2018年 · 第53卷第11期

The essence of menopause is ovarian failure. With the decline of ovarian function, women will experience a variety of menopause-related symptoms, tissue atrophy and degeneration, and metabolic dysfunction, resulting in a series of physical and mental health problems. With the prolongation of human life, menopausal transition and late menopause have become the longest stages in women's life cycle. It is necessary to provide comprehensive lifestyle guidance and health management for women at this stage, including diet, exercise, tobacco control, alcohol restriction, etc., and guide suitable people to carry out menopause hormone therapy (MHT), or use non-hormone therapy for unsuitable people to relieve menopause-related symptoms and improve their quality of life.

The reason why every species can exist in the world depends on reproduction, and the reproductive processes of each species are slightly different but basically the same, including hormonal changes accompanied by reproductive endocrine regulation, gamete formation, gamete combination to form zygotes, early embryo development and differentiation, and higher organisms also have embryo implantation, intrauterine development and childbirth. And all these processes, today, when medicine is so advanced and there is a deeper understanding of other systems besides the reproductive system, reproductive medicine is still at a loss. Reproductive medicine is a "mysterious" discipline. Under the background of rapid development of science and technology, it has also ushered in great progress. In vitro fertilization (IVF) technology has been widely used in clinical practice since the birth of Louis Brown, the world's first "in vitro fertilization" on July 25, 1978. More than 5 million babies are born with IVF and related technologies worldwide every year^[1]。 Although this technology allows humans to witness the birth of the earliest embryos for the first time in history, and seems to be the closest to being able to answer the philosophical conundrum of "where do we come from?", the question also arises: Where is the regulation of reproductive endocrine initiated? How are gametes produced? How does the uterus receive the embryo as an allograft? Why is there fertility failure? Is there a better way to tell if an embryo is good or bad? Science itself is constantly advancing, driven by strong scientific curiosity.

unexplained recurrent spontaneous abortion (URSA) refers to ≥2 consecutive spontaneous abortions with the same sexual partner, excluding anatomical, chromosomal, endocrine, infective and immune causes. URSA accounts for 40% to 80% of recurrent abortions^[1]In recent years, there has been a gradual upward trend. The etiology of URSA is diversified, the pathogenesis is unclear, and the curative effect is uncertain, which brings great difficulties to clinical treatment. Recent studies have shown that URSA is closely related to vascularization disorders in villi and insufficient blood supply to embryo^[2]。 The proliferation of villus vessels in early pregnancy contributes to the invasion of trophoblast cells into the endometrium and the normal development of the embryo in early pregnancy. microRNA (miRNA) is a non-protein encoded single-stranded small RNA, which is involved in cell division, proliferation, apoptosis and gene expression regulation, and is closely related to organ development, tumorigenesis and immune response^[3]。 miR-29a is one of the miRNA molecules closely related to tumors. It is low expressed in many tumors such as gastric cancer, ovarian epithelial cancer, prostate cancer and other tissues. miR-29a inhibits the proliferation and invasion of tumor cells by inhibiting the expression of target genes^[4]。 The biological behavior of gestational trophoblasts with infiltrative ability has many similarities with tumor cells. Therefore, this study analyzed the expression level of miR-29a in villi tissues of patients with URSA and its correlation with vascular endothelial growth factor (VEGF) and microvessel density (MVD), so as to explore the expression and regulation mechanism of miR-29a in villi tissues of patients with URSA, so as to provide theoretical basis for the prevention and treatment of URSA.

Vulvar cancer accounts for 3% ~5% of primary malignant tumors of female reproductive organs^[1]Open inguinal lymphadenectomy + extensive vulvectomy, as a traditional radical surgery for vulvar cancer, has a good tumor reduction effect, but there are many postoperative complications, such as incision dehiscence in the inguinal area, incision infection, incision scar contracture, lymphedema, lymphocyst, etc., which seriously affect the quality of life of patients^[2]。 In recent years, the widespread development of laparoscopic techniques has reduced the complications common to traditional surgery^[3]However, with the improvement of surgical instruments and the deepening understanding of minimally invasive concepts, some limitations of laparoscopy are gradually revealed; The newly developed Da Vinci surgical system breaks the limitations of laparoscopy. In addition to the advantages of standard laparoscopy, the magnified three-dimensional video imaging makes the exposure of the narrow area of the inguinal area clearer, and the flexible inner wrist system can better complete the operations such as separation, suture and knotting^[4]These advantages overcome the shortcomings of open surgery and traditional laparoscopy, and become a brand-new minimally invasive procedure for gynecological surgery treatment, which greatly promotes the development of gynecological surgery. From October 2014 to October 2017, the First Affiliated Hospital of Zhengzhou University used Da Vinci robotic surgery system to perform inguinal lymphadenectomy on 8 patients with vulvar cancer, and achieved good clinical results. The results are reported below.

