in smaller ones in type Ⅲ sFGR [15.1% (10/66) vs 4.5% (3/66), χ2=5.72, P<0.001]. (3) In type Ⅱ group, seven neonates died (one case of cerebral hemorrhage, two cases of gastrointestinal perforation, two cases of septic shock, and two cases of necrotizing enterocolitis), and four cases withdrew the treatment. In type Ⅲ group, four neonates died (two cases of necrotizing enterocolitis, one case of gastrointestinal perforation, and one case of cerebral hemorrhage), and three cases withdrew from the treatment. (4) Totally, 71 children in type Ⅰ, 61 in type Ⅱ, and 58 in type Ⅲ group were followed up at the age of 2-3. Children with type Ⅱ or type Ⅲ sFGR lagged behind those in type Ⅰ group and control group in physical growth [ M ( P25- P75), Z-scores:－0.46 (－0.87-0.42),－0.35 (－0.62-0.71), 0.05 (－0.61-0.51), and 0.14 (－0.57-0.75); H=6.20, P=0.001]. In type Ⅱ and Ⅲ groups, the smaller fetuses lagged the larger fetuses in physical growth at 2-3 years of age. ASQ-3 scores in communication, gross motor, fine motor, problem-solving and personal-social areas were all lower in type Ⅱ and Ⅲ groups than in type Ⅰ and control groups. ASQ-3 scores in the five dimensions of the smaller fetuses in the type Ⅱ group were lower than those of the larger fetuses. In the type Ⅲ group, the smaller fetuses had lower ASQ-3 scores in communication and gross motor than the larger ones [communication ability: (42.6±18.8) vs (56.4±9.4) scores, t=19.63, P<0.001; gross motor: (45.5±19.7) vs (54.5±9.7) scores, t=12.64, P=0.003]. Conclusion:The neonatal morbidity is significantly increased in type Ⅱ and Ⅲ sFGR, and babies lagged others in height, weight, and ASQ-3 score at 2-3, which is worthy of early attention.

Establishment and validation of predictive model for histologic chorioamnionitis during expected treatment of preterm premature rupture of membrane before 34 weeks of gestation / 中华围产医学杂志

Objective:To establish and verify a model to predict histologic chorioamnionitis (HCA) for women during expected management of preterm premature rupture of membranes (PPROM) at 24-34 weeks of gestation.Methods:This retrospective study enrolled 493 pregnant women who were diagnosed with PPROM at 24-33 +6 weeks of gestation and delivered in Peking University Third Hospital from January 1, 2012, to December 31, 2020. They were randomly divided into the modeling set ( n=345) and validation set ( n=148) at a ratio of 7∶3. Basic information, risk factors, clinical treatment, and maternal and infant outcomes were compared between participants with and without HCA using Chi-square test, t test, or Mann-Whitney U test. Multivariate logistic regression analysis was performed to analyze the independent risk factors for HCA. The predictive values of different indexes for HCA were compared and the predictive model was then established and verified using the receiver operating characteristic (ROC) curve and area under curve (AUC). Results:There were no significant differences in the basic information, common risk factors for premature rupture of membranes (PROM), or the use of tocolytics, antibiotics or dexamethasone between women in the HCA and non-HCA groups (all P>0.05). Compared with the non-HCA group, the HCA group showed an earlier onset of PROM [31.3 (24.0-33.9) vs 32.3 (27.0-33.9) gestational weeks, U=4 103.00, P=0.017], longer expected treatment [66.5 (0.7-895.3) vs 18.0 (0.3-1 123.0) h, U=1 791.00, P<0.001] and higher incidence of neonatal asphyxia, sepsis, and intracranial hemorrhage [24.3% (58/239) vs 13.2% (14/106), χ 2=5.44; 9.6% (23/239) vs 2.8% (3/106), χ 2=4.86; 41.0% (98/239) vs 17.9% (19/106), χ 2=17.45; all P<0.05]. Moreover, the positive rate of bacterial culture, C-reactive protein (CRP) level, neutrophil/lymphocyte ratio (NLR), white blood cell (WBC) and neutrophil counts were significantly increased in the HCA group [37.2% (89/239) vs 22.6% (24/106), χ 2=7.10; 8.2 (0.0-273.0) vs 5.0 (0.0-218.9) ng/ml, U=2 419.00; 5.6 (1.2-58.6) vs 4.6 (1.7-18.7), U=2 357.50; 11.9 (4.5-30.0)×10 9/L vs 10.1 (5.8-21.8)×10 9/L, U=4 074.50; 9.5 (2.5-28.1)×10 9/L vs 7.6 (3.5-18.5)×10 9/L, U=4 021.50; all P<0.05], while the lymphocyte count was decreased [1.5 (0.5-3.7)×10 9/L vs 1.6 (0.7-3.9)×10 9/L, U=4 237.00, P=0.017]. CRP level, NLR, the gestational week at the onset of PROM and the duration of expected treatment were independent risk factors for HCA ( OR=1.069, 95% CI: 1.024-1.117; OR=1.192, 95% CI: 1.048-1.356; OR=0.906, 95% CI: 0.867-0.947; OR=1.017, 95% CI: 1.007-1.026). Based on the four risk factors, the predictive model was established and ROC curve was drawn. AUC for evaluating the performance of the predictive model was 0.880, which indicated a clinical significance. Conclusion:The model established based on the four risk factors, which were CRP level, NLR, the gestational week at onset of PROM and the duration of expected treatment, performs well in the prediction of HCA in women with PPROM during expected treatment and has good clinical practical value.

