Maternal Serum Angiogenic Factor sFlt-1 to PlGF Ratio in Preeclampsia: A Useful Marker for Differential Diagnosis and Prognosis Evaluation in Chinese Women.

The ratio of soluble fms-like tyrosine kinase-1 to placental growth factor (sFlt-1/PlGF) is elevated and proved to be useful in preeclampsia (PE) diagnosis. Its value in differential diagnosis with other pregnancy complications and prediction of pregnancy duration has yet to be clarified in Chinese population. We retrospectively analyzed 118 singleton pregnancies with suspected or diagnosed PE at the Peking Union Medical College Hospital (PUMCH) in China. Among these, 62 pregnancies were diagnosed as PE (48 early onsets and 14 late onsets, with 39 and 5 severe PE, respectively), 12 gestational hypertension (GH), 15 chronic hypertension (chrHTN), 16 autoimmune diseases, and 13 pregnancies with uncomplicated proteinuria. And 76 normal pregnancies were included as control. The results showed (1) the sFlt-1/PlGF ratio in early onset PE subgroup was significantly higher than that in GH, chrHTN, and control groups; the sFlt-1/PlGF ratio in late onset PE subgroup was significantly higher than that in chrHTN and control groups, but similar as GH group; the sFlt-1/PlGF ratio was similar among GH, chrHTN, and control groups. (2) The sFlt-1/PlGF ratio was significantly increased in the PE group compared with autoimmune disease and uncomplicated proteinuria pregnancies. (3) By ROC curve analysis, the cutoff value of the sFlt-1/PlGF ratio was less than 21.5 to rule out PE and higher than 97.2 to confirm the diagnosis of PE. (4) The sFlt-1/PlGF ratio was higher in PE pregnancies delivering within 7 days than those more than 7 days, either in early onset PE or severe PE. In conclusion, we show that maternal sFlt-1/PlGF ratio is an efficient biomarker in the diagnosis and differential diagnosis of PE. This ratio can be used to predict the timing of delivery for PE pregnancies.

Genetic counseling, prenatal screening and diagnosis of Down syndrome in the second trimester in women of advanced maternal age: a prospective study.

BACKGROUND: The incidence of autosomal trisomy in livebirths is strongly dependent on maternal age. Special consideration is given to the provision of prenatal screening and cytogenetic testing to women of advanced maternal age (AMA). The aim of this study was to evaluate the effectiveness of second trimester prenatal screening and amniocentesis for Down syndrome (DS) and compare the trends of choice of screening and amniocentesis among AMA women. METHODS: A total of 5404 AMA patients with natural singleton pregnancy were recruited for this prospective study from January 2008 to December 2010. The gestational weeks were from 15 weeks to 20(+6) weeks. The patients referred were grouped into a screening group (2107 cases) and an amniocentesis group (3297 cases) by their own decision. The prevalence of DS was compared between the two groups by chi-square test. Choice rates for each maternal age with trends were compared by regression analysis. RESULTS: There were 18 cases of fetal DS detected in the screening group with a prevalence of 8.54‰ (18/2107). Twenty-five cases of fetal DS were diagnosed in the amniocentesis group with a prevalence of 7.58‰ (25/3297). No statistical difference was observed in the prevalence of DS between the screening and amniocentesis group (P = 0.928). The invasive testing rate for DS in the amniocentesis group was 5.54 times higher than that of the screening group (1/131.88 vs. 1/23.78). With the increase of the maternal age, the choice of amniocentesis increased while the choice of the screening showed an opposite trend. The choice of the AMA women between the screening and amniocentesis was significantly age relevant (P = 0.012). CONCLUSIONS: The second trimester serum screening in combination with maternal age was more effective than maternal age alone to screen for DS. We suggest educating the patients by recommending AMA women be informed of both screening and amniocentesis options.

[Pregnancy outcomes of eight pregnant women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency].

