2018年 · 第53卷第12期

abnormal uterine bleeding (AUB) is a common symptom in gynecological clinic. It refers to bleeding that does not meet the normal parameters of the "four elements" of the normal menstrual cycle (i.e., the frequency, regularity, menstrual length and bleeding volume) and originates from the uterine cavity^[1,2,3]。 This guide refers to the International Federation of Obstetrics and Gynecology (FIGO) and national guidelines^[2]AUB is limited to non-pregnant women during the fertile period, thus excluding pregnancy and puerperal-related bleeding, and excluding prepubertal and postmenopausal bleeding. FIGO recommends abandoning the term "dysfunctional uterine bleeding", recommending the use of "acute AUB" instead of the concept of "massive bleeding", and dividing the common causes of AUB into two categories and nine subtypes. For the convenience of memory, it is abbreviated as "PALM-COEIN" according to the English acronym, that is: P indicates AUB caused by endometrial polyp (polyp), A indicates AUB caused by adenomyosis (adenomyosis), L indicates AUB caused by leiomyoma (leiomyoma), M indicates AUB caused by malignancy and hyperplasia of the endometrium, C indicates AUB caused by systemic coagulopathy (AUB-C), O indicates ovulatory dysfunction (AUB-O), E indicates AUB caused by endometrial abnormalities (AUB-E), I indicates iatrogenic AUB (AUB-I), and N indicates not yet classified AUB (AUB-N). Among them, AUB-O is the most common, accounting for about 50% of AUB^[4]。

The diagnosis of gynecological tumors involves clinical, imaging, serum tumor markers and pathological diagnosis. At the current level of medical science, pathological diagnosis is still the final diagnosis of gynecological tumor diagnosis, and it is also an important basis for the subsequent formulation of tumor treatment plans. In recent years, with the progress of molecular technology, some new classifications of gynecological tumors have been proposed, which has changed the clinical follow-up treatment and prognosis judgment. Clinicians need to understand these changes, and pathologists have the responsibility to explain the reasons and significance of these changes in more detail. Communication and cooperation between the two parties can better provide patients with accurate diagnosis and treatment. Therefore, this article will focus on some changes in pathological diagnosis and classification of uterine tumors in recent years and their influence on clinical treatment and prognosis judgment.

amniotic fluid embolism (AFE) is a rare complication unique to obstetrics. Its clinical characteristics are sudden onset, dangerous and unpredictable, which can lead to serious adverse outcomes such as disability and even death of mother and child. The obstetrics group of the obstetrics and gynecology branch of the Chinese medical association combined with domestic and foreign literature, referred to the "AFE guidelines" of the American Society for Maternal-Fetal Medicine (SMFM)^[1]et al., formulated this consensus based on clinical practice in China, aiming to improve and standardize the diagnostic and rescue treatment capabilities of AFE to improve maternal and perinatal outcomes.

Endometriosis (endometriosis) is a common disease in women of reproductive age^[1,2]。 In the past 10 years, we have gained new understanding of the occurrence, development, diagnosis and treatment of endometriosis, from common diseases of women of reproductive age to social problems and health problems worldwide; From the classical theory of menstrual blood reflux to eutopic endometrial determinism^[3]Then to "Source Cure"^[2], multiple doctrines complement each other; From radical surgery to the treatment concept of "pain relief, fertility improvement, comprehensive treatment, long-term management"^[4]These changes reflect the change and progress of the concepts of life, organs, fertility, human nature and individuals, and improving the quality of life of patients has become the core content of endometriosis treatment^[5]。

placenta accreta is the invasion of placental villi into the myometrium to varying degrees. The clinical manifestation is that the placenta is difficult to strip completely after the fetus is delivered, which is easy to cause severe intrapartum and postpartum bleeding^[1], is one of the leading causes of emergency perinatal hysterectomy and maternal mortality. At present, the mechanism of placental implantation is mainly muscular scar^[2]Decidual loss or dysfunction^[3]Abnormal angiogenesis at the implantation site^[4]et al., the mechanism of abnormal trophoblast invasion is not clear^[5]。 Studying the invasive behavior of placental implanted trophoblast cells can provide more strategies and ideas for clinical diagnosis and treatment.

Mature teratoma is a common benign germ cell-derived tumor of the ovary, which is common in women of childbearing age. It is mostly cystic, and mature multi-germ tissue components can be seen in histology. The malignant rate of mature ovarian teratoma was 0.46% ~4.00%^[1]It mostly occurs after the age of 45, and all germ tissues contained in it can be secondary to malignant transformation. However, because of its rarity, there is little understanding of its clinicopathological characteristics in clinic^[2]The preoperative diagnosis rate is extremely low. In this study, the clinical and pathological data of 9 patients with malignant transformation of mature ovarian teratoma were retrospectively analyzed in order to increase the understanding of clinical and pathologists.

