[Current status and perspectives of obstetrics in China: an insight from evidence-based medicine].

Nationwide epidemiological data on pregnancy and childbirth was lacking in China during the last decades. Since the establishment of the national data monitoring network and the booming of regional epidemiological studies, more information has emerged. The results and suggestions from the China Labor and Delivery Survey are crucial for improving current clinical practices. Researches that are conducted based on national data monitoring network and hospital-based medical history system, and multicenter clinical trials will provide plenty of useful evidences. These high-quality evidences would further improve clinical practice and development of obstetrics in China.

[A retrospective analysis of single preterm birth incidence and high-risk factors based on maternal age stratification].

Objective: To compare the preterm birth rate among different age groups and analyze relative high-risk factors of preterm birth. Methods: A retrospective analysis was conducted on clinical data of single pregnant women ≥28 gestational weeks from January 2013 to May 2019 in the First Affiliated Hospital of Chongqing Medical Hospital. All involved women were divided into three groups according to age, Group 1 (aged<35 years), Group 2 (aged 35-39 years), and Group 3 (aged ≥40 years). The preterm birth rate among 3 groups was compared and their high-risk factors were analyzed. Results: There were 48 288 singleton pregnancies during the study period, of which 3 351 were preterm births， preterm birth rate was 6.94% (3 351/48 288). In Group 1, there were 42 020 women, of which 2 699 were preterm births (6.42%, 2 699/42 020); in Group 2, there were 5 061 women, of which 491 were preterm births (9.70%, 491/5 061); and in Group 3, there were 1 207 women, of which 161 were preterm births (13.34%, 161/1 207). Comparing the spontaneous preterm birth rates among the three groups, Group 1 was the lowest one and Group 3 was the highest one (3.72% vs 4.51% vs 5.88%); comparing the medical preterm birth rates among the three groups, Group 1 also was the lowest one and Group 3 also was the highest one (2.70% vs 5.20% vs 7.46%); the differences were statistically significant (P<0.05). The incidence of spontaneous and medical preterm birth according gestational weeks were compared among three groups and there were no significant differences (P>0.05). Comparing and analyzing the high-risk factors of medical preterm birth, the incidence of intrahepatic cholestasis of pregnancy and fetal distress in Group 1 were higher than those in Group 2 and 3; the incidence of placenta praevia were significantly higher in Group 2 and 3 than that in Group 1; the differences were statistically significant (P<0.05). Conclusions: Maternal age is a significant high-risk factor of both spontaneous preterm birth and medical preterm birth, and the risk of preterm birth increases with age. For medical preterm birth, compared with right-age pregnant women, placenta praevia is the high-risk factor for women in advanced maternal age(AMA), which have great effect on medical preterm birth rate of AMA.

[Current status of uterine rupture: a multi-center survey in China].

Objective: To investigate the current status of uterine rupture in pregnant women in China and analyze the impacts of different surgical histories on the pregnancy outcomes of pregnant women with uterine rupture. Methods: The clinical records and pregnancy outcomes of 84 uterine rupture cases were collected and analyzed retrospectively. All cases came from 21 hospitals of 13 provinces (or municipality) in China, dated from January 1st 2014 to December 31st 2015. The total deliveries were 283 614 during the period. For 84 pregnant women with symptomatic uterine rupture, the impacts of different surgical histories on pregnancy outcomes were compared and the results were statistically analyzed. Results: (1) Totally, 84 cases of uterine rupture were with symptoms and diagnosed. The median age, median gestational age were 32.5 years old (23.0-44.0 years old) and 35.7 weeks (9.3-41.0 weeks), respectively. The incidence of uterine rupture was 0.03% (84/283 614). The proportion of patients with cesarean section history was 66.7% (56/84). The proportion of patients with other gynecological surgery history was 20.2% (17/84). (2)Compared with the group of cesarean section history, the group with other gynecological surgery history had a significant increase in complete uterine rupture (16/17 vs 66.1%, P<0.05). Meanwhile, regarding the massive blood transfusion (red blood cell transfusion≥1 000 ml) in the treatment of uterine rupture, patients with other gynecological surgery history had significant more cases than the group with cesarean section history (9/17 vs 23.2%, P<0.05). There was no statistical difference for the other outcomes. Compared with the patients with cesarean section history, the rate of hysterectomy was higher in the group without major surgery history when uterine rupture happened (4/11 vs 7.1%, P<0.05). The incidence of postpartum hemorrhage significantly increased in patients without major surgery history, compared with those with cesarean section (8/11 vs 28.6%, P<0.05). There were no statistic difference for other outcomes. (3) Patients with uterine rupture in the non-abdominal pain group had a significantly increased risk of massive blood transfusion (5/8 vs 27.6%, P<0.05),and the incidence of neonatal asphyxia and hypoxic ischemic encephalopathy (4/7 vs 22.2%, P<0.05) were significantly increased. There were no significant difference between two groups regarding the other outcomes, such as preoperative diagnosis, complete rupture of uterus, hysterectomy, postpartum hemorrhage, shock, intrauterine fetal death or neonatal death, admission to neonatal ICU. Conclusions: In addition to considering cesarean section history as one of the known risk factors, patients with non-cesarean section uterine surgery history should also be considered. The management of these patients should be strengthened during their pregnancy and delivery. There might be much more dangerous maternal and neonatal outcomes for the patients with uterine rupture who does not have any abdominal pain during pregnancy and delivery. To reduce the incidence of severe complications, uterine rupture should be diagnosed earlier. The early recognition and diagnosis of uterine rupture helps to improve maternal and neonatal outcomes.