OBJECTIVE: To investigate the clinical features and pregnant outcomes of the pregnant women with congenital adrenal hyperplasia (CAH) 21-hydroxylase deficiency (21-OHD). METHODS: The clinical features, therapies, pregnant outcomes of the pregnant women with 21-OHD were retrospectively reviewed in Peking Union Medical College Hospital, from January 2005 to April 2011. RESULTS: There were 8 pregnant women with 21-OHD including 5 simple virilizing patients and 3 nonclassical 21-OHD women. Eight patients were accepted progestational and prenatal continual lower glucocorticoid treatment. During the gestational period, the dosage of glucocorticoid was adjusted in one pregnancy. The serum level of 17-alpha hydroxyprogesterone (17-OHP) were elevated after pregnancy [(70 ± 38) versus (24 ± 23) nmol/L, P < 0.05]. The fertility and offspring rate of 8 patients was 8/12, the fertility and offspring rate of patients who started treatment at preadolescence was significantly increased (4/5 versus 4/7). Four patients were accepted genital reconstructive surgery (clitorectomy, clitoroplasty, vulvoplasty) before pregnancy. The incidence of GDM was 1/8. All patients selected caesarean at from 37(+6) gestation weeks to 39(+6) gestation weeks. The average newborn birth weight was (3210 ± 447) g, and height was (48 ± 2) cm of 8 neonates, none of them was CAH. CONCLUSIONS: Medical and surgical therapy provides satisfactory fertility and pregnancy outcomes for women with 21-OHD. It is safe to pregnant women with 21-OHD and their fetus in continual lower glucocorticoid treatment. The dosage of glucocorticoid should be carefully adjusted during the pregnancy individually according to serum level of 17-OHP.

[Relationship of adverse pregnancy outcomes and a high risk serum screen for Down syndrome in the second trimester].

OBJECTIVE: To investigate the the relationship of a high risk serum screen for Down syndrome in second trimester and adverse pregnancy outcomes, and to evaluate the predictive value for adverse pregnancy outcomes. METHODS: The tri-marker second trimester maternal serum screening for Down syndrome (alpha-fetoprotein, free beta-hCG and unconjugated estriol) was performed on the pregnant women at Peking Union Medical Hospital from January 2009 to January 2011. The cutoff valvue was 1/270. Pregnancy outcomes were followed up. The general condition and pregnancy complications of the pregnant women with high risk (high-risk group) were compared to that of the pregnant women with low risk (low-risk group); and with 35 years old as a demarcation, the incidences of adverse pregnancy outcomes were calculated in the two groups. RESULTS: (1) A total of 1935 cases were collected. And 1784 cases were with low risk, and 151 cases were with high risk. The difference of weight and gestational age between the two groups was not statistically significant (P > 0.05); the difference of age between the two groups was statistically significant (P < 0.01). (2) Pregnancy complications were found in 791 cases. In high-risk group, the incidences of gestational diaetes mellitus (GDM, 13.9%), neonatal asphyxia (4.0%) and small for gestational age infant (SGA, 4.6%) were higher than that in low-risk group (8.4%, 1.0%, 1.6%), the difference was statistically significant (P < 0.05). The incidences of gestational hypertension disease, premature labor, oligohydramnios, placenta previa, placenta abruption, fetal macrosomia in the two groups was not statistically different (P > 0.05). (3) In 1705 cases aged less than 35 years, 129 cases (7.6%) were GDM, 43 cases (2.5%) were gestational hypertension disease, 61 cases (3.9%) were premature labor; in 230 cases aged 35 years or more, 41 cases (17.8%) were GDM, 12 cases (5.2%) were gestational hypertension disease, 15 cases (6.5%) were premature labor, and the difference between the two groups was statistically significant (P < 0.05). In < 35 years old group, the incidences of GDM, neonatal asphyxia and SGA (12.3%, 4.4%, 5.3%) were higher in the high-risk group than that (7.2%, 0.9%, 1.6%) in the low-risk group, and the difference was statistically significant (P < 0.05). In ≥ 35 years old group, the incidences of GDM, neonatal asphyxia and SGA (18.9%, 2.7%, 2.7%) were slightly higher in the high-risk group than that (17.6%, 1.6%, 1.6%) in the low-risk group, the difference between the two groups was not statistically significant (P > 0.05). CONCLUSIONS: The present study revealed apparent increase in the adverse pregnancy outcomes in women with a high risk of Down syndrome screening test. Advanced age is the most important risk factor for a high risk of Down syndrome screening test and adverse pregnancy outcomes. More attention should be attached to the patients whose age were < 35 years old and with a high risk of Down syndrome screening test.