Factors influencing pH value of umbilical arterial blood gas analysis in preterm infants / 中华围产医学杂志

Objective:To analyze the factors influencing pH value in umbilical arterial blood gas (UABG) analysis in preterm infants.Methods:A retrospective study was conducted on live singleton preterm infants ( n=573) who received UABG analysis in Peking University Third Hospital from January 2017 to February 2019. Analysis of variance, independent sample t-test, Spearman's or Pearson's correlation analysis, or linear regression analysis was used to analyze the influencing factors. Results:There was no significant difference in UABG pH value between preterm infants of different gestational ages (F=1.74, P=0.077). Spearman's correlation analysis found no correlation between gestational age and UABG pH value in premature infants ( r=0.003, P=0.940), and neither did Pearson's correlation between birth weight and pH value ( r=0.025, P=0.548). UABG pH value in preterm infants was linearly correlated with vaginal delivery ( t=－5.72, P<0.001), gestational hypertension ( t=－3.99, P<0.001) and placental abruption ( t=－4.52, P<0.001). Conclusions:Preterm infants at different gestational ages show a similar pH value in UABG. For those born to mothers with gestational hypertension or placental abruption, when vaginal delivery is pending, close monitoring and full preparation for resuscitation are necessary.

Pregnancy outcome and placental characteristics of twin-to-twin transfusion syndrome with different vascular patterns following fetoscopic laser surgery / 中华围产医学杂志

