Preterm Births in Peking Union Medical College Hospital in the Past 25 Years.

Objective To investigate the changes in preterm birth rate,its gestational age distribution,and possible contributors in Peking Union Medical College Hospital (PUMCH) over the last 25-year period. Methods The clinical data of premature deliveries,both singleton and twins,in PUMCH from January 1,1990 to December 31,2014 were retrospectively analyzed. We counted the number of premature fetuses and assessed the changes of preterm birth rate and its gestational age distribution (including extremely preterm birth,early preterm birth,and late preterm birth) over time. The etiologies (including spontaneous and iatrogenic) of preterm birth were also surveyed. Results The overall preterm birth rate was 7.8% in PUMCH,showing a slightly up-trend in both singletons and twins. Twin prematurity accounted for 23.8% of total preterm births,increased from 15.1% to 28.5%. Preterm births subgrouped by gestational age included 26 cases (0.7%) of extreme prematurity (<28 weeks),1199 cases (33.9%) of early preterm birth (28- 33+6 weeks),and 2310 cases (65.3%) of late preterm birth (34- 36+6 weeks). The gestational age distribution in singletons and twins showed no significant difference(z=0.844,P=0.398). Changes in the proportion of preterm birth before 28 weeks was little,gradually increased in the 28- 33+6 weeks group (from 23.8% to 36.1%) and gradually decreased in the 34- 36+6 weeks group (from 75.5% to 63.3%). Trends of gestational age distribution of singleton and twins were similar to that of the total. Spontaneous preterm labor,preterm premature rupture of membrane,and medically indicated (iatrogenic) preterm birth accounted for 20.2%,38.9%,and 40.9% respectively. There was no difference in singletons and twins(χ2=1.071,P=0.301).The proportion of iatrogenic preterm was increased. Common reasons for iatrogenic preterm birth included gestational hypertension,fetal indications (including fetal distress,fetal growth restriction),placenta previa,and pregnancy complicated by heart disease. Conclusions The overall preterm birth rate shows an upward trend in the general hospital as a result of more multifetal gestations and more medically indicated preterm births. Reducing multifetal gestations and effective control of pregnancy complications should be the priorieties in preterm birth intervention.

[Clinical analysis of pregnancies after vaginal radical trachelectomy].

OBJECTIVE: To explore the pregnancy outcome and obstetric management of pregnancy and delivery after vaginal radical trachelectomy (VRT). METHODS: Forty-two cases of VRT from December 2003 to May 2012 in Peking Union Medical College Hospital were analyzed retrospectively. Among them ten cases got pregnant successfully. RESULTS: The average age of patient at VRT surgery was (30.6 ± 3.7) years old and average follow-up time was 29.5 months. There were 31 patients attempted conception. Ten of them got fourteen conceptions successfully. Overall conception rate was 45% (14/31). There were four cases of first trimester abortion. Among them, two were miscarriage, two were elective abortion. There was one case of ectopic pregnancy operation and non of second trimester loss. Nine cases reached the third trimester. The total preterm delivery rate was 4/9. There were two cases delivered before 32 gestational weeks (2/9). Cesarean section was performed through a transverse incision in all of nine cases. No uterine rupture and postpartum hemorrhage occurred. All newborns had good outcomes. The average follow-up time after postpartum was 22.9 months. All cases were disease-free. CONCLUSIONS: The conception rate of patients after VRT in our series is 45%. The preterm birth rate of pregnancy after VRT is higher. Routine cerclage of cervix during VRT procedure and pregnancy is not necessary. Cesarean section shortly after full term pregnancy through a transverse incision should be considered as a suitable and safe procedure.

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.

[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 induction delivery on maternal-neonatal outcomes in 41 gestational weeks primiparae].