[Management of pregnancy with myasthenia gravis: 7 cases report].

OBJECTIVE: To discuss the interaction of pregnancy and myasthenia gravis (MG) and the management of pregnancy with MG. METHODS: Seven cases of pregnancy with MG in Peking Union Medical College Hospital were analyzed retrospectively, with respect to the therapy of MG, pregnancy complications and outcomes. RESULTS: Totally 38,683 pregnant women were admitted to Peking Union Medical College Hospital between Oct. 1983 and Oct. 2010. Among them there were 9 patients suffered from MG, with the incidence of 0.023%. Two pregnancies were terminated because of personal reasons, and seven continued. (1) Onset of MG: in the 7 cases, 6 were diagnosed before conception, with the mean course of 5.9 years. The other one occurred in the third trimester. (2) MANAGEMENT: all the cases were under close surveillance during pregnancy. Four women took thymectomy before conception, and one of them kept taking medication after surgery. In those who received thymectomy, 3 cases remained stable and 1 case worsened during pregnancy. The latter one took medication at 33 weeks, and continued to full term. MG exacerbated in the other three women who had not undergone thymectomy before conception. Among them, one woman complicated with systemic lupus erythematosus and lupus nephritis delivered the baby at 31 weeks. (3) Delivery and neonatal outcomes: cesarean deliveries were performed in 5 cases and the other two underwent vaginal deliveries. All the newborns were admitted to neonatal intensive care unit for surveillance. There were three smaller than gestational week (SGA) infants. No MG was observed in newborns. CONCLUSIONS: Patients with MG should have an overall evaluation before conception. The course of MG during pregnancy is unpredictable. They may get a promising outcome under the control of a multidisciplinary team including obstetricians and neurologists. Newborns should be carefully monitored for sings of transitory MG in the department of pediatrics.

Management of pregnancy with ankylosing spondylitis.

OBJECTIVE: To discuss the interaction between pregnancy and ankylosing spondylitis, and the management of pregnancy with ankylosing spondylitis. METHODS: Twelve cases of pregnancy with ankylosing spondylitis in Peking Union Medical College Hospital from September 2004 to July 2011 were analyzed retrospectively, focusing on the arteritis condition, pregnancy complications, and outcomes. RESULTS: All the 12 patients had full-term pregnancy. Five cases gave birth naturally, and 7 cases received cesarean section for maternity factors. No adverse pregnancy outcomes were encountered. Waist pain appeared in 2 cases in the second trimester, for both of which medication failed. One of the 2 cases had natural childbirth, while the other maintained pregnancy smoothly to cesarean section. CONCLUSIONS: Pregnancy monitoring can help obtain favorable pregnancy outcomes. Attention should be paid to postpartum change of the illness.

[Prenatal genetic test and clinical guidance for 213 hereditary deaf families].

OBJECTIVE: To summarize the workflow, strategy and experience of prenatal genetic test for deafness based on the 6-year clinical practice. METHODS: There were 213 families who received prenatal test from 2005 to 2011. Among the 213 families, 205 families had had one deaf child, including 204 couples with normal hearing and one couple of the deaf husband and normal wife, 8 families including 6 couples with normal hearing and 2 deaf couples, had no child before test. Genomic and mitochondrial DNA of each subject was extracted from whole blood. The etiology and recurrent risks in 212 families were confirmed by means of the genetic test of GJB2, SLC26A4 and mtDNA 12sRNA, but one family carried POU3F4 c.647G > A heterozygous mutation causing X-linked hereditary hearing impairment confirmed by pedigree study. The prenatal test was carried out during the pregnancy of all mothers from 11 to 30 weeks, and the following genetic information and counseling were supplied based on the results. RESULTS: The recurrent risk was 25% in 209 families, including 204 families with one deaf child and 5 families without child, among which all couples were GJB2 or SLC26A4 mutation carriers and deaf children were caused by homozygous or compound GJB2/SLC26A4 mutations; The recurrent risk was 50% in 3 families, the father and his child in one family had compound SLC26A4 mutations and the mother with heterozygous SLC26A4 mutation, the wife had POU3F4 c.647G > A heterozygous mutation in another one family, and the husband with compound SLC26A4 mutations and the wife with mtDNA A1555G mutation and heterozygous SLC26A4 mutation simultaneously happened in the rest one family; The recurrent risk was 100% in one family of the deaf couple who were both found to carry homozygous or compound GJB2 mutations, and the deaf wife got pregnant by artificial insemination with the sperm from the local Human Sperm Bank. 226 times of prenatal test were applied in all 213 families that 11 families of them received prenatal test twice, and one family received three times. 46 times of prenatal testing showed that the fetuses carried parental mutations simultaneously or the same mutations with probands; while 180 times of prenatal test showed that the fetuses carried only one parental mutation or did not carry any mutation from parents. The following visit showed that all of these 180 families had given birth to babies who were all revealed to have normal hearing by new born hearing screening test. CONCLUSIONS: Prenatal diagnosis for deafness assisted by genetic test can provide efficient information about offspring's hearing condition, and the normative workflow and precise strategy highly guarantee the safe and favorable implementation of prenatal diagnosis.