[Risk factors and sonographic findings associated with the type of placenta accreta spectrum disorders].

Objective: To evaluate the risk factors and sonographic findings of pregnancies complicated by placenta increta or placenta percreta. Methods: Totally, 2 219 cases were retrospectively analyzed from 20 tertiary hospitals in China from January 2011 to December 2015. The data were collected based on the original case records. All cases were divided into two groups, the placenta increta (PI) group (79.1%, 1 755/2 219) and the placenta percreta (PP) group (20.9%, 464/2 219) , according to the degree of placental implantation. The risk factors and sonographic findings of placenta increta or percreta were analyzed by uni-factor and logistic regression statistic methods. Results: The risk factors associated with the degree of placental implantation were age, gravida, previous abortion or miscarriage, previous cesarean sections, and placenta previa (all P<0.05), especially, previous cesarean sections (χ(2)=157.961) and placenta previa (χ(2)=91.759). Sonographic findings could be used to predict the degree of placental invasion especially the boundaries between placenta and uterine serosa, the boundary between placenta and myometrium, the disruption of the placental-uterine wall interface and loss of the normal retroplacental hypoechoic zone(all P<0.01). Conclusions: Previous cesarean sections and placenta previa are the main independent risk factors associated with the degree of placenta implantation. Ultrasound could be used to make a prenatal suggestive diagnosis of placenta accreta spectrum disorders.

Cartilage-specific deletion of Alk5 gene results in a progressive osteoarthritis-like phenotype in mice.

OBJECTIVE: Previous studies have shown that Transforming growth factor-ß (TGF-ß)/TGFßRII-Smad3 signaling is involved in articular cartilage homeostasis. However, the role of TGF-ß/ALK5 signaling in articular cartilage homeostasis has not been fully defined. In this study, a combination of in vitro and in vivo approaches was used to elucidate the role of ALK5 signaling in articular cartilage homeostasis and the development of osteoarthritis (OA). DESIGN: Mice with inducible cartilage-specific deletion of Alk5 were generated to assess the role of ALK5 in OA development. Alterations in cartilage structure were evaluated histologically. The expressions of genes associated with articular cartilage homeostasis and TGF-ß signaling were analyzed by qRT-PCR, western blotting and immunohistochemistry. The chondrocyte apoptosis was detected by TUNEL staining and immunohistochemistry. In addition, the molecular mechanism underlying the effects of TGF-ß/ALK5 signaling on articular cartilage homeostasis was explored by analyzing the TGF-ß/ALK5 signaling-induced expression of proteoglycan 4 (PRG4) using specific inhibitors. RESULTS: Postnatal cartilage-specific deletion of Alk5 induced an OA-like phenotype with degradation of articular cartilage, synovial hyperplasia, osteophyte formation, subchondral sclerosis, as well as enhanced chondrocyte apoptosis, overproduction of catabolic factors, and decreased expressions of anabolic factors in chondrocytes. In addition, the expressions of PRG4 mRNA and protein were decreased in Alk5 conditional knockout mice. Furthermore, our results showed, for the first time, that TGF-ß/ALK5 signaling regulated PRG4 expression partially through the protein kinase A (PKA)-CREB signaling pathway. CONCLUSIONS: TGF-ß/ALK5 signaling maintains articular cartilage homeostasis, in part, by upregulating PRG4 expression through the PKA-CREB signaling pathway in articular chondrocytes.