Pregnant woman, 24 years old, 2nd birth 0, died on 17 December 2017 due to "22 weeks of pregnancy⁺⁶Symmetric erythema on bilateral cheeks with severe decrease in platelet and hemoglobin levels for 2 weeks "was admitted to the emergency department of Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine. Two weeks ago, the pregnant woman developed symmetric erythema on bilateral cheeks, and the platelet count was 8×10 in another hospital⁹/L, the erythrocyte sedimentation rate was 124 mm/h, and the complement C3 was 0.54 g/L and C4 was 0.06 g/L; Immune indicators: anti-double-stranded DNA antibody 13.59, anti-nuclear antibody 1:640, anti-Sjogren's syndrome A antibody positive (+), lupus anticoagulant (+), plasma lytic protease (ADAMTS13) test was 0; The pregnant woman is considered to have thrombotic thrombocytopenic purpura (TTP) and is recommended to terminate the pregnancy. Physical examination on admission: poor spirit, scleral yellowing, symmetrical erythema on both cheeks, severe anemia, slow response, scattered ecchymosis on both lower limbs. Laboratory test: white blood cells 3.81×10⁹/L, 44 g/L for hemoglobin and 4×10 for platelets⁹/L. Urinary protein was 200 g/L, urine free hemoglobin (+); Peripheral blood smears showed 4% of abnormal erythrocytes. He had a history of epilepsy in the past, and stopped taking the drug for more than 2 years. This year, he had more frequent seizures, 1 or 2 times a month.

The pregnant woman was 26 years old, pregnant with 2 deliveries and 1 deliveries. On 4 December 2016, she was menopaused for 16 weeks.⁺⁶, high fever, cough for 1 week "was admitted to hospital. In 2013 due to thrombocytopenia (61×10⁹/L) A baby girl was delivered by cesarean section with a platelet count of 73×10 at discharge⁹/L. No history of infectious diseases or chronic diseases. There was no abnormality in the prenatal examination of this pregnancy. Physical examination at admission: body temperature 36.5 ℃, pulse 140 beats/min, breathing 25 beats/min, blood pressure 99/60 mmHg (1 mmHg =0.133 kPa), poor spirit, scattered wet rales can be heard in both lungs, longitudinal oval bulge in the abdomen, soft abdominal wall, no tenderness or rebound pain. Three fingers under the fundus umbilicus, extremely weak irregular contractions can be reached, and the fetal heart is not smelled. Laboratory test: white blood cell count 6.9×10⁹/L, the percentage of neutrophils was 86%, and the red blood cell count was 2.52×10¹²/L, with a hemoglobin level of 71 g/L and a platelet count of 16×10⁹/L. The results of tuberculosis and autoimmune antibody, 1,3-β-D glucan, galactomannan and blood transfusion were all negative. Tumor marker CA₁₂₅386 kU/L ( Normal range<35 kU/L). Color ultrasound showed: intrauterine pregnancy (stillbirth), fetal biparietal diameter is equivalent to 14 weeks of pregnancy, and femoral length is equivalent to 16 weeks of pregnancy; Cystic mass in the biadnexal region. Preliminary diagnosis: missed abortion; Bilateral ovarian cyst; The causes of thrombocytopenia and fever are to be investigated.