Clinical analysis of placenta previa complicated with previous caesarean section / 中国医学科学杂志(英文版)

<p><b>OBJECTIVE</b>To investigate the clinical features and treatment of placenta previa complicated with previous caesarean section.</p><p><b>METHODS</b>The clinical data of 29 patients with placenta previa complicated with a previous caesarean section (RCS group) admitted in Peking Union Medical College Hospital during a period from 2003 to 2011 were retrospectively reviewed and compared with those of 243 patients with placenta previa without a previous caesarean section (FCS group) during the same period.</p><p><b>RESULTS</b>There was no difference in the mean age (28.9±3.6 vs.28.1±4.5 years) and the average gravidity (2.35±1.48 vs.2.21±1.53) between RCS group and FCS group (all P>0.05).The RCS group had more preterm births (24.1% vs.13.2%), complete placenta previa (55.2% vs.4.9%), placenta accreta (34.5% vs.2.5%), more blood loss during caesarean section (1412±602 vs.648±265 mL), blood transfusion (51.7% vs.4.9%), disseminated intravascular coagulation (13.8% vs.2.1%), and obstetric hysterectomy (13.8% vs.0.8%) than the FCS group (all P<0.05).The preterm infant rate (30.0% vs.13.0%), neonatal asphyxia rate (10.0% vs.4.9%), and perinatal mortality rate (6.7% vs.0.4%) of the RCS group were higher than those of the FCS group (all P<0.05).</p><p><b>CONCLUSIONS</b>More patients had complete placenta previa and placenta accreta, postpartum hemorrhage, transfusion, uterine packing, obstetric hysterectomy, and perinatal morbidity in the placenta previa patients with previous caesarean section.The patient should be informed of the risk and unnecessary first cesarean sections should be avoided.</p>

Expert recommendations for the diagnosis and treatment of iron-deficiency anemia during pregnancy and the postpartum period in the Asia-Pacific region.

Anemia during pregnancy and the postpartum period is commonly caused by iron deficiency and is a significant worldwide issue with severe consequences for both mother and developing fetus. From a worldwide perspective, iron-deficiency anemia (IDA) during pregnancy is highest in the Asia-Pacific region; however, there has been little guidance in this region for safe and effective treatment. An expert panel was convened to develop a concise and informative set of recommendations for the treatment of IDA in pregnant and postpartum women in the Asia-Pacific region. This manuscript provides these recommendations and aims to reduce the morbidity and mortality associated with IDA in pregnant and postpartum women in the Asia-Pacific region. The consensus recommendations define anemia as a hemoglobin (Hb) level <10.5 g/dL during pregnancy and <10 g/dL during the postpartum period, and provide cut-off Hb levels to initiate therapy with oral iron, intravenous iron or red blood cell transfusion.

Current situation and development of prenatal diagnosis in China.

Prenatal screening and diagnosis are major methods for control of birth defects, which is a very important problem in China. Here, we review current situation and development of prenatal screening and diagnosis in mainland China, including prenatal screening and prenatal diagnosis of fetal chromosome abnormalities, non-invasive prenatal diagnostic techniques and prenatal diagnosis of monogenic diseases, polygenic disease and congenital metabolic diseases. We also discuss epidemiology of birth defects and genetic diseases in China and related ethical issues of prenatal diagnosis.

