2015年 · 第50卷第10期

The Group of Hypertensive Disorders during Pregnancy of the Branch of Obstetrics and Gynecology of the Chinese Medical Association organized relevant experts according to the latest research progress at home and abroad, and referred to the latest relevant guidelines of academic organizations in the United States, Canada, Britain, Australia and other countries and regions^[1,2,3,4]Combined with China's national conditions and clinical practice experience, the "Guidelines for the Diagnosis and Treatment of Hypertensive Disorders in Pregnancy (2012 Edition)" published in 2012^[5]This guideline follows the concept of evidence-based medicine, and gives evidence evaluation of the relevant treatment plan (evidence level is shown in Roman numerals, and recommendation level is shown in English letters)^[6]To further standardize the clinical diagnosis and treatment of hypertensive disorders of pregnancy in China.

During the formation and differentiation of female reproductive organs, if they are affected by certain endogenous factors (such as gene or chromosome abnormalities) or exogenous factors (such as the use of sex hormones), the differentiation and development of primitive gonads, the fusion of internal genital primitives, the lumenization and development of ducts, and the evolution of external genitals can change, resulting in various malformations of female internal and external reproductive organs. The clinical manifestations of reproductive organ malformations are diverse, some malformations are uncommon, and they are easy to be misdiagnosed and mistreated in clinic. Unnecessary surgery and organ removal are particularly warning problems in the management of reproductive organ malformations. Different types of patients with reproductive organ malformations have different treatment plans. Therefore, with reference to the results of evidence-based medicine research at home and abroad and the latest international classification and classification, combined with the specific situation in China, the consensus of Chinese experts on the diagnosis and treatment of female reproductive organ malformations is proposed as follows.

hypertensive disorders of pregnancy include a variety of pregnancy pathological conditions and pregnancy disorders caused by blood pressure regulation disorders. In this group of diseases, it can occur and develop due to the presence of various basic pathological conditions of pregnant women, or due to the influence of environmental factors during pregnancy. preeclampsia and preeclampsia (preeclampsia-eclampsia) are one of the hypertensive diseases in pregnancy. Until now, they are still more considered as "idiopathic" diseases in pregnancy. However, with the continuous expansion of basic and clinical research on this disease, especially in the study of the difference between the etiology, pathogenesis, clinical manifestations and prognosis of "early-onset" and "late-onset" preeclampsia, the main common clinical manifestations of preeclampsia and eclampsia, which are caused by multi-factor pathogenesis and multi-pathway mechanisms, and promoted in this special window period of pregnancy, are becoming more and more clear. Whether this veil can be lifted involves how to greatly improve the level of prevention and diagnosis and treatment. At present, it is impossible to completely prevent the occurrence of preeclampsia and eclampsia, at least it is impossible to ensure that all pregnant women receive regular prenatal examination and high-risk people receive examination before pregnancy. However, it is not impossible to analyze and understand the pathogenesis of preeclampsia and eclampsia with multiple factors and mechanisms, so that we can gradually analyze and clarify each risk factor.

Bihorn uterus is a common symmetric uterine malformation, and its incidence rate is about 13.6% of uterine malformations^[1]； The reason is that during embryonic development, after the fusion of two paramesonephric ducts (Müllerian ducts), the middle segment is not completely absorbed, forming one cervix and two uterine cavities. The upper part of the uterine cavity and the base of the uterus are bifurcated, and the unabsorbed septum ends are blunt and round. 40% of bihorn uterus can cause miscarriage and premature birth during pregnancy^[2]There may also be abnormal childbirth or infertility^[3]。 The fundamental treatment of bihorn uterus lies in the fusion of two narrow uterine cavities into one normal uterine cavity. The traditional surgical method is open hysteroplasty (Strassman metroplasty). With the maturity and widespread application of combined hysteroscopic and laparoscopic surgery, the Hysteroscopic Center of Fuxing Hospital affiliated to Capital Medical University performed 10 cases of hysteroscopic and laparoscopic combined complete bihorn hysteroplasty from October 2006 to October 2011, of which 4 cases delivered successfully 5 times, 3 cases were not pregnant, 1 case was infertile due to male factors, and 2 cases were lost to follow-up. The report is now as follows.

