2016年 · 第51卷第08期

In recent years, the number of women with a history of cesarean section to get pregnant again has increased year by year. There are risks such as scar uterine pregnancy, dangerous placenta previa, and uterine rupture when pregnant again after cesarean section. There are two kinds of delivery methods for re-pregnancy after cesarean section: elective repeat cesarean section (ERCS) and trial of labor after cesarean section (TOLAC). The success rate of TOLAC varies from country to country, ranging from 60% to 80%^[1,2,3,4]； And the risk of uterine rupture is higher than that of ERCS, but the overall risk rate is less than 1%^[5,6]Once uterine rupture occurs, the rate of blood transfusion, hysterectomy and perinatal morbidity and mortality of pregnant women increase significantly. Therefore, pregnant women who are pregnant again after cesarean section but willing to TOLAC must implement TOLAC on the premise of adequate prenatal assessment, indications for vaginal delivery, standardized intrapartum management and corresponding emergency plans. In order to standardize the indications, intrapartum management and emergency plan of TOLAC, the Obstetrics Group of Obstetrics and Gynecology Branch of Chinese Medical Association based on the research experience at home and abroad in recent years and relevant guidelines from the United States, Canada, the United Kingdom, France and other countries^[1,2,3,4,5]Combined with the current situation in China, the "Expert Consensus on the Management of vaginal birth after cesarean (VBAC) after cesarean Section" was formulated. Due to the lack of effective and high-quality evidence-based medical evidence in many aspects, especially the lack of evidence-based data in China, this consensus needs to be continuously improved in future clinical practice.

operative vaginal delivery refers to the process in which the operator uses forceps or fetal head aspirator to help the parturient quickly deliver the fetus in the second stage of labor. It is an important means to deal with dystocia. During the operation, the safety of mother and child should be ensured and complications of delivery should be reduced^[1]。 Vaginal surgical midwifery technique plays an important role in dealing with cephalic dystocia. Senior obstetricians need to master at least one vaginal surgical midwifery technique in order to deal with emergencies in the second stage of labor and improve the prognosis of mother and child. The application of vaginal surgery assisted midwifery in China is not standardized, and it is urgent to formulate relevant guidelines in China. Therefore, the Obstetrics Group of the Obstetrics and Gynecology Branch of the Chinese Medical Association, based on the reference of domestic and foreign literature in related fields, combined with the 2001 and 2015^[1,2]Royal Society of Obstetricians and Gynecologists (RCOG) 2011^[3]Canadian Association of Obstetricians and Gynecologists (SOGC) 2004^[4]This guide was compiled on the basis of extensive consultation on the guidelines on "vaginal surgery assisted birth". This guide covers the indications, contraindications, complications, equipment selection and precautions of vaginal surgery assisted birth. This guide aims to standardize and guide the application of vaginal midwifery surgery for obstetricians in China.

cesarean scar pregnancy (CSP) refers to a type of ectopic pregnancy in which the fertilized egg is implanted in the scar of the uterine incision of the previous cesarean section. It is a time-limited definition and is limited to the early pregnancy (≤12 weeks); CSP in the second trimester after 12 weeks of pregnancy is diagnosed as "intrauterine middle pregnancy, uterine scar pregnancy after cesarean section, placenta implantation". If it is complicated by placenta previa, it is diagnosed as "intrauterine middle pregnancy, uterine scar pregnancy after cesarean section, placenta implantation, placenta previa". In the second and third trimester, it is placenta implantation and placenta previa, that is, the so-called pernicious placenta previa (pernicious placenta previa). Because CSP can cause uncontrollable massive bleeding, uterine rupture, peripheral organ damage, and even hysterectomy during and after uterine curettage, which seriously threatens women's reproductive health and even life, it has attracted great attention in clinical practice.

In recent years, our government, academic groups, obstetricians and midwives have actively taken various measures to reduce the rate of cesarean section, especially those without medical indications, on the premise of ensuring the safety of mothers and children. However, in the past, the excessive cesarean section rate has led to the adjustment of the "two-child" policy, and the proportion of women with a history of cesarean section who are pregnant again has increased significantly, which makes obstetricians have to face more and more pregnant women who are pregnant again after cesarean section. How to scientifically and reasonably choose the delivery method has attracted more and more attention! Looking back at history, as early as 1916, foreign scholar Cragin once proposed "one cesarean section, another cesarean section", while in 1966, Pauerstein proposed "one cesarean section, or vaginal trial delivery"^[1]。 Until now, the mode of delivery of another pregnancy after cesarean section is still a highly controversial topic.

gestational diabetes mellitus (GDM), the first abnormal glucose tolerance occurring during pregnancy, is one of the common complications during pregnancy^[1]The incidence of GDM in China is 17.5%^[2]。 GDM is associated with various adverse pregnancy outcomes such as macrosomia, shoulder dystocia and neonatal hypoglycemia^[3]To explore the pathogenesis of GDM, it is crucial to control blood sugar early and reduce its incidence. Recent studies have found that the increased innate immune response in patients with hyperglycemia, hyperlipidemia or metabolic syndrome can activate downstream regulatory pathways and induce insulin resistance, which may play an important role in the pathogenesis of GDM^[4]。 toll-like receptor 4 (TLR4) also known as CD₂₈₄As an important part of the innate immune system, its regulatory pathway participates in the formation of insulin resistance in liver, fat, skeletal muscle and other tissues and organs, and plays an important role in the pathogenesis of metabolic syndrome manifested by type 2 diabetes, hypertension, obesity, etc.^[4]。 The role of TLR4 in the development of type 2 diabetes has been studied^[5]It was found that its expression was correlated with impaired islet β cell function and apoptosis^[6]。 The maternal innate immune response is enhanced during pregnancy, and the expression level of TLR4 increases^[7]It is associated with the onset of preterm labor, premature rupture of membranes, intrauterine infection, preeclampsia and other pregnancy diseases^[8,9]And the expression level of TLR4 in peripheral blood of GDM pregnant women was significantly increased compared with that of healthy pregnant women^[10,11]。 This study aimed to explore the relationship between the changes of innate immune response and the pathogenesis of GDM by comparing the expression level of TLR4 in peripheral blood of pregnant women with healthy pregnant women and its relationship with blood glucose, blood lipid level and body mass index (BMI).