[Establishment of multiple quantitative fluorescent polymerase chain reaction assay and its application in rapid prenatal diagnosis of common chromosome aneuploidies].

OBJECTIVE: To establish the multiple quantitative fluorescent polymerase chain reaction (QF-PCR) assay and evaluate its clinical application in prenatal diagnosis. METHODS: Totally 170 samples were collected between May 2008 and July 2009 in prenatal center of Peking Union Medical College Hospital; 123 of them were amniotic fluid, 9 were chorionic villous samples, 20 were fetal blood and 18 were villi from aborted fetuses. All samples were from women of Han nationality, with mean age of (34.1 ± 4.6) years old, and with mean gestational age of (19.6 ± 1.0) weeks. Cytogenetic cultures and karyotyping were made to every sample. Genomic DNA was extracted from the samples. The sequences of twenty short tandem repeat (STR) markers were designed according to the GenBank and references, including 6 STR markers in chromosome 21, 4 in chromosome 18, 4 in chromosome 13, 4 in chromosome X, 1 in chromosome Y and 1 universal marker in both X and Y chromosome. Each sample was amplified by two sets of multiple QF-PCR, which included 4 STR markers in each of 21, 18, 13 and sex chromosomes. If the result was uninformative, the third set of another 4 STR markers was added. RESULTS: (1) Karyotyping. Cytogenetic analysis were made for all the 170 samples, 151 (89%) of which were normal, and 19 (11%) were abnormal. (2) QF-PCR assay. 167 (98%) samples were detected by QF-PCR. The results were obtained within 2 - 3 days after sampling. 134 samples were proved normal by QF-PCR, which was consistent with karyotyping. Among the 19 abnormal karyotype samples, 18 were detected as abnormal(eight were 21-trisomy, three were 18-trisomy)by QF-PCR. Among the 167 samples, 150 (90%) were detected using the first and second set of STR mixtures, and 3 (2%) were detected when the third set of STR was added. The remain 14 (8%) were uninformative. (3) The diagnostic efficiency of QF-PCR. The sensitivity of QF-PCR in prenatal diagnosis of common aneuploidities was 95%, the specificity, the false positive rate, the false negative rate, the positive predictive value and negative predictive value were 100%, 0, 5%, 100% and 99%, respectively. (4) Autosome and sex chromosome detection by QF-PCR. Among all the STR markers, D21S1270 and D21S1411 had the highest heterozygosities in chromosome 21, and DXS8377 had the highest in sex chromosome. The amplifications were stable. CONCLUSION: Multiple QF-PCR assay is a valid alternative in rapid prenatal diagnosis of common chromosome aneuploidies. With high accuracy, it can be used for numerous sample test in large-scale laboratories.

[Correlation of a disintegrin and metalloprotease 12 level in maternal serum during the first trimester with pregnancy outcome].

OBJECTIVE: To explore the relationship between pregnant outcomes and the maternal serum level of a disintegrin and metalloprotease 12 (ADAM 12) in the first trimester. METHODS: From July 2007 to January 2008, the serum levels of ADAM 12 of 511 women in their first trimester (6 - 13 gestational weeks), who attended the clinics at Peking Union Medical College Hospital, were tested by Time-Resolved Fluorescence Immunoassay (TR-FIA), and the results and pregnant outcomes were analyzed. RESULTS: (1) The median levels of ADAM 12 at 6, 7, 8, 9, 10, 11, 12, 13 weeks of gestation were 14.63 microg/L, 35.08 microg/L, 88.90 microg/L, 186.51 microg/L, 370.62 microg/L, 537.71 microg/L, 632.55 microg/L, and 769.42 microg/L, respectively, showing a linear increase with the gestational age (r =0. 992, P < 0.01). (2) Among the 511 pregnancies, 427 were normal singleton term pregnancies and 84 had adverse perinatal outcomes. Twenty-seven miscarriages (5.3%, 27/511) and 5 ectopic pregnancies were reported and the Multiple of Medians (MOM) of them were 0.24 and 0.32, respectively, which was significantly lower than the normal singleton pregnancies (1.01, P < 0.05). However, the serum level of ADAM 12 in 5 women with placenta previa (MOM = 1.45) was significantly higher than the normal ones (P < 0.05). No significant correlation was found between the fetal birth weight and maternal serum level of ADAM 12 in the first trimester (r = -0.15, P < 0.05). (3) Thirteen cases with chromosomal abnormalities was identified out of 97 cases who received fetal karyotyping, including 3 Down's syndrome and 2 Turner syndrome, and the MOM of ADAM 12 in these 13 cases (0.34) was significantly different from those normal singleton pregnancies (P < 0.05). MoMs of ADAM 12 in 10 euchromosome aneupolyhaploids cases (0.29)were lower than the normal ones (P < 0.05). CONCLUSION: The maternal serum level of ADAM 12 in the first-trimester is a potential marker for aneupolyhaploid screening and early fetal loss prediction, and is suggested to be tested at 9-12 gestational weeks as part of prenatal screening.