OBJECTIVE: To estimate the maternal-neonatal morbidity associated with induction deliveries compared with spontaneous deliveries in 41 gestational weeks uncomplicated primiparae. METHODS: Three hundred and seventy-four uncomplicated primiparous deliveries at 41 gestational weeks at Peking Union Medical College Hospital from Sept 2002 to Apr 2007 were reviewed, including 225 women undergoing induced labor and 149 women undergoing spontaneous labor. The induction methods included drug induction (173), rupture of membrane induction (5) and combined drug with rupture of membrane induction (47). The maternal morbidity, delivery method, maternal cost on hospital stay and neonatal asphyxia associated with induction deliveries or spontaneous deliveries were retrospectively analyzed. RESULTS: (1) There was no maternal death. The caesarean section rate in the induction group (44.0%, 99/225) was significantly higher than that of spontaneous group (18.1%, 27/149; P<0.05). (2) No statistically significant difference (P>0.05) was observed between induction group and spontaneous group in the following puerperal complications: postpartum hemorrhage (2.7%, 6/225 and 1.3%, 2/149 respectively), puerperal morbidity (0.9%, 2/225 and 0.7%, 1/149 respectively), severe amniotic fluid contamination (11.6%, 26/225 and 13.4%, 20/149 respectively), wound infection (0.9%, 2/225 and 0.7%, 1/149 respectively) ,urinary retention(4.4%, 10/225 and 3.4%, 5/149 respectively), traumata (0.4%, 1/225 and 0 respectively) and neonatal asphyxia (1.3%, 3/225 and 2.0%, 3/149 respectively). (3) The average duration of first stage of labor in the induction group (413 min) was not significantly different from that of spontaneous group (461 min; P>0.05). In the induction group, more women had precipitate labors (P<0.05) and the average duration of the second stage of labor was shorter than that of spontaneous group (40 min and 48 min, P<0.05). (4) Spontaneous group had shorter maternal hospital stay [(5.7 +/- 1.9) days vs (6.9 +/- 2.7) days, P<0.05] and caesarean section after induction had the highest hospital expense (P<0.05). CONCLUSIONS: Induction delivery at 41 weeks of gestation increases the rates of caesarean section, precipitate labor, clinical workload and hospital costs. Induction delivery as a prevention method of over due labor needs to be further discussed. Uncomplicated pregnancies of 41 weeks should be intentionally monitored if continued surveillance is possible. They should wait for spontanous delivery, and decision of induction should be made based on its benefit to the case.

[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.

[Clinical analysis of maternal and neonatal outcomes in uncomplicated term nulliparous after different routes of delivery].

OBJECTIVE: To compare maternal and neonatal outcomes after induction, elective cesarean section and spontaneous onset of labor in uncomplicated term nulliparous women. METHODS: A total of 3751 uncomplicated term nullipara who delivered in Peking Union Medical College Hospital from Sept 2002 to April 2007 were retrospectively analyzed. They were divided into three groups: the induction group, the elective cesarean section group, and the spontaneous onset of labor group. Their general conditions (such as age, weeks of pregnancy, hospital days and cost), postpartum complications (such as postpartum hemorrhage, puerperal morbidity, urinary retention, blood transfusion, delayed healing, and trauma), and Apgar score were compared by statistic methods. RESULTS: (1) Among 3751 women, 501 (13.3%) of them underwent induction( the induction group), 1634 (43.6%) delivered by cesarean section (cesarean section group), the other 1616 (43.1%) women underwent spontaneous onset of labor (the spontaneous onset of labor group). (2) Results of general conditions: the spontaneous onset of labor group had the shortest hospital days, which was longer in the induction group, and the longest in the selective cesarean section group (P < 0.01). The selective cesarean section group had the most cost during hospitalization, which was less in the induction group, and least in the spontaneous onset of labor group (P < 0.01). Women who undergwent emergent cesarean section after induction spent more money on hospitalization than those who were in the selective cesarean section group and the spontaneous onset of labor group (P < 0.01). (3) Puerperal complications: (1) postpartum hemorrhage: the incidence of postpartum hemorrhage was 3.0% (15/501) in the induction group, 0.6% (9/1634) in the selective cesarean section group and was 1.2% (19/1616) in the spontaneous onset of labor group (P < 0.01). (2 Urinary retention: the incidence of urinary retention was 4. 6% (23/501) in the induction group, 0 in the selective cesarean section group, and 3.3% (54/1616) in the spontaneous onset of labor group. So the rate of urinary retention was lower in the cesarean section group than in the other two groups (P < 0.01). (3) Blood transfusion: the incidence of blood transfusion in delivery was 2.0% (10/501) in the induction group, 0.1% (1/1634) in the selective cesarean section group, and 0.4% (6/1616) in the spontaneous onset of labor group (P < 0.01). (4) Trauma: the incidence of trauma in delivery was 0. 6% (3/501) in the induction group, 0 in the selective cesarean section group, and 0.4% (7/1616) in the spontaneous onset of labor group. So the rate of trauma was lower in the cesarean section group than in the other two groups (P < 0.01). (5) Delayed healing: the incidence of delayed healing of incision was 0.8% (4/501) in the induction group, 0 in the selective cesarean section group, and 0.2% (4/1616) in the spontaneous onset of labor group (P < 0.01). (6) Puerperal morbidity: there was no difference in puerperal morbidity among the three groups (P < 0.01). (7) Neonatal asphyxia: the incidence of neonatal asphyxia was 1.2% (6/501) in the induction group, 0.1% (1/1634) in the selective cesarean section group, and 1.0% (17/1616) in the spontaneous onset of labor group. The rate of neonatal asphyxia was lower in the cesarean section group than in the other two groups (P < 0.01). CONCLUSIONS: Induction may increase incidences of postpartum hemorrhage and blood transfusion, yet, it does not decrease the incidence of urinary retention and neonatal asphyxia. Generally, selective cesarean section is safer than induction and spontaneous onset of labor, but it costs most.