Objective:To evaluate the effect of different superficial vascular patterns on pregnancy outcome and residual anastomosis following laser coagulation in placentae with twin-to-twin transfusion syndrome (TTTS).Methods:This study retrospectively collected and analyzed the clinical data and postnatal placenta perfusion characteristics of 57 cases of TTTS who received fetoscopic laser occlusion of chorioangiopagous vessels (FLOC) and delivered at Peking University Third Hospital from April 2014 to April 2019. According to the vascular pattern, all the cases are divided into four groups, which were parallel, staggered, mixed, and monoamniotic groups. Differences in the operation time and method, pregnancy outcome, and residual vascular anastomosis between the four groups were compared using analysis of variance, non-parametric tests, and Chi-square (or Fisher's exact) tests. Results:Among the 57 cases, the staggered, mixed, parallel, and monoamniotic types were accounted for 68.4%(39/57), 15.8%(19/57), 14.0%(8/57), and 1.7%(1/57), respectively. After exclusion of one case of monoamniotic type, gestational weeks at onset and surgery in the parallel group were both later than the staggered and mixed groups [23.0 (22.0-26.3) weeks vs 21.0 (17.0-24.7) weeks and 22.6 (21.3-23.9) weeks, H=10.306, P=0.006; 25.0 (22.6-26.3) weeks vs 22.0 (17.4-24.9) weeks and 23.2 (22.4-24.0) weeks, H=9.926, P=0.007; all P'<0.016 7]. There was no statistical significance in the differences in operation time and method, gestational age at the end of the pregnancy, neonatal birth weight, or birth weight discordance between the three groups. The diameter of residual vascular anastomosis of women in the staggered group was less than that in the mixed group [0.6 (0.1-5.0) mm vs 1.4 (0.3-5.1) mm, P'<0.016 7], but no significant difference was observed in the parallel-group [0.9 (0.2-3.6) mm] neither with the mixed or staggered group. The staggered group was noted for an increased distance ratio of umbilical cord insertion compared with the parallel and the mixed group [0.66 (0.59-1.00) vs 0.49 (0.25-0.55) and 0.48 (0.42-0.53); P'<0.016 7]. There was no significant difference between the parallel and the mixed groups. Conclusions:Placental superficial vascular patterns may affect the residual vascular anastomosis in women with TTTS following FLOC, which should be thoroughly evaluated before the operation to develop an individual management plan to reduce residual anastomosis incidence.

Fetoscopic cord laser therapy in management of monochorionic monoamniotic twin pregnancies / 中华围产医学杂志

Objective:To analyze fetoscopic cord laser therapy for management of monochorionic monoamniotic (MCMA) twin pregnancies.Methods:The clinical data of fetoscopic cord laser therapy, including cord occlusion, transection, and disentanglement in three pairs of MCMA twins from January 2020 to January 2021 in Peking University Third Hospital were summarized. Literature on cord occlusion and/or transection in MCMA twins were retrieved from Cochrane Library, PubMed, EMBASE, CBM, WanFang, and CNKI from the time at establishment to December 2020. The clinical conditions, surgical indications and methods, disease progression, and maternal and infant prognosis were analyzed.Results:Three cases of MCMA twins in this study period received fetoscopic cord laser therapy between 17-24 weeks, among which two cases gave birth at full-term without any maternal or infant complications, and one was terminated due to fetal malformation. Seven English articles including 29 MCMA twin pregnancies were retrieved. In addition to the three cases reported in this article, a total of 32 cases were analyzed. The indication of cord occlusion and/or transection included twin-reversed arterial perfusion sequence (21.9%, 7/32), fetal malformation (46.9%, 15/32), selective fetal growth restriction (sFGR) (21.9%, 7/32), twin-to-twin transfusion syndrome (TTTS) (3.1%, 1/32), TTTS combined with sFGR (3.1%, 1/32), single intrauterine death (3.1%, 1/32). Gestational age at surgery was between 14 +1 to 27 +3 weeks. No maternal complication due to the operation was reported. After exclusion of two cases who did not receive cord transection and one case was terminated due to fetal malformation, all the other 29 co-twins were born alive at the gestational age between 24 +3 to 40 weeks and birth weight between 800-3 800 g. Among the 29 live born babies, four died soon after birth with unclarified reasons in the literature and one was born with multiple malformations which were detected prenatally, and the other 24 neonates were healthy during the follow-up from 1 month to 9 years old. Conclusions:For MCMA twin pregnant women with umbilical cord entanglement or other indications for fetal reduction, cord occlusion, transection, and disentanglement using fetoscopic cord laser is safe and effective for protecting the surviving fetus.