Pregnancy outcomes of repeat cesarean section in Peking Union Medical College Hospital.

OBJECTIVE: To evaluate the effect of elective repeat cesarean section on the maternal and neonatal outcomes. METHODS: A retrospective clinic- and hospital-based survey was designed for comparing the maternal and neonatal outcomes of elective repeat cesarean section [RCS group (one previous cesarean section) and MRCS group (two or more previous cesarean sections)] and primary cesarean section (FCS group) at Peking Union Medical College Hospital from January 1998 to December 2007. RESULTS: The incidence of repeat cesarean section increased from 1.26% to 7.32%. The mean gestational age at delivery in RCS group (38.1+/-1.8 weeks) and MRCS group (37.3+/-2.5 weeks) were significantly shorter than that in FCS group (38.9+/-2.1 weeks, all P<0.01). The incidence of complication was 33.8% and 33.3% in RCS group and MRCS group respectively, and was significantly higher than that in FCS group (7.9%, P<0.05). Dense adhesion (13.5% vs. 0.4%, OR=7.156, 95% CI: 1.7-30.7, P<0.01) and uterine rupture (1.0% vs. 0, P<0.05) were commoner in RCS group compared with FCS group. Neonatal morbidity was similar among three groups (P>0.05). CONCLUSIONS: Repeat cesarean section is associated with more complicated surgery technique and increased frequency of maternal morbidity. However, the incidence of neonatal morbidity is similar to primary cesarean section.

Influential and prognostic factors of small for gestational age infants.

BACKGROUND: Small for gestational age (SGA) infants are associated with a high rate of oligohydramnios, stillbirth and cesarean delivery. Among SGA patients there is a higher risk of neonatal complications, such as polycythemia, hyperbilirubinemia, and hypothermia. Additionally, the SGA infant is prone to suffer from major neurologic sequelae, as well as cardiovascular system disease, in later life. Proper monitoring and therapy during pregnancy are, therefore, of utmost importance. The present study aimed to investigate the influential and prognostic factors of SGA infants. METHODS: From January 2001 to June 2007, a total of 55 SGA neonatal infants were included in a study group. All were born at Peking Union Medical College Hospital, with regular formal antenatal examinations. In addition, a total of 122 cases of appropriate for gestational age (AGA) infants were born at the same time and were registered into a control group. All cases were singleton pregnancies with detailed information of the maternal age, gravidity, parity, maternal height and weight, complications, uterine height and abdominal circumference, results from transabdominal ultrasonography between 32 - 38 gestational weeks, pregnancy duration, delivery manner, placenta, umbilical cord, and neonatal complications. RESULTS: Significant differences were observed in placenta weight and neonatal malformations between the study and control groups. Multivariate analysis revealed increased parity, maternal hyperthyroidism and hyperthyroidism history as risk factors. Fetal abdominal circumferences less than 30 and 32 cm at 32 - 38 gestational weeks respectively, as determined by ultrasonography, resulted in a Youden index of 0.62. CONCLUSIONS: SGA infants were associated with a greater risk of smaller placentas and infant malformations. Increased parity, maternal hyperthyroidism, and a hyperthyroid history were risk factors for SGA infants. Fetal abdominal circumference less than 30 cm at 32 gestational weeks and less than 32 cm at 38 weeks, as determined by ultrasonography, was considered an effective index for SGA.