Adenomyosis is a common clinical disease in gynecology, mainly manifested as secondary progressive aggravation of dysmenorrhea, increased menstrual flow and infertility, the incidence rate is as high as 10% ~66%^[1]。 Traditional hysterectomy can achieve the purpose of radical cure of adenomyosis. However, for young patients with severe adenomyosis who have fertility requirements, who are ineffective after conservative treatment with drugs and who strongly want to preserve the uterus, conservative surgery as an optional and effective treatment method is continuously making new progress. Since 1952 Hyams^[2]Focal resection of adenomyosis has been described for the first time. So far, a variety of resection procedures have been used in clinical research, including Fujishita et al. in 2004^[3]"Transverse H-shape Method", 2010 Nishida et al.^[4]The "asymmetric method", Osada 2011, et al.^[5]However, these surgical methods still have the risk of uterine rupture in pregnancy and a certain recurrence rate^[6]。 Therefore, it is an important part of standardizing conservative surgical treatment of adenomyosis to explore efficient, safe and feasible surgical methods for adenomyosis resection and long-term effective measures to prevent recurrence.

Endometrial cancer is a common malignant tumor of female reproductive system. Diagnosis and curettage is the main diagnostic method of endometrial cancer, with a positive rate of 94%. Hysteroscopy can avoid the missed diagnosis of routine curettage. However, endometrial cancer originating from the malignant transformation of adenomyosis has its clinical, pathological and auxiliary examination particularities, and routine diagnosis and curettage and hysteroscopy often miss the diagnosis. Two patients with adenomyosis malignant to endometrial cancer were reported. Hysteroscopy and curettage were performed respectively, but the diagnosis was missed. The clinicopathological data are summarized as follows.

The abnormal development of female reproductive system is caused by the stagnation of embryonic development at a certain stage due to the influence of internal and external factors during the development process. Among them, uterine development abnormality, that is, uterine malformation, is the most common. Uterine malformation is caused by the development, fusion or absorption of Müllerian ducts. Uterine malformation combined with endometrial carcinoma is very rare in clinical practice^[1]。 This article collects the clinicopathological data of 3 patients with uterine malformation and endometrial cancer admitted to Tianjin Medical University General Hospital from 2013 to 2015, and reviews the relevant literature reported from 1990 to 2015^{[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19]}To analyze the similarities and differences between clinicopathological features and prognosis of endometrial carcinoma with uterine malformation and endometrial carcinoma without uterine malformation.

Emergency cesarean section is an emergency rescue operation to save the life of mother and child. Whether the rescue is timely or not is closely related to the prognosis of mother and child. All parties have different opinions on the decision to delivery interval (DDI). At present, a relatively unified view suggests that DDI should be within 30 minutes; In emergency states such as umbilical cord prolapse, uterine rupture, etc., the shorter the DDI, the better<15 min can significantly improve the prognosis and survival ability of newborns^[1,2]。 Medical teamwork is an emerging theme to promote patient safety in the world. Xiamen Chang Gung Memorial Hospital adopts the medical team resource management (TRM) model. Specialists and nurses in obstetrics, anesthesiology and neonatology departments set up a 24-hour maternity and infant rescue and care team (referred to as "666" team. Because the emergency code of the whole hospital headed by the anesthesiology department is "999", the code of the maternity and infant rescue and care team is "666" for difference) to rescue critical and severe perinatal cases and fetal distress. This study collected pregnant women who started the "666" group from January 2009 to December 2014, and retrospectively analyzed the DDI and maternal and infant prognosis of each case.

gestational diabetes mellitus (GDM) is a common complication during pregnancy, and its incidence has increased recently, which seriously threatens the health of mothers and children. According to the latest WHO diagnostic criteria in 2013, the International Diabetes Association estimates that 16.8% of pregnant women WHO give birth to live births have experienced various forms of gestational hyperglycemia, of which 84% are GDM^[1]。 The incidence of GDM in China is 17.5%^[2]。

Polycystic ovary syndrome (PCOS) is an endocrine disorder syndrome in which reproductive dysfunction and abnormal glucose metabolism coexist. Persistent anovulation, excessive androgen and insulin resistance are its important clinical features. PCOS is the most common cause of menstrual disorders (oligomenorrhea or amenorrhea) or infertility in young women, and it is also closely related to endometrial hyperplasia, endometrial cancer, obesity and cardiovascular diseases. Studies show that about 30% of PCOS patients have endometrial hyperplasia, and endometrial hyperplasia is closely related to endometrial cancer^[1], PCOS patients have a 3-fold higher risk of endometrial cancer than the general population^[2]。 Therefore, it is necessary to seek effective methods to reduce the risk of endometrial cancer in PCOS patients.