Labour patterns in Chinese women in Chongqing.

OBJECTIVE: To obtain data on the characteristics of labour from a regional sample of Chinese parturients and to assess the pattern of progress of labour among nulliparous women. DESIGN: A prospective observational study. SETTING: The study was conducted in the First Affiliated Hospital of Chongqing Medical University. POPULATION: The final sample involved 1200 Chinese parturients with singleton, vertex and term gestation; spontaneous onset of labour; vaginal delivery; and without adverse perinatal outcomes. METHODS: A repeated-measures analysis was used to depict labour curves while an interval-censored regression was used to estimate the duration of labour centimetre by centimetre. MAIN OUTCOME MEASURES: Labour curves and the duration of labour at the 50th and 95th percentiles. RESULTS: Among 1091 nulliparous women, 57.7% had cervical dilation of 3 cm or less at the time of admission, and the mean duration of the first stage of labour was 9.1 ± 3.3 hours. From 5 to 9 cm of cervical dilation it sometimes took more than 2 hours for dilation to advance 1 cm. No obvious inflection points appeared in the labour curve of Chinese nulliparae, and no deceleration was observed. CONCLUSION: Progress of labour in Chinese parturients was more gradual than in their Western counterparts. Obstetric practice standards based on data generated from Western countries may not be appropriate for Chinese women. TWEETABLE ABSTRACT: A prospective study has evaluated labour patterns in Chinese women using regional data from nulliparae.

[Preconception reproductive health and birth outcome cohort in Chongqing: the cohort profile].

Birth cohort is an important platform to study the effect of early-life exposure on health outcome, but large cohorts to investigate the effect of preconception exposure, especially paternal exposure, on reproductive health and birth outcome are limited. The Preconception Reproductive Health and Birth Outcome Cohort (PREBIC) is a prospective birth cohort study which pays equal attention to the contribution of environmental, psychological, behavioral as well as other factors to reproductive health and adverse birth outcomes in both men and women in Chongqing, China. PREBIC started in 2019 and plans to recruit 20 800 reproductive-age couples with child-bearing willingness. Followed up was conducted to understand the conception status of the women within two years. Women in pregnancy would be visited at first, second, third trimesters and after delivery. The offspring would be monitored until 2 years old to understand the incidences of preterm birth, low birth weight, birth defects, neurodevelopmental disorders and other outcomes. Related information and biospecimen collections (including semen, peripheral blood, urine, placenta, umbilical cord, cord blood and oral swab) were scheduled in each period. By January 2022, PREBIC had recruited 8 698 participants from all 38 districts in Chongqing. The goal of PREBIC is to establish one of the largest prospective preconception birth cohorts covering both men and women, which might provide a unique insight to understand the effects of the full reproductive cycle on reproductive health and adverse outcomes, with especial emphasis on preconception exposures.

Ursodeoxycholic acid and S-adenosylmethionine in the treatment of intrahepatic cholestasis of pregnancy: a multi-centered randomized controlled trial.

OBJECTIVE: Intrahepatic cholestasis of pregnancy (ICP) is a special complication of pregnancy characterized by skin pruritus, abnormal liver function tests and bile acids. To compare the efficacy of ursodeoxycholic acid (UDCA) and S-adenosylmethionine (SAMe) monotherapy with their combined effect on intrahepatic cholestasis of pregnancy (ICP). PATIENTS AND METHODS: Singleton pregnancies with ICP in five tertiary medical centers were randomly divided into three treatment groups: oral UDCA 4×250 mg daily (Group 1, n = 41), intravenous SAMe 1000 mg daily (Group 2, n = 38), and a combination of both drugs (Group 3, n = 41) until delivery. Paired t test, analysis of covariance and non-parametric test were used. RESULTS: All therapies significantly and equally improved pruritus. The serum levels of total bile acids (TBA), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin (TB) in each group significantly decreased after treatment (p < 0.05). Group 1 was more effective than Group 2 in reducing TBA concentration (p < 0.05), Group 1 and Group 3 showed more effective than Group 2 in reducing AST and TB concentrations (p < 0.05), and Group 1 facilitated deliveries at term. No perinatal death or adverse drug reactions were observed. CONCLUSIONS: UDCA and SAMe are both effective and safe in the treatment of ICP. UDCA monotherapy should be used as the first line therapy for ICP because it is more efficacious, cost-effective and convenient.