[Clinical analysis of 47 cases of placenta accreta in the second and third trimesters].

OBJECTIVE: To explore the clinical characters, diagnosis and treatment methods of placenta accreta. METHODS: A retrospective analysis was made of 47 cases of placenta accreta admitted during May 1997 to May 2007 into Peking Union Medical College Hospital. They included 17 cases in the second trimester and 30 cases in the third. RESULTS: Among all the patients, the incidence of placenta accreta was 0.262% (47/17 918). Most of these cases (81%, 38/47) experienced a uterine procedure. 30% (14/47) of the cases were found with placenta previa and 11% (5/47) with myoma in the current pregnancy. 11% (5/47) of all the cases suffered postpartum hemorrhage. In the 17 cases in the second trimester, 12 were diagnosed by ultrasonography and 5 by clinical evidence. While in the 30 cases in the third trimester, 8 were diagnosed by biopsy, 2 by ultrasonography, and 20 by clinical evidence. 45 cases were cured by conservative treatment, which included dilatation and curettage, uterine artery embolization (UAE) with or without methotrexate (MTX), tamping B-lynch suture, singly with MTX, and mifepristone. Only 2 cases received cesarean hysterectomy. CONCLUSIONS: The incidence of placenta accreta seems on the rise. The incidence in the second trimester is higher than that in the third. In the second trimester, most cases can be diagnosed by ultrasonography after labor, and presently UAE is the best conservative management. While in the third trimester clinical evidence is the most frequent diagnostic approach. A majority of the cases could be cured by conservative therapies, which help them avoid a hysterectomy.

[Effect of pregnancy and spontaneous delivery on the morphology of levator ani muscle and expression of vaginal nerve fibers].

OBJECTIVE: To investigate the effect of pregnancy and spontaneous delivery on the morphologic characteristics of the levator ani muscle and innervation of the vaginal mucosa. METHODS: Eight nullipara without pelvic floor dysfunction (PFD) and 64 normal primipara undergoing spontaneous delivery were enrolled in this study during July to December 2006 in Peking Union Medical College Hospital. Biopsy specimens of levator ani muscle (LAM) and anterior and posterior vaginal walls were obtained from the puerpera as well as from the 8 nullipara undergoing vaginal operation. The structures of LAM were examined with histological techniques. Vaginal mucosa specimens were examined using immunohistochemistry staining for protein gene product 9.5 (PGP 9.5), vasoactive intestinal peptide (VIP) and ne uropeptide Y (NPY), and the positive stained nerve fibers were calculated respectively. RESULTS: The LAMs of the puerpera undergoing spontaneous delivery presented myogenetic and neurogenetic changes, both acute and chronic. Type I muscular fibers were predominant (79%) with both types increasing in diameters [(86 +/- 9) microm and (79 +/- 15) microm]. Significantly different (P < 0.05) innervation of PGP 9.5, VIP, and NPY nerve fibers was observed between epithelial lamina of anterior vaginal wall (5.9 +/- 3.3, 7.6 +/- 3.1 and 8.2 +/- 3.2, respectively) and that of posterior vaginal wall (3.8 +/- 2.9, 5.9 +/- 3.1 and 6.0 +/- 3.0, respectively), with the nerve fibers being more in epithelial lamina of anterior vaginal wall, while no difference in the innervation of nerve fibers was observed in the lamina propria. Significantly different (P < 0.05) innervation of PGP 9.5 and VIP nerve fibers was observed in the lamina propria of the anterior vaginal wall in puerperal undergoing vaginal delivery (6.9 +/- 3.2 and 4.9 +/- 2.1) compared with those in nullipara (3.9 +/- 3.6 and 3.1 +/- 1.2). CONCLUSIONS: Pathologic changes occur in LAMs and pelvic floor nerves during labor and delivery. LAM fibers become hypertrophy to adapt to the physiological changes during pregnancy. Richer innervation of PGP 9.5 and VIP nerve fibers in the lamina propria of the anterior vaginal wall in puerpera undergoing spontaneous delivery is beneficial for dilation of the blood vessels and smooth muscles and makes preparation for delivery.