2015年 · 第50卷第08期

With the development of assisted reproductive technology and the increase of elderly pregnant women, the incidence of twin pregnancy is increasing year by year. Twin pregnancy has become an important cause of miscarriage, premature birth, birth defects and increased perinatal morbidity and mortality. However, at present, there is no definite epidemiological data on twin pregnancy in China, and there is a lack of diagnosis and treatment guidelines based on evidence-based medicine and combined with China's national conditions. Therefore, the Fetal Medicine Group of Perinatal Medicine Branch of Chinese Medical Association and the Obstetrics Group of Obstetrics and Gynecology Branch of Chinese Medical Association organized national expert discussions and compiled this guide. The guidelines mainly review the important foreign literature on twin pregnancy, combined with the current clinical practice in China, and refer to the 2011 Royal College of Obstetricians and Gynaecologists (RCOG)^[1]2011 French Society of Obstetrics and Gynecology^[2]2014 American Association of Obstetricians and Gynecologists^[3]Hong Kong College of Obstetricians and Gynecologists 2006^[4,5]The guidelines for the diagnosis and treatment of twin pregnancy were compiled. This guide summarizes some opinions that have been accepted or close to acceptance in academic circles at present, and gives recommendation levels for reference.

Delayed spondyloepiphyseal dysplasia tarda (SEDT) is a type of chondrodysplasic disease characterized by spinal deformity and irregular changes in long bone epiphyses, with obvious genetic heterogeneity^[1]。 Autosomal dominant inheritance, autosomal recessive inheritance and X-linked recessive inheritance have been reported^[2]。 Among them, X-linked SEDT, also known as late-onset vertebral epiphyseal dysplasia, onset later than autosomal SEDT, with obvious dwarfism, and obvious vertebral lesions in lumbar spine. The genetic mode is male onset and female transmission. The incidence of SEDT was 1.7/1 million^[3], more than 9% of patients with skeletal dysplasia requiring orthopedic treatment are SEDT, of which 22% are X-linked SEDT. The main pathological changes of X-linked SEDT were abnormal intrachondral osteogenesis and degenerative lesions of articular cartilage, clinically characterized by asymmetric short, vertebral body deformity, early onset major joint osteoarthritis, especially in the hip, characterized by short trunk, upper/lower mass<1^[4]。 Growth retardation occurred at the age of 3-10 years, most obviously between 10-14 years, and the SEDT pathogenic gene was SEDL gene located in Xp22.2^[5]。 A patient with X-linked SEDT was recently admitted to the First Affiliated Hospital of Nanjing Medical University. His clinical manifestations, imaging characteristics and SEDL gene mutation types are analyzed in family, and the results are reported as follows.

Female genital tract hypoplasia is often associated with urinary system malformations, and anorectal malformations are rare in clinical practice. All cases are reported in the literature, and most of them are vaginal atresia combined with anal atresia, rectovaginal fistula and cloaca malformations^[1]However, Peking Union Medical College Hospital recently diagnosed and treated one patient with special types of reproductive tract malformations combined with digestive tract and urinary system malformations, which has not been reported yet. The case is reported as follows in combination with literature review.

Placental site trophoblastic tumor (PSTT) is a relatively rare type of gestational trophoblastic tumor (GTN). Its most common clinical manifestations are menopause and irregular vaginal bleeding, which can be accompanied by uterine enlargement. However, cases with nephrotic syndrome are very rare, and there are few reports in domestic and foreign literatures. The main clinical manifestations are proteinuria, hypoalbuminemia, hyperlipidemia and edema. Peking Union Medical College Peking Union Medical College Peking Union Medical College Hospital of Chinese Academy of Medical Sciences recently treated two patients with PSTT with nephrotic syndrome as the first clinical manifestation. The efficacy of treating nephrotic syndrome alone is not good, but with the improvement of PSTT, their symptoms of nephrotic syndrome such as proteinuria, hypoalbuminemia and edema naturally resolved, which is now reported in combination with the literature review as follows.