Selective fetal reduction for monochorionic and dichorionic triplet / 中华围产医学杂志

Monochorionic triplet and dichorionic triplet pregnancies result in a higher risk of complications than trichorionic triplet due to its monochorionic part, and often lead to adverse pregnancy outcomes. We discuss the impact of different fetal reduction numbers, object and surgical methods on the outcome of monochorionic triplet and dichorionic triplet pregnancies. Compared with expectant management, several common fetal reduction strategies can reduce the risk of premature birth, prolong gestational weeks, and increase fetal birth weight. Reduction of the fetus with a separate placenta does not avoid the complications of monochorionic twins, and reducing one of the monochorionic pairs might cause the death of the remaining fetus, thereby requiring skilled surgeons. So, reduction of the monochorionic pair was preferred. More study are needed to evaluate the reduction strategy of monochorionic triplet.

Diagnostic characteristics of acute complicated appendicitis during pregnancy / 中华普通外科杂志

Objective:To analyze the diagnostic characteristics of complicated as acute appendicitis in pregnancy.Methods:Data of pregnant patients who were treated surgically and diagnosed as acute appendicitis pathologically at the Third Hospital of Peking University from Aug 2007 to Aug 2018 were collected,including uncomplicated acute appendicitis (UCAA) such as simple and purulent appendicitis, and complicated acute appendicitis (CAA) (perforated, gangrenous appendicitis or periappendiceal abscess).Result:There were 127 pregnant patients with acute appendicitis (47 CAA and 80 UCAA). CAA group had a higher proportion of positive symptoms, signs and examinations than UCAA group. ROC results showed that when pre-hospital time (the time from symptom onset to visiting the hospital, PT) and WBC critical values were 15.5 h and 17.11×10 3/mm 3, respectively, the sensitivity of CAA were 76.6% and 57.4%, and specificity of CAA were 75.0% and 82.5%. PT≥15.5 h ( OR=8.435,95% CI:2.933-24.262) and WBC>17.11×10 3/mm 3 ( OR=5.215,95% CI:1.626-16.729) were independent risk factors for CAA. Conclusion:CAA in pregnancy is associated with atypical clinical features, but the clinical manifestations of CAA are more serious. When PT exceeds 15 h and WBC exceeds 17.11×10 3/mm 3, CAA should be suspected and active operation should be suggested to avoid obstetric adverse outcomes.

Evaluation the application of intra-operative cell salvage in cesarean section based on multicenter data / 中华妇产科杂志

Objective:To investigate the safety, efficacy and application indication of intra-operative cell salvage (IOCS) in cesarean section.Methods:A total of 1 265 pregnant women who received IOCS blood transfusion during cesarean section in 11 tertiary A hospitals from August 2016 to January 2019 were collected and divided into <1 500 ml group (796 cases) and ≥1 500 ml group (469 cases) according to the amount of blood loss during cesarean section. The general clinical data, ultrasonic imaging data, perinatal and puerperium indicators were analyzed retrospectively. The risk factors of intraoperative blood loss ≥1 500 mL using IOCS transfusion were analyzed by logistic multivariate regression.Results:(1) A total of 848 001 ml of blood was recovered and a total of 418 649 ml of blood was transfused in 1 265 pregnant women who received IOCS transfusions, which was equivalent to 23 258 U red blood cell suspension, greatly saving medical resources. The intraoperative blood loss in <1 500 ml group and ≥1 500 ml group was 800 ml (300-1 453 ml) and 2 335 ml (1 500-20 000 ml), respectively. No amniotic fluid embolism, severe adverse reactions, shock and death occurred in the two groups. (3) Multivariate regression analysis showed that age ≥35 years ( OR=1.5, 95% CI: 1.1-1.9), prenatal hemoglobin level <110 g/L ( OR=1.7, 95% CI: 1.3-2.2), history of uterine surgery ( OR=1.8, 95% CI: 1.3-2.6), placenta previa ( OR=1.9, 95% CI: 1.1-3.1), placenta accreta ( OR=2.6, 95% CI: 1.8-3.9), blood pool in the placenta ( OR=1.6, 95% CI: 1.1-2.3), abnormal posterior placenta muscle wall ( OR=1.8, 95% CI: 1.2-2.6), placenta projecting to the anterior uterine wall ( OR=3.0, 95% CI: 1.3-7.0) were risk factors for blood loss ≥1 500 ml in obstetric transfusion using IOCS technique, with statistical significance (all P<0.05). Conclusion:IOCS is safe and effective in cesarean section, which could save the medical resources and reduces medical expenses, however, it is necessary to strictly master the application indication.