[Study on the correlation of serum folate and red blood cell folate level with birth defects and unexplained recurrent pregnancy loss].

OBJECTIVE: To understand the correlation of lower serum folate, and red blood cell (RBC) folate level with birth defects including unexplained recurrent pregnancy loss, and to evaluate the role of RBC folate level as a suitable marker for folate supplement. METHODS: Two hundred and ninety-nine non-pregnant women at child-bearing age with a birth defect history were selected as birth defect group. The levels of serum and RBC folate, and serum vitamin B(12) were determined. By comparing with the group of non-pregnant women at child-bearing age without any birth defect history (control group), we evaluated the correlation between lower serum folate, RBC folate level and main kinds of birth defects including unexplained recurrent pregnancy loss. And the levels of serum and RBC folate of birth defect group were also determined and compared before and after oral folate intake (5 mg/d) for one month. RESULTS: The serum folate level of birth defect group was not different from the control group (17 - 26 vs 14 nmol/L, P > 0.05). The RBC folate level of birth defect group except the urinary defect was significantly lower compared with the control group (233 - 547 vs 689 nmol/L, P < 0.05). After the oral folate intake (5 mg/d), the serum folate level of unexplained recurrent pregnancy loss group and neural tube defects group were significantly increased than before [(22 +/- 9) vs (27 +/- 12) nmol/L, (19 +/- 10) vs (25 +/- 18) nmol/L; P < 0.05]. The RBC folate level of unexplained recurrent pregnancy loss group and congenital heart defect group were significantly increased than before [(374 +/- 275) vs (567 +/- 397) nmol/L, (322 +/- 205) vs (527 +/- 351) nmol/L, P < 0.05]. CONCLUSION: RBC folate level is more closely correlated than serum folate level with the incidence of main birth defect.

Clinical significance and prognosis of fetal arrhythmias.

OBJECTIVE: To explore fetal arrhythmia clinical significance and its correlation with fetal prognosis. METHODS: Twenty-six cases of fetal arrhythmia detected among 12,799 pregnant women recorded over a ten-year period in Peking Uinon Medical College (PUMC) Hospital were reviewed retrospectively. Fetal arrhythmia was diagnosed by fetal auscultation, ultrasonography, electric fetal heart monitoring, and fetal echocardiography. RESULTS: Twenty-six fetuses were documented with fetal arrhythmia (3 tachycardia, 4 bradycardia, 19 normal heart rate with irregular fetal cardiac rhythm). The incidence of fetal arrhythmia in our hospital was 0.2%. They were diagnosed at the average of 35 weeks' gestation (15 to 41 weeks). Twenty-two cases were diagnosed by antenatal fetal auscultation, 1 case was diagnosed by ultrasonography, and 3 cases were diagnosed by electric fetal heart monitoring. Fetal echocardiograms were performed on 17 fetuses, 6 cases (35.3%) of which showed that ventricular premature beats with normal structure of fetal heart. All neonates survived postnatally and 24 of them (92.3%) were followed up. Echocardiograms were performed for 16 neonates and 2 of them were identified as atrial septal defects with normal heart rhythms. The results of follow-up showed that the two patients had no apparent clinical manifestation. The echocardiogram showed that atrial septal defect obliterated already. CONCLUSION: The prognosis is well for most of the fetuses with arrhythmias, with low incidence of heart deformation.