The patient was 63 years old and had 15 years of surgical menopause. Due to abdominal distension for more than one month, I went to the local hospital on October 20, 2016. Ultrasound examination found a huge cystic mass in the abdomen and peritoneal effusion; Check serum CA₁₂₅Level was 124.5 kU/L, CA_19-9The level was 393.2 kU/L; CT examination showed that the abdominal and pelvic cavity occupied a huge cystic-solid space with a large amount of fluid effusion, which considered the possibility of cystadenocarcinoma and metastasis. For further diagnosis and treatment, he was admitted to our hospital. Physical examination after admission: scattered and multiple pigmentation was visible on the lips, fingers, palms and toes; The abdomen is swollen, with an abdominal circumference of 85 cm, and an irregular mass is palpable in the left lower abdomen, about 18 cm ×15 cm ×10 cm in size, hard in texture, uneven on the surface, and poor mobility. Gynecological examination: no tumor was seen on the vaginal stump; Because of the obvious abdominal swelling and unsatisfactory double diagnosis, a huge pelvic mass can be palpable, and the upper boundary reaches below the xiphoid process. The patient underwent bilateral tubal ligation 34 years ago, intestinal resection for intestinal polyps and intussusception 20 years ago, total hysterectomy for endometrial cancer 15 years ago, and small intestinal polypectomy under colonoscopy 3 years ago. No postoperative pathological reports were found. The patient's mother died of a huge abdominal mass (details unknown), and her daughter had undergone colonoscopic polypectomy for large and small intestinal polyps. The patient underwent gastroscopy after admission, which showed that there were multiple polyps in the stomach, and the biopsy results were consistent with proliferative polyps; Colonoscopy showed that there were multiple polyps scattered in the inner opening of the appendix, paracecal valve, and colorectum, and the biopsy results were consistent with tubular adenoma (Figure 1）。

A 60-year-old patient underwent total hysterectomy + bilateral adnexectomy for serous papillary cystadenocarcinoma of the ovary. The tumor recurred with inferior vena cava tumor thrombosis 17 years after operation. The disease progressed 1 year after tumor cytoreductive surgery. After chemotherapy, he has survived with the tumor for more than 5 years. The patient underwent right adnexectomy due to torsion of ovarian cyst pedicle in 1996. Intraoperative rapid frozen pathological examination revealed serous papillary cystadenocarcinoma of the ovary (G₂), total hysterectomy + bilateral adnexectomy, intraperitoneal cisplatin chemotherapy once, carboplatin + doxorubicin + cyclophosphamide regimen chemotherapy for 6 courses, followed by regular follow-up, no abnormalities were found. In December 2001, the patient suffered from serum CA₁₂₅The level increased to 42 kU/L, and no abnormalities were found by positron emission tomography (PET) -CT examination. After 4 courses of chemotherapy with paclitaxel + cisplatin regimen, serum CA₁₂₅Levels dropped to normal. Abdominal CT examination in 2010 revealed multiple enlarged lymph nodes near the abdominal aorta, which was not diagnosed and treated. In 2013, he developed edema of both lower limbs with right subcostal pain, serum tumor markers were normal, and abdominal CT examination revealed abnormal retroperitoneal soft tissue mass (Figure 1), considered as tumor recurrence. The patient experienced changes in consciousness after standing and in the evening, which were considered to be caused by tumor thrombosis of the inferior vena cava. Because of the long interval between tumor recurrence and good response to chemotherapy, tumor cytoreductive surgery was performed on 25 January 2013 after multidisciplinary discussion. No ascites and pelvic abnormalities were found during intraoperative exploration. The retroperitoneal mass wrapped the abdominal large blood vessels, up to the level of renal blood vessels and down to the bifurcation of the left and right common iliac blood vessels. The tumor invaded the right ureter, and the abdominal large blood vessels and ureteral surface tumor removal was performed. During exploration, a tumor thrombus of about 6 cm in the inferior vena cava was touched, so the inferior vena cava upstream of the tumor thrombus was blocked, the inferior vena cava was incised to remove the tumor thrombus, and the inferior vena cava filter was placed. Some tumors remained, and the operation was satisfactory. Postoperative pathological examination revealed poorly differentiated carcinoma and tumor thrombus formation in inferior vena cava. Intraperitoneal carboplatin chemotherapy was performed once, and intermittently intravenous chemotherapy mainly with platinum drugs was performed. The tumor inhibition effect was good. One year later, the lesion progressed, and the tumor growth was successfully inhibited after chemotherapy with bleomycin + nedaplatin + etoposide. Regular reexamination of serum CA after chemotherapy₁₂₅No residual tumor progression was observed by level and PET-CT examination, and the patient has survived with tumor for 63 months (January 2013 to April 2018).