Incidence and trend of severe postpartum hemorrhage between 2016 and 2019 in China / 中华妇产科杂志

Objective:To investigate the incidence and trend of severe postpartum hemorrhage (sPPH) in China, and to provide basic data for the development and evaluation of sPPH prevention and control strategy.Methods:Obstetric data was extracted from annual national representative sampling surveys based on the National Clinical Improvement System. From 2016 to 2019, 2 978, 3 400, 4 576 and 4 594 maternity hospitals with sPPH cases were included for statistics. The annual incidence of sPPH was calculated according to province and type of medical institutions and generalized linear model was emplyed to identify the determinants affecting sPPH incidence.Results:In China, sPPH incidence increased from 0.62% in 2016 to 0.93% in 2018, and was 0.92% in 2019. Eighteen provinces had an inverted U-shaped trend of sPPH over time and most of them had the highest incidence in 2018; ten provinces had an upward trend of sPPH and 3 provinces had a U-shaped trend. In 2019, the top five provinces with the highest sPPH incidence were Yunnan (1.88%), Beijing (1.45%), Jiangsu (1.31%), Guizhou (1.26%), and Ningxia Hui Autonomous Region (1.22%); the top five provinces with the lowest incidence were Henan (0.55%), Jiangxi (0.60%), Inner Mongolia Autonomous Region (0.64%), Liaoning (0.64%) and Gansu (0.69%). In 2019, the sPPH incidence in different types of medical institutions were as follows: tertiary public general hospital (1.15%), tertiary public specialized hospital (1.02%), secondary public general hospital (0.81%), private hospital (0.61%) and secondary public specialized hospital (0.58%). sPPH incidence was positively associated with proportion of twin pregnancies, macrosomia, primipara, and puerpera aged ≥35 years in maternity hospitals ( P<0.05). Conclusions:sPPH incidence generally showes an increasing trend from 2016 and is stable at a high level in recent two years in China. It is warranted to further strengthen the monitoring of postpartum hemorrhage, and improve the capability of hierarchical management and treatment in maternity institutions and regions, in order to reduce sPPH incidence and maternal mortality.

Clinical characteristics of critically ill pregnant women with different admission methods to intensive care unit: data analysis from 2006 to 2019 in the university hospital / 中华危重病急救医学