[Clinical evaluation of propess for induction of term pregnancy].

OBJECTIVE: To explore the efficacy and safety of continuously released prostaglandin E(2) (PGE(2)) suppository-propess used for induction of term pregnancy. METHODS: A multicenter, prospective, case control clinical study was carried out, propess was used in 100 cases as study group, the suppository without PGE(2) was used in 49 cases as control group. The cervical maturity (by Bishop scoring), the time to labor starting, membrane rupture and delivery, the application of oxytocin, ceserean section rate, fetal and neonatal condition were compared between 2 groups after inserting of the suppository. At the same time, side effects caused by propess were investigated. RESULTS: Bishop score was increased >or= 2 points in 93% cases, >or= 3 points in 87% cases in study group, whereas only 4% cases whose Bishop score increased >or= 2 points in control group. The time to labor starting, membrane rupture, and delivery was shortened obviously in study group than that in control group after inserting suppository. The application of oxytocin was much less in study group, cesarean section rate was reduced in study group (32% vs 61%). There was no significant difference between 2 groups in fetal and neonatal conditions. The overstimulation of uterine contraction and mild gastrointestinal tract reaction occurred in 3 cases and 2 cases respectively in study groups. CONCLUSION: Propess can be used for induction of term pregnancy effectively and safely.

[Application of intrapartum fetal oxygen saturation rate monitoring].

OBJECTIVE: To study the accuracy of the application of the intrapartum fetal oxygen saturation (FSO2) monitoring in predicting fetal acidosis and diagnosing intrauterine fetal distress. METHODS: Continuous FSO2 monitoring as well as internal and external fetal heart rate monitoring were applied respectively in 60 women in labor during active phase of the first stage and the second stage. All the monitoring methods were validated with standard sensitivity, specificity, positive predictive value, negative predictive value, and accuracy on the bases of Apgar score and cord artery blood analysis. RESULTS: The mean FSO2 in the active phase of the first stage were significantly higher than in the second stage of labor. FSO2 correlated with pH, PO2, PCO2, and base excess (BE) of cord blood to a significant degree. There was linear correlation between FSO2 and cord artery blood pH. Using 30% cutoff diagnosing intrauterine fetal distress, the sensitivity, specificity, and accuracy were 80%, 100% and 98.3%, respectively. CONCLUSION: FSO2 monitoring is an effective method diagnosing intrauterine fetal distress.

[Screening by maternal serum markers for Down's syndrome].

OBJECTIVE: To investigate the optimal method of screening for Down's syndrome (DS) with maternal serum mankers. METHODS: Screening by maternal serum markers for Down's syndrome was offered to all 2886 pregnant women in Peking Union Medical Hospital during 1996.11-2001.3. Alpha-fetoprotein (AFP), human chorionic gonadotrophin (free beta-HCG) were used as markers during the first year of pregnancy. Alpha-fetoprotein, free human chorionic gonadotrophin (HCG) and pregnancy-associated plasma protein A (PAPP-A) were used as mid pregnancy and first-trimester markers in next three years. Amniocentesis and (CVS) were done in those defined as risk cases. RESULTS: The detection rate of Down's syndrome by maternal serum markers was 3.8% (11/2886). The proportion of false positive results in group of triple markers (alpha FP, free beta-HCG, PAPP-A) was 5%. CONCLUSIONS: The PAPP-A was a good marker to detect Down's syndrome in early pregnancy and may be used to predict the outcome during mid trimester of pregnancy. The AFP and free beta-HCG can be useful markers to detect Down's syndrome and fetal abnormality. While prenatal diagnostics can be shifted to an early pregnant period.

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.