Pregnancy complicated by metastatic choriocarcinoma (choriocarcinoma) is extremely rare^[1]Pregnancy complicated with pelvic metastatic choriocarcinoma is more rare. This article analyzes the clinical data of a patient with pelvic massive metastatic choriocarcinoma in late pregnancy admitted to the Hospital of Obstetrics and Gynecology affiliated to Zhejiang University School of Medicine in February 2014, and reviews the relevant literature reports as follows.

Ovarian metastasis of cervical cancer is rare, and the incidence rate is 0.9% ~2.2% reported in literature^[1,2,3]。 The incidence of ovarian metastasis in different pathological types of cervical carcinoma was significantly different. The ovarian metastasis rate of cervical squamous cell carcinoma was 0~1.5%, and that of cervical adenocarcinoma and adenosquamous cell carcinoma was 1.7% ~12.5%^[1,2,3]。 Because the incidence of ovarian metastasis from cervical cancer is low, it is a routine and safe procedure for most young cervical cancer patients to perform ovarian displacement in conjunction with radical cervical cancer surgery to preserve ovarian function. At present, most of the ovarian metastases reported in the literature are found by pathological examination after extensive hysterectomy + bilateral adnexectomy after initial treatment, while there are few reports of postoperative displaced ovarian metastases, especially cervical squamous cell carcinoma. So far, only 2 articles have been searched on Pubmed, a total of 3 patients with ovarian metastasis of cervical squamous cell carcinoma, and all of them are clinical stage IB1 of the International Federation of Obstetrics and Gynecology (FIGO)^[4,5]。 In November 2013, the Cancer Prevention and Treatment Center of Sun Yat-sen University admitted a patient with stage IA2 cervical squamous cell carcinoma with metastatic ovary. It is now reported in combination with the literature review as follows.

With the development of radiotherapy technology, precision radiotherapy has become more and more widely used in clinical practice. radiotherapy for cervical cancer has also developed from traditional extensive conformal field irradiation to a new type of precision intensity modulated radiotherapy (IMRT)^[1]。 The clinical application of precise radiotherapy protocol is based on precise position and precise dose. Precise positioning is the effective guarantee of radiotherapy, and cone beam CT (CBCT) as an image-guided method is widely used in clinic.In this study, the positioning error of IMRT patients after cervical cancer surgery was measured and manually corrected, in order to provide a reference for the external expansion of planning target volume (PTV) of IMRT after cervical cancer surgery.

The patient was 32 years old, pregnant 1 and delivered 0. He was admitted to hospital on July 5, 2014 due to 23 weeks of menopause, lower limb edema for 10 days, blood pressure increase for 1 day, and fetal heart rate disappeared for 10 min. The last menstrual period was on January 25, 2014, and the gestational age was checked correctly. The blood pressure at 20 weeks of pregnancy was 120/80 mm Hg (1 mm Hg =0.133 kPa), the urine protein test was negative, the blood pressure was 160/110 mmHg 1 day before admission, and the blood pressure on the day of admission was 178/103 mmHg. He was previously in good health, and her mother developed cerebral infarction around the age of 40. Physical examination at admission: blood pressure 210/130 mmHg, no abnormalities in the heart and lungs, no fetal heart rate, and edema (+ +). Diagnosis at admission: (1) 23 weeks of intrauterine pregnancy, 1 pregnancy and 0 delivery; (2) severe preeclampsia; (3) Intrauterine fetal death. Yanidine was continuously pumped to control blood pressure, and laboratory tests were improved. The D-dimer level was 3,000 μ g/L, and the rest of the indicators were roughly normal. After the blood pressure was controlled smoothly, he was given rivanol intraamniotic injection to induce labor. On July 8, 2014, a male stillbirth was delivered, and the stillbirth appearance was not abnormal. The postoperative blood pressure was between 130 and 140/80 and 90 mmHg. On the third day after surgery, the patient experienced vague upper abdominal discomfort, no nausea and vomiting, mild tenderness under the xiphoid process and no rebound pain. The blood and urine amylase levels were detected to be normal, and the patient was given oral treatment with Daxi tablets. On the 5th day after surgery, the upper abdominal pain was significantly aggravated with vomiting, which was stomach contents, accompanied by diarrhea, and pale yellow watery stool. After the administration of acid suppressant drugs, the abdominal pain persisted, showing "knife-like" pain, discharging watery stool 6 times, and there was tenderness in the upper abdomen during physical examination, without rebound pain and muscle tension. Blood routine showed white blood cells 7.53×10⁹/L, neutrophils 72.0%, platelet count 241×10⁹/L, D dimer: 12 443 μ g/L, fecal occult blood positive. Abdominal CT examination revealed a high possibility of superior mesenteric vein thrombosis. Exploratory laparotomy was performed on July 14th: small intestinal necrosis of about 80 cm was seen during the operation, and "partial small intestinal resection + anastomosis" was performed, and a large number of dark red thrombus was removed from the mesenteric vein. Postoperatively, urokinase combined with heparin sodium was treated with anticoagulation, and then subcutaneous injection of low molecular weight heparin was changed. Postoperative pathological report: Extensive congestion, edema and hemorrhage of intestinal wall tissue in some small intestine resection specimens, and degeneration and loss of mucosal epithelium in some small intestine resection specimens; Thrombosis can be seen in the mesenteric vessels. (Intravenous) thrombotic components. At the same time, acid suppression and other treatments were given after operation. The levels of plasma protein C, S and antithrombin Ⅲ were detected. No mutation was found in the detection of prothrombin gene. The patient recovered well and was discharged on the 20th postoperative day. After continuing low molecular weight heparin anticoagulation therapy for 7 days, it was changed to oral rivaroxaban tablets until now. Discharge diagnosis: (1) 23 weeks of intrauterine pregnancy, 1 pregnancy and 0 delivery, fetal death intrauterine, stillbirth has been delivered; (2) severe preeclampsia; (3) Superior mesenteric vein thrombosis, after partial small intestine resection + anastomosis.