In recent years, the incidence of placental implantation is increasing with the increasing proportion of repregnancy and elderly pregnant women after cesarean section in the world, including China. The main risks of placental implantation are fatal postpartum hemorrhage and high hysterectomy rates, and even maternal death in severe cases^[1]。

congenital heart disease (CHD) is a common birth defect, accounting for about 1% of all neonatal abnormalities^[1]It is one of the leading causes of child death worldwide^[1]。 Currently, the overall survival rate of adults with CHD is>90%^[2]。 The etiology of CHD is unknown, and it may be the interaction of genetic and non-genetic factors, among which genetic factors cannot be ignored. As various antenatal screening methods continue to advance, genetic counseling has become increasingly complex, making it more challenging to provide individualized and comprehensive assessment of CHD fetuses. The purpose of this paper is to summarize the genetic detection methods and imaging examinations of various CHD fetuses, and to provide relevant phenotypic expression, clinical prognosis, long-term survival rate and better genetic counseling suggestions for children with CHD.

Embryo implantation is the key to a successful pregnancy. There are three prerequisites for successful embryo implantation: embryo with implantation capacity, well-receptive endometrium, and synchronous development of embryo and endometrium. In the past, for a long time, implantation failure usually occurred with 2 factors in mind, namely, abnormalities in the embryo or damage to the endometrium. Therefore, scholars study the morphology and phase of embryos, and select the best embryos through pre-implantation diagnosis technology. At the same time, they study endometrial imaging, histopathology and molecular biology to discover the pathophysiological problems of endometrium. However, there is still a problem. Under the premise of good embryo and endometrial receptivity, if the two cannot maintain coordination and synchronization in time, the embryo implantation may still fail, and this phenomenon can happen precisely in assisted reproductive therapy^[1]。 The embryo implantation time is the 20th to 24th day of the natural menstrual cycle, which is the window of implantation (WOI); In the field of assisted reproduction, the name is used to define the optimal time when the endometrium receives embryo implantation. During natural conception, the development of the embryo and the WOI of the endometrium are usually determined by the follicles, the progesterone level rises briefly after ovulation, the sperm combines with the oocyte, and the endometrium transitions to the secretory phase, and the two proceed simultaneously, and the final implantation is successful. In the assisted reproductive cycle, there is a periodic difference in the time of endometrial transition to secretory phase, and there is also a difference in the time of blastocyst formation, so the synchronicity between the two is broken. Therefore, some scholars have put forward the concept of "embryo-endometrial synchrony". The core of this concept is time, which emphasizes both endometrial development time and embryonic development time, and highlights the importance of synchronization between the two^[2]。 This article reviews the related contents of synchronous development of embryonic endometrium.

The mortality rate of epithelial ovarian cancer (ovarian cancer) ranks first among gynecological malignancies. Although the surgical and adjuvant treatment methods of ovarian cancer have made continuous progress in the past 10 years, the 5-year survival rate of patients still hovers around 47%^[1]。 The main reason is that the high recurrence rate of ovarian cancer is still a major clinical problem besides the lack of effective diagnostic means in the early stage of ovarian cancer. Therefore, it is particularly important to develop new therapeutic drugs. autophagy, as one of the main modes of programmed cell death, is closely related to the occurrence, development and treatment of ovarian cancer. Especially as a new direction of tumor treatment, the relationship between autophagy and ovarian cancer has been paid more and more attention in recent years. On the one hand, autophagy can provide material and energy support for tumor growth, thereby facilitating the proliferation of ovarian cancer cells; On the other hand, inhibition of autophagy in specific environments can also significantly inhibit the activity of ovarian cancer tumor cells. Sun et al.^[2]Studies have found that autophagy can promote apoptosis of cervical cancer cell line CaSki cells; However, for ovarian cancer cell line SKOV3, autophagy can ultimately lead SKOV3 cells to become resistant to cisplatin by protecting their survival^[3]。 In order to provide a new direction for the treatment of ovarian cancer, we reviewed the research progress of the relationship between autophagy and ovarian cancer.