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Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee早产pretermlabor温州医学院附属第一医院妇产科周美茜Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee早产的定义妊娠满28周至不满37足周(196～258日)间分娩者称早产(pretermlabor,PTL)。此时娩出的新生儿称早产儿(prematureinfant)，出生体重为1000～2499g，各器官发育尚不够成熟。Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee•每年有超过400,000因为早产和其他妊娠原因的早产儿出生，占分娩总数5-15%.•早产是婴儿死亡的首要原因.并发症：呼吸窘迫综合征、坏死性结肠炎、高胆红素血症、脑室内出血、动脉导管未闭、视网膜病变、脑瘫等.•早产引发婴儿疾病,死亡,与大量社会公共费用与人力的投入.早产的流行病学Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee美国早产儿实际发生的比例1990-20040246810121990199319951997199920002003200410.6111111.411.811.612.312.5HoyertDL,etalPediatrics2006Jan;117(1):168-83.Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee早产的流行病学•多胎儿的发生:18.9/1000出生比198031.5/1000出生比2003(3.3%oftotalbirths)Hovertetal.,2006•超过半数的双胞胎(54%)和超过90%的多胎生育是早产儿,约9.6%的单胎是早产儿.Gardneretal.,1995Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee①胎膜早破、绒毛膜羊膜炎②下生殖道及泌尿道感染③妊娠合并症与并发症:如妊娠期高血压疾病、妊娠期肝内胆汁淤积症、妊娠合并心脏病、慢性肾炎④子宫膨胀过度及胎盘因素：如羊水过多、多胎妊娠、前置胎盘、胎盘早剥等⑤子宫畸形：如纵隔子宫、双角子宫等⑥宫颈内口松弛早产的病因学Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee早产的诊断几个概念区分：•Braxton-Hick’s宫缩•先兆早产妊娠满28周小于37周的孕期,伴有规律性宫缩(通常20分钟内至少4次或60分钟内至少8次)和宫颈进行性扩张2cm以上及宫颈管缩短≧75%,既可诊断为早产临产Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee早产的临床表现可有晚期流产、早产及产伤史，此次妊娠满28周后至37周前出现较规则宫缩（间隔5-6min，持续≧30秒）肛查：宫颈管消失，宫口扩张部分可伴有少量阴道流血或流水Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee早产的预测•高危因素分析•宫颈评估•超声检查•宫颈阴道分泌物检查Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee宫颈检查Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee超声检测宫颈长度：对早产预测很有价值宫颈长度评估Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee胎儿纤维连接蛋白fetalfibronectin,fFN•原理–绒毛膜胎膜表面的特异性蛋白，早产时绒毛膜的蛋白水解酶的活性增强，fFN外溢，进入宫颈阴道的分泌物中•阴道后穹隆棉拭子检测fFN50ng/mlThisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee病因分析常用方法•B超检查•阴道窥器检查及阴道流液涂片：找羊水结晶，了解有无胎膜早破•宫颈及阴道分泌物培养•羊膜穿刺Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee早产的治疗治疗原则：•若胎儿存活、无明显畸形、无胎儿窘迫、胎膜未破，无严重妊娠合并症及并发症、宫口开大2cm以下、应设法抑制宫缩延长孕周。•若胎膜已破，早产已不可避免时，应尽力设法提高早产儿的存活率。Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee治疗方法一般处理–卧床休息–补液治疗–心理治疗抑制宫缩促胎儿肺成熟Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee抑制宫缩•β-受体激动剂：利托君（安宝）、沙丁胺醇（硫酸舒喘灵）•硫酸镁•钙离子阻滞剂•前列腺素合成酶抑制剂Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee硫酸镁•机制：直接作用子宫肌细胞，拮抗钙离子对子宫收缩活性•用法：–25%MgSO430ml+5%GS500ml,ivgtt–1.5-2.0g/h–总量20g•注意事项Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommitteeRitodrine(利托君，安宝）•1980年美国FDA批准治疗早产•用法：先静脉给药：ivgtt安宝100mg+5%GS500ml，5-10滴/分开始，10分钟增加5滴/分，最大滴数不超过35滴/分，宫缩完全抑制后继续静滴12-18h,后改为口服（静滴结束前1/2h）安宝片10mgq2hх1天以后1#/4-6h，每日总量不超过12#•注意事项：心电监护，HR130次/分Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee沙丁胺醇•以往国内最常用•2.4mg-4.8mg,q6-8h,po•宫缩消失后停药•药物说明书注明孕妇慎用，故现使用较少Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee钙离子阻滞剂——心痛定（nifedipine）•影响钙离子细胞内流而抑制宫缩•注意心率、血压•充血性心力衰竭、主动脉瓣狭窄者禁用•口服制剂–首剂：20mg；以后10-20mg/6-8hThisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee吲哚美辛（消炎痛）（Indomethacin）•特点–治疗早产最有效的方法–副作用强：动脉导管提前关闭，羊水减少–二线药物:其他药物无效，但仍需保胎者–孕周34w，当早产合并羊水过多时——首选•用法–口服：首剂50mg，维持25mg/6-8h；–直肠用药：100mg/d–必要时仅能短期(不超过1周)服用Thisyear,mytownconstructionworkinthecity,municipalgovernment,municipalconstructionBureauofthedirectleadershipandsupport,theTownpartycommittee促胎肺成熟•用法–倍他米松12mg，im，q2