Objective:To compare the clinical characteristics of critically ill pregnant women admitted to the intensive care unit (ICU) with different admission methods, in order to make more effective and rational use of ICU resources.Methods:A retrospective study was conducted. The clinical data of critically ill pregnant women admitted to ICU of Peking University Third Hospital from January 2006 to July 2019 were analyzed. According to the admission mode to ICU, the pregnant women were divided into emergency admission group (transferred to ICU on the same day or the next day due to critical illness) and planned admission group (transferred to ICU 2 days after admitting in obstetric ward). The clinical characteristics of ICU critical pregnant women, such as the incidence, causes of admission, severity of the disease, main treatment measures, mortality, and medical expenses were collected, and a comparative analysis between the two groups was performed.Results:During the nearly 14 years, a total of 576 critical pregnant women in ICU were enrolled, accounting for 0.8% (576/71 790) of the total number of obstetric inpatients and 4.6% (576/12 412) of the total number of ICU inpatients. Seven maternal deaths accounted for 1.2% of all critically pregnant women transferred to ICU, and the overall mortality of pregnant women was 10/100 thousand. Of the 576 critically pregnant women, there were 327 patients (56.8%) in the emergency admission group and 249 patients (43.2%) in the planned admission group. Compared with the planned admission group, the proportion of elective cesarean section in the emergency admission group was significantly lower (17.7% vs. 94.0%, P < 0.01), and the proportion of emergency cesarean section was significantly higher (65.1% vs. 2.4%, P < 0.01), the acute physiology and chronic health evaluation (APACHE Ⅱ, APACHE Ⅲ) scores, simplified acute physiology score Ⅱ (SAPS Ⅱ) and Marshall score were significantly higher [APACHE Ⅱ score: 6.0 (4.0, 9.8) vs. 4.0 (3.0, 7.0), APACHE Ⅲ score: 14.0 (11.0, 20.3) vs. 12.0 (9.0, 16.0), SAPS Ⅱ score: 8 (0, 12) vs. 3 (0, 8), Marshall score: 2 (1, 4) vs. 1 (1, 3), all P < 0.01]. The length of ICU stay in the emergency admission group was significantly longer than that in the planned admission group [days: 2 (1, 5) vs. 2 (1, 3), P < 0.01], and the total length of hospital stay was significantly shorter [days: 9 (7, 13) vs. 13 (10, 18), P < 0.01]. Both in the emergency admission group and the planned admission group, obstetric factors were the main reason for admission, 60.9% (199/327) and 70.3% (175/249), respectively. The proportion of postpartum hemorrhage was the highest [35.2% (115/327) and 57.0% (142/249)], followed by preeclampsia/eclampsia [7.0% (23/327) and 7.6% (19/249)]. Only 7 of the 19 critically pregnant women with puerperal infection were planned admission. All 21 patients with acute fatty liver of pregnancy (AFLP) during pregnancy were emergency admission. Among the emergency and planned admission patients, 73 patients (22.3%) and 42 patients (16.9%) required mechanical ventilation (duration of mechanical ventilation > 24 hours), 99 patients (30.3%) and 35 patients (14.1%) needed vasoactive agents, 67 patients (20.5%) and 20 patients (8.0%) received hemodynamic monitoring, and 123 patients (37.6%) and 154 patients (61.8%) were given anticoagulation therapy, respectively. In terms of severity score of critical pregnant women, there were significant differences in APACHE Ⅱ, APACHE Ⅲ, SAPS Ⅱ and Marshall scores of pregnant women with different diseases. Among them, the APACHE Ⅲ, SAPS Ⅱ and Marshall scores of AFLP were the highest [21.0 (15.0, 32.5), 12.0 (6.0, 16.5) and 6.0 (3.5, 8.0), respectively]. The APACHE Ⅱ and APACHE Ⅲ scores of postpartum hemorrhage were the lowest [4.0 (3.0, 7.0), 12.0 (10.0, 16.0)]. The SAPS Ⅱ score of pneumonia was the lowest [2.0 (0, 14.0)]. The Marshall score for puerperal infection was the lowest [1.0 (0, 3.0)]. In terms of the total medical expenses, the cost in the emergency admission group was significantly lower than that in the planned admission group [10 thousand Yuan: 3.1 (2.0, 4.7) vs. 4.1 (2.9, 5.8), P < 0.05]. Conclusions:Compared with the critically ill pregnant women who planned to be admitted to ICU, the patients emergency admitted to ICU were more complicated and urgent, and the severity of the condition was scored higher. At present, the severity scoring system commonly used in ICU can only partly evaluate the severity of critically ill pregnant women, therefore, it is necessary to design the specific severity scoring system for critically ill pregnant women to effectively and rationally use the precious ICU resources.