The 50-year-old patient was admitted to the Seventh People's Hospital of Chenghua District, Chengdu on October 6, 2011 due to the discovery of left labia mass. The patient began to suffer from constipation when she was pregnant with her second child in 1984. During normal delivery, a mass about 1 cm ×1 cm in size appeared at the midpoint of the left labia majora. After that, it grew slowly, sometimes with mild swelling and pain. It was diagnosed as "Bartholin gland cyst and hernia" by many hospitals. Physical examination: There was a 6 cm ×5 cm ×4 cm semi-oval mass on the left labia majora. The mass compressed the vestibule and vaginal opening of the vagina and covered the right labia beyond the midline. It was soft in texture, with the sensation of holding snow and the sound of air passing through water. After squeezing, the mass becomes smaller to 5 cm ×4 cm ×3 cm in size. For the purpose of exploring the urethra and placing the catheter safely during surgery, the mass becomes smaller after squeezing, and gradually returns to its original shape soon, seeFigure 1； There was a pea-sized slightly hard nodule at 3 points in the rectal ampulla at the lithotomy position, 5 cm from the anus. Color ultrasound examination showed that the tumor was located subcutaneously and presented a strong echogenic spot gas light band sonogram. On 5 October 2011, colposcopy in an external hospital revealed "vulvar mass (direct hernia possible)". Admission diagnosis: The nature of the left labia mass is to be investigated. Exploratory surgery was performed on October 7, 2011, and extensive adhesion between the tumor and the surrounding tissues was observed; During separation, the tumor was accidentally punctured. The tumor was a cyst with a cyst wall thickness of 2 mm. The inner surface of the cyst wall was rough, dark red edema, the cyst cavity was filled with gas, methylene blue physiological saline and fecal residue from preoperative enema. The cyst contents are removed and the probe is inserted from the cyst rupture through the center of the slightly hard nodule of the rectal ampulla into the rectal cavity; The bottom of the cyst is enlarged and located in the left labia, and the body is slender and connected to the neck through the pelvic floor. The neck is short and communicates with a slightly hard nodule in the rectal ampulla. Suture through the neck, remove the cyst, suture a 5 mm purse around the slightly hard nodule of the rectal ampulla, and send the stump into the rectal cavity for ligation. Pathological examination results showed that the cyst wall was chronic non-specific inflammation with simple cyst formation and fistula changes; Diverticular cyst of the left labiorectum was diagnosed. He was successfully cured and discharged from hospital, and there was no abnormality in follow-up so far.

The 44-year-old patient was admitted to the Department of Respiratory Medicine, the First Affiliated Hospital of Zhengzhou University on February 12, 2014 due to fever for more than one month. The patient had no induced fever 1 month ago, with a maximum body temperature of 37.8℃, accompanied by chills, fatigue, dizziness, cough, expectoration, chest tightness, chest pain, hemoptysis and other symptoms. After 3 days of antibiotic treatment, the body temperature dropped to normal. CT examination of the chest showed that dozens of round-like nodules were seen in both lungs, with different sizes, the largest of which was 4.1 cm ×3.3 cm, which was considered metastatic tumor; Lung puncture biopsy was performed, and pathological examination showed that the tumor cells were spindle-shaped, and alveolar wall tissue was visible around them, seeFigure 1。 Immunohistochemical SP assay showed that cytokeratin (CK), S-100 protein, epithelial membrane antigen (EMA), CD₃₄The expression of cell proliferation-associated nuclear antigen (Ki-67) was positive about 5%, alpha smooth muscle actin (SMA,Figure 2), desmin, vimentin (Vim), bcl-2, ER and PR were all positive expressions. The patient underwent total hysterectomy in a local hospital 11 years ago due to uterine fibroids. Admission diagnosis: uterine leiomyoma pulmonary metastasis. After admission, the gynecologist consults and gives triptorelin to reduce the level of sex hormones in the body. Specific usage: Triptorelin 3.75 mg, intramuscular injection, once/month, for 3 consecutive months. On July 23, 2014, I came to the gynecology department of our hospital due to fatigue and chest tightness for 2 months. Reexamination of chest CT showed that there was no significant change in round nodules in both lungs compared with before, and no swollen lymph nodes were seen. Because of the poor effect of drug treatment, we communicated with the patient and his family and planned to perform bilateral adnexectomy in order to reduce the level of sex hormones in the body. Intraoperative exploration showed that the left adnexus was absent, only the right adnexus was seen, and the right adnexectomy was performed. Postoperative pathological examination showed that the right ovary was consistent with luteal hematoma and the right mesangial cyst. The patient came to our outpatient clinic for re-examination 2 months after operation, and did not complain of discomfort. The re-examination of chest CT showed that the round nodules in both lungs were significantly smaller than before.