The patient is 24 years old. Due to the repeated discovery of uterine fibroids in the past and the concurrent resection, she plans to be pregnant again and needs to clarify the nature of "fibroids". She went to our hospital in October 2017. Past history: In 2010, the patient went to the doctor for severe anemia caused by menorrhagia and found two concurrent resection of "uterine fibroids", the larger one was 6.5 cm in diameter; Pathological return: Uterine smooth muscle tumor, active hyperplasia, obvious abnormality, tending to atypical leiomyoma, leiomyosarcoma to be excluded. A new "uterine fibroid" was discovered during cesarean section in 2013 and was removed concurrently. "Uterine fibroids" were found again in 2014, and the size increased to 6.0 cm in 2017. Family history: The patient's mother underwent hysterectomy due to severe anemia caused by uterine fibroids at the age of 32, and the patient's sister found uterine fibroids at the age of 22; No kidney or skin tumors were found in the immediate family members of the patients. This time, the patient went to a doctor for consultation because he planned to get pregnant again. The obstetrician suggested that the pathology department should consult to clarify the nature of "fibroids" to judge whether he could get pregnant again and formulate this surgical plan. Consultation of the pathology department of our hospital: The tumor cells have diffuse moderate atypia, with large eosinophilic nucleoli and halo around the nucleoli; Eosinophilic bodies in the cytoplasm are easy to see; The blood vessels are thin-walled and have "staghorn-like" branches; Focal with "alveolar" edema; Mitotic elephants are not abundant. SeeFigure 1。 Because both pathological morphology and family history suggest that leiomyomatosis and hereditary leiomyomatosis and renal cell carcinoma (HLRCC) -related uterine leiomyomatosis may be possible, it is recommended that patients undergo germline mutation detection of the pathogenic gene FH, and a pathogenic missense mutation in exon 2 of FH gene was found. Based on this, the final diagnosis was HLRCC-associated uterine leiomyomatosis, so the patient and immediate family members were recommended to undergo genetic counseling and regular kidney cancer screening. Follow-up in August 2018, the patient found 2 new uterine fibroids again; Three reddish-brown nodules the size of mung beans appeared on the chest skin without discomfort and no biopsy was performed; No kidney tumor was revealed on imaging.

Preeclampsia is a disease caused by multiple factors, multiple mechanisms and multiple pathways. It is an idiopathic disease during pregnancy, which can affect various organs and systems of the body. Preeclampsia, which accounts for approximately 3.9 percent of all pregnancies, is one of the leading causes of maternal and perinatal mortality, with approximately 76,000 maternal and 500,000 perinatal deaths due to hypertensive disorders during pregnancy each year^[1,2]。 Studies have shown that pregnant women with preeclampsia and their offspring are at high risk of cardiovascular and cerebrovascular diseases, such as stroke and pulmonary hypertension, especially pregnant women with early onset and/or severe preeclampsia^[1,2]。 Therefore, the prevention, early diagnosis and treatment of preeclampsia have become an urgent problem.

Endometriosis (endometriosis) affects approximately 4% of women of reproductive age, and is less common in adolescents and postmenopausal women^[1]； Is a common cause of a range of pelvic symptoms, such as menstrual disorders, chronic pelvic pain, painful intercourse, and infertility. Despite advances in disease development and hormonal mechanisms, therapeutic processes and early diagnosis of endometriosis remain poorly understood. At present, the diagnosis of endometriosis is mainly based on clinical symptoms, imaging examination and surgery; The "gold standard" of diagnosis is laparoscopy, but it is not only expensive, but also requires general anesthesia, and may also cause the formation of adhesions. At the same time, macroscopic diagnosis without histopathological diagnosis is unreliable^[2,3]。 pelvic pain is not a valid diagnostic indicator to distinguish endometriosis^[4]。 CA₁₂₅Is the most commonly used predictor of endometriosis^[5]But is not a reliable tool for diagnosis^[6,7,8]。 Due to the lack of specific symptoms and non-invasive tests, endometriosis is often missed or delayed^[9,10,11]。

endometrial cancer is a common malignant tumor in gynecology, endometrial atypical hyperplasia (EAH) and early endometriod adenoncarcinoma (EEC). Its standard surgical treatment is total hysterectomy + bilateral adnexectomy + pelvic (or paraaortic) lymphadenectomy, which will lead to loss of fertility in young patients. In order to meet the strong demand of such patients to preserve fertility function, in recent decades, many research teams have found that progesterone treatment can successfully reverse endometrial lesions and achieve the purpose of preserving fertility function. Several clinical studies have reported that the complete response rate of EAH and EEC for the initial treatment of progesterone is 42% to 100%^[1,2], but the recurrence rate is also relatively high, Gallos et al.^[3]The meta-analysis of found a recurrence rate of 26.0% after conservative treatment for EAH and 40.6% for EEC. recurrence means that EAH and EEC have reached complete remission after systemic initial treatment, and in the subsequent follow-up process (the follow-up time after complete remission is 3 to 6 months), the pathological examination of endometrial biopsy reveals EAH, EEC or endometrioid intraepithelial neoplasia (EIN) again. At present, there is no consensus on how to treat recurrence after EAH and EEC fertility-preserving treatment. Many literatures suggest standard surgical treatment as soon as recurrence occurs; Another researcher suggested that when EAH and EEC relapse after complete remission but the lesion does not progress to exceed the standard of fertility-preserving treatment, it is safe and effective to choose conservative treatment again. This article reviews whether progesterone therapy can be repeated in patients with relapse after complete remission after EAH and EEC conservative therapy by reviewing the relevant research literature at home and abroad in recent years.

On November 22, 2018, Professor Zhang Xiyin, a famous expert in obstetrics and gynecology in China, one of the founders and pioneers of gynecological oncology and gynecological laparoscopic surgery, an outstanding member of the Communist Party of China, deputy editor-in-chief of Chinese Journal of Obstetrics and Gynecology, and Professor Zhang Xiyin of Obstetrics and Gynecology Hospital affiliated to Fudan University (formerly Shanghai Red House Obstetrics and Gynecology Hospital) died at the age of 92 due to ineffective treatment of respiratory failure.

Professor Jiao Shuzhu, a famous expert in obstetrics and gynecology in China, one of the pioneers of gynecological oncology, an educator in obstetrics and gynecology, an outstanding member of the Communist Party of China, an editorial board member and consultant of Chinese Journal of Obstetrics and Gynecology, and a lifelong expert of Tianjin Medical University General Hospital, died at 1: 52 on November 26, 2018 at the age of 93 due to ineffective treatment.