Patient, 30 years old. Due to menopause for 36 weeks⁺⁴He was admitted to hospital on April 15, 2015 after finding that his blood pressure was high for more than 5 months. The patient usually had regular menstruation, and had spontaneous fetal movement at the 5th month of pregnancy. At the 12th week of pregnancy, his blood pressure was 147/95 mmHg (1 mmHg =0.133 kPa). Oral labetalol was used to reduce his blood pressure. At the 25th week of pregnancy, the heart color ultrasound showed severe aortic coarctation and extensive collateral vascularization due to heart murmur. The blood pressure fluctuated from 145 to 179/68 to 95 mm Hg during pregnancy, and general activities during pregnancy were not restricted. Admission examination: blood pressure 155/76 mmHg, heart rate 89 beats/min, rhythm was uniform, and grade III systolic blow-like murmur was heard in the mitral valve auscultation area, aortic valve auscultation area, pulmonary valve and tricuspid valve auscultation area. Obstetric situation: uterine height 33 cm, abdominal circumference 91 cm, head presentation, fetal left anterior position into pelvis, fetal heart rate 142 beats/min, no palpable uterine contractions, 50% regression of cervical canal, cervical Bishop score 3 points. Admission diagnosis: (1) Congenital heart disease: aortic coarctation (severe); Pregnancy 1 delivery 0, 36 weeks gestation⁺⁴, single live tire; Chronic hypertension. After admission, the relevant examinations were completed, and the blood pressure and blood gas analysis of the upper and lower limbs were dynamically monitored. Cardiac color Doppler ultrasound showed that the initial segment of the descending aorta was stenotic and distorted, and the stenosis ranged from the opening of the left subclavian artery to 32 mm below it, with an inner diameter of about 2.8 mm at the narrowest point, where the blood flow was dim and the velocity decreased, while the blood flow velocity in the distal segment increased. Collateral circulation was seen in the distal segment of the descending aorta. The velocity of blood flow in the abdominal aorta decreased and the arterial three-phase wave disappeared. Pulmonary systolic pressure was estimated at 34 mmHg. MRI-enhanced angiography of the thoracic aorta showed that the lumen in the isthmus area of the aortic arch was twisted and narrowed, with an involved length of about 25 mm and a diameter of about 3 mm at the narrowest point. The lumen of the distal descending aorta was locally dilated, with an involved length of about 46 mm and a diameter of about 20 mm at the widest point. The proximal ascending aorta, anonymous artery, left common carotid artery, left subclavian artery and both thoracic arteries were all dilated to different degrees. The initial part of the descending aorta was narrowed, and many collateral circulations were seen around it; The coarctation distal descending aortic lumen was locally dilated, and no aortic dissection was observed. After admission, I consulted the cardiothoracic surgery department, and recommended cesarean section to terminate the pregnancy. On April 17, 2015, I performed cesarean section of the lower uterus, and successfully delivered a live baby girl with no deformity in appearance, clear amniotic fluid, neonatal birth weight of 2 920 g, length of 48 cm, and neonatal Apgar score of 1 minute and 10 points. On April 24, 2015, the mother and child were discharged safely. Discharge diagnosis: (1) Congenital heart disease: severe aortic coarctation (post-catheter type); (2) Pregnancy 1 delivery 0, single live fetus at 37 weeks of gestation, after cesarean section; (3) Chronic hypertension (secondary).