In the past, due to the limitation of information acquisition methods such as fetal heart structure, rhythm and function, the help that clinicians can provide to families with fetal arrhythmia and the value of evaluating the prognosis of children are limited. With the rapid progress of medical imaging technology, the level of prenatal diagnosis of cardiovascular diseases has been greatly improved, and a complete and accurate prenatal diagnosis of fetal arrhythmia has been gradually achieved. It can screen the severity of fetal arrhythmia, provide timely and appropriate intervention for severe cases, provide reference suggestions and psychological counseling for affected families and expectant parents, and assist in dynamic and appropriate clinical decision-making.

Hydatidiform mole is the most common gestational trophoblastic disease (GTD), characterized by villoedema degeneration and trophoblastic proliferation. The incidence of hydatidiform mole in Asian countries is higher than that in Western countries, but it is usually sporadic. Women who have previously developed hydatidiform mole have a higher risk of re-developing hydatidiform mole than the general population, ranging from 1% to 15%^[1]； The risk of hydatidiform mole in future pregnancies will be reduced when a normal pregnancy occurs after hydatidiform mole^[2]。 The etiology of hydatidiform mole is unknown, and it is generally believed to be related to genetic, environmental factors and other factors.

The concept of fast-track surgery (FTS) is a brand-new surgical treatment model proposed in recent years. It is mainly based on evidence-based medical evidence to optimize and integrate a series of perioperative interventions to minimize the surgical stress response, accelerate the postoperative recovery process of patients, reduce surgery-related complications, and improve the prognosis of surgical patients. Therefore, it is also called enhanced recovery after surgery (ERAS)^[1,2]。 As a new surgical treatment mode, FTS can significantly promote the postoperative recovery and shorten the average hospital stay, thus optimizing the allocation of medical resources^[2]。 In 2001, the FTS concept was first adopted by Møller et al.^[3]It has been applied to gynecological surgery, and has gradually been recognized and popularized. Gynecological tumor surgery, especially gynecological malignant tumor surgery, often has the characteristics of large surgical wounds and many surgical complications, which leads to slow postoperative recovery, prolonged hospitalization and increased medical expenses, thus increasing the physical, psychological and economic burden of patients. The introduction of FTS concept in gynecological oncology surgery is beneficial to the perioperative management of patients, reduces the incidence of surgical complications, accelerates the postoperative recovery of patients and improves medical efficiency, and finally benefits patients clinically. This article summarizes the development of FTS concept in recent years and its application prospect in gynecological tumor surgery as follows.

From March 13th to 15th, 2015, the 11th National Obstetrics and Gynecology Academic Conference of Obstetrics and Gynecology Branch of Chinese Medical Association was held in Xiamen, Fujian Province. The conference received more than 2,100 submissions, with more than 4,300 registered participants, 181 special speeches and 257 conference speeches. Academician Lang Jinghe, chairman of the Obstetrics and Gynecology Branch of Chinese Medical Association, gave a special speech on "Think twice about medicine and think twice about medicine" at the main venue, pointing out that medicine is the intersection and integration of natural sciences, social sciences and humanities, and emphasizing the importance of humanities medicine. Professors Wei Lihui, Xie Xing, Yang Huixia and Yu Qi respectively summarized the research status and progress in general gynecology, gynecological oncology, obstetrics, gynecological endocrinology and menopause related fields. Professor Peter George McCulloch of Oxford University and Khalid Khan, editor-in-chief of the British Journal of Obstetrics and Gynecology (BJOG), gave wonderful reports on evidence-based medicine and medical paper writing respectively. The meeting was divided into five sub-venues, and the contents are introduced as follows.