Pregnancy outcome of monochorionic triamniotic triplet pregnancies and its relationship with multifetal pregnancy reduction / 中华围产医学杂志

Objective:To summarize the pregnancy outcome of monochorionic triamniotic (MCTA) triplet pregnancy and its relationship with multifetal pregnancy reduction.Methods:This study retrospectively recruited 23 women with MCTA pregnancy who delivered at Peking University Third Hospital from January 1, 2012, to January 1, 2020. All 23 cases received regular prenatal examination at our hospital from the first trimester, who were divided into two groups: selective fetal reduction group (randomly reduced one fetus, n=8) and expectant group ( n=15). Pregnancy outcome was described in all participants, differences in maternal age, gestational weeks and outcomes were compared between the two groups. The selective fetal reduction group was further divided into two subgroups: first-trimester vacuum aspiration group ( n=3) and second-trimester radiofrequency ablation group ( n=5), to evaluate the differences in pregnancy outcomes. Two independent samples- t test and Fisher's exact test were used as statistical methods. Results:(1) There was no significant difference in the gestational weeks at the end of the pregnancy [(31.7±4.1) vs (28.8±8.8) weeks], preterm delivery after 32 weeks (9/15 vs 4/8), at least two surviving children (12/15 vs 4/8) and at least one surviving child (13/15 vs 5/8) between the expectant group and the selective fetal reduction group (all P>0.05). One case with twin-twin transfusion syndrome in the expectant group underwent fetoscopic surgery at 19 weeks of gestation and delivered three live infants through cesarean section at 33 +2 weeks due to premature rupture of membranes. One case with twin reversed arterial perfusion sequence at 17 weeks of gestation refused fetal reduction and gave birth to a child at 33 weeks when one fetus's heart stopped beating and one was acardia. (2) The first-trimester vacuum aspiration group and the second-trimester radiofrequency ablation group showed no significant differences in the average gestational weeks at the end of the pregnancy [(28.5±7.6) vs (28.9±10.4) weeks, t=1.145, P>0.05], or the rate of at least one (2/3 vs 3/5, Fisher's exact test, P>0.05) or two surviving children (2/3 vs 2/5, Fisher's exact test, P>0.05). No postoperative infection or amniotic fluid leakage was reported in the subgroups. Conclusions:The pregnancy outcome of MCTA triplet with fetal reduction is not different with expectant group.

Predictive value of MRI image-based scoring model for diagnosis and adverse clinical outcomes of invasive placenta accrete / 中华围产医学杂志

Objective:To explore the predictive value of a scoring model based on MRI images for diagnosing invasive placenta accreta and associated adverse clinical outcomes.Methods:This retrospective cohort study involved 260 patients delivered at Peking University Third Hospital from January 2015 to December 2018, who were suspected to be placenta accreta with two or more ultrasound image findings and underwent MRI examination. Placenta accreta was finally diagnosed and classified based on the intraoperative clinical findings or pathological examination. Adverse clinical outcomes were defined as intraoperative bleeding ≥1 500 ml and/or having hysterectomy. Quantitative and qualitative interpretation of five MRI signs were performed, including intraplacental low-intensity band on T2 weighted imaging, abnormal intraplacental vascularization, vascularization of uterovesical interface, uterine bulging and cervical involvement. Chi-square and t test were used for univariate analysis of the five MRI signs and the receiver operating characteristics (ROC) curve of each MRI sign for predicting invasive placenta accreta and adverse clinical outcomes were drawn. The predictive value was assigned as 1 when ≥ the cutoffs that matched to the maximum Yoden index values, and was assigned as 0 when below the cutoffs. A scoring model based on the five MRI signs was established, ROC curves of the model for predicting invasive placenta accreta and adverse clinical outcomes were drawn and the area under the curve (AUC), sensitivity, specificity and Youden index were calculated. Results:(1) Univariate analysis showed that all five MRI signs were significantly associated with invasive placenta accreta and adverse clinical outcomes. Except for cervical involvement, the other four signs had an AUC value of greater than 0.5 in predicting invasive placenta accreta and adverse clinical outcomes. (2) The predictive cut-off values of abnormal intraplacental vascularization image and intraplacental dark band area on T2 weighted imaging were 2.0 cm 2 and 0.6 cm 2, respectively, and were all 1.0 for the other three signs. The AUC value of MRI signs-based scoring model for predicting invasive placenta accreta was 0.863. When the score was ≥ 2 points, the diagnostic sensitivity was 0.836 and the specificity was 0.726. The scoring model predicted adverse clinical outcomes with an AUC of 0.841. When the score was ≥3 points, the predictive sensitivity was 0.707 and the specificity was 0.818. Conclusions:The scoring model based on MRI signs is of good value for the diagnosis of invasive placenta accreta and the prediction of adverse clinical outcomes.

Effect of placental vascular distribution on residual anastomoses after fetoscopic laser surgery for twin to twin transfusion syndrome / 中华妇产科杂志

Objective:To investigate the effect of placental vascular distribution on residual anastomoses (RA) after fetoscopic laser occlusion of chorioangiopagous ressels (FLOC) for twin to twin transfusion syndrome (TTTS).Methods:A total of 57 cases of TTTS after laser surgery were retrospectively analyzed from April 2014 to April 2019 in Peking University Third Hospital. The patients were divided into RA group (24 cases) and non-RA group (33 cases) according to whether RA occurred in the placenta after laser surgery. The clinical characteristics, perioperative conditions, pregnancy outcomes and placental structure characteristics of the two groups were compared. Multivariate logistic regression was used to analyze the risk factors of placental vascular distribution for RA. The RA group was further divided into non-remission group and remission group, and the placental characteristics and pregnancy outcome of the two groups were compared.Results:(1)General clinical characteristics: the age, application of assisted reproductive technology, incidence of gestational hypertension, gestational diabetes mellitus, preoperative maximum amniotic fluid depth of the donor and recipient twins, Quintero stage and placental position of TTTS patients in the two groups were compared respectively, and there were no statistically significant differences (all P>0.05).The gestational age of patients received FLOC in the RA group was significantly higher than the non-RA group [(23.0±2.4) vs (21.9±2.7) weeks, P=0.033].(2) Perioperative conditions and pregnancy outcomes: the delivery gestational age of the RA group was significantly lower than that of the non-RA group (median:31.8 vs 34.4 weeks, P=0.002);The newborn birth weight in the RA group was significantly lower than that in the non-RA group [(1 648±597) and (2 013±481) g, P=0.003].The birthweight difference in the RA group was significantly higher than that in the non-RA group (median:0.30 vs 0.11, P=0.005). (3) The placental structure and the risk factors influencing RA happened: the differences in the proportion of four types of placental vascular distribution in the RA group and non-RA group were different significantly ( χ2 =10.214, P=0.012), with a detail of parallel type 29% (7/24) and 3% (1/33), staggered type 58% (14/24) and 76% (25/33), hybrid 8% (2/24) and 21% (7/33), monoamniotic membrane type 4% (1/24) and 0 respectively. Multivariate logistic regression analysis showed that parallel placental vascular distribution was an independent risk factor for RA after FLOC ( OR=24.5, 95% CI 1.7-336.2, P=0.017). (4) Placental characteristics and pregnancy outcomes in the remission and non-remission groups of the RA group: the incidence of three kinds of anastomoses, the total number, total diameter and proportion of RA, and the placental territory discordance ratio were compared between the two groups, and there were no statistical significances ( P>0.05);The birth weight difference ratio in the non-remission group was higher than that in the remission group (median:0.41 vs 0.28, P=0.036). Conclusion:The parallel type of placental vascular distribution may be an independent risk factor for RA in TTTS after laser surgery.