The 41-year-old patient developed intermittent fever with headache 2 weeks after cervical microwave treatment, and the maximum body temperature was 38.5℃. At that time, he had no symptoms such as abdominal pain and vaginal bleeding. The other hospital considered upper respiratory tract infection and gave anti-inflammatory treatment for 13 days, but the body temperature did not drop significantly. Four weeks after microwave treatment, dull pain in the lower abdomen appeared, which was aggravated during urination. Pelvic B-ultrasound examination showed cystic mass in the left ovary (considering inflammatory mass), and hospitalization was recommended. The patient was referred to our hospital in April 2015 for confirmed diagnosis. B-ultrasound examination revealed a multilocular wall thick cystic mass of 7.1 cm ×5.5 cm ×5.3 cm in the left ovary, and gynecological examination revealed a tender mass in the left adnexa area. Considering acute pelvic inflammatory disease, anti-inflammatory treatment was continued for 1 week. The patient still had intermittent dull pain in the lower abdomen with low fever, so hospitalization was recommended. Blood test after admission CA₁₂₅1 291.0 kU/L, CA₁₉₉395.6 kU/L, high-sensitivity C-reactive protein 39.2 mg/L, erythrocyte sedimentation rate 106 mm/h, procalcitonin level normal; Culture of cervical secretion showed positive Ureaplasma urealyticum and massive growth of Gardnerella. CT examination showed a cystic mass in the left ovary, and the inflammatory mass was considered first. Combined with the unsatisfactory effect of anti-inflammatory treatment and a history of ovarian cyst, the patient now has CA₁₂₅CA₁₉₉The level was abnormally elevated. Considering that ovarian malignant tumor with infection could not be ruled out, anti-inflammatory treatment was continued for 1 week and surgical treatment was performed. Preoperative CA was reviewed₁₂₅833.1 kU/L, CA₁₉₉250.3 kU/L. In view of the fact that the patient was 41 years old, he underwent transabdominal adnexectomy on the affected side first. During the operation, the left adnexal was widely densely adhered to the surrounding intestine, pelvic wall and posterior uterine wall, and at the same time, tubal and ovarian abscess (TOA) was formed. The right adnexal was obviously congested and adhered to the surrounding tissues. Intraoperative freezing and postoperative routine pathological examination showed chronic inflammation of the tubal and ovary. After continuing anti-inflammatory therapy for 1 week, he was discharged from hospital with good recovery. CA was reviewed on postoperative day 1₁₂₅574.9 kU/L, CA₁₉₉191.5 kU/L; CA checked 1 week after surgery₁₂₅319.2 kU/L, CA₁₉₉109.7 kU/L; CA was reviewed 2 weeks after surgery₁₂₅All of them have returned to normal levels.

The patient was 52 years old, 145 cm tall and 35 kg in weight. She was admitted to the hospital in June 2014 because of uterine fibroids with degeneration for 1 month found by B-ultrasound in an outside hospital. Past menstrual regularity. Admission physical examination: abdominal swelling, uterus as pregnant as full-term size, surface uneven; Gynecological color Doppler ultrasound reveals: multiple uterine fibroids; Hemoglobin 85 g/L, CA₁₂₅39 kU/L. Admission diagnosis: multiple leiomyomas of the uterus, anemia. After admission, total open hysterectomy was performed, with intraoperative bleeding of 1,000 ml, supplementation of sodium chloride of 1,000 ml + hydroxyethyl starch of 1,000 ml + red blood cells of 4 U, urine volume of 900 ml and clear color. After operation, he returned to the ward safely, and was infused with 2 U of hematocrit red blood cells and 200 ml of plasma, and at the same time, he was given 1 500 ml of glucose sodium chloride +3 g of potassium chloride fluid rehydration treatment and infection prevention treatment. On June 18, 2014, at 5:35 am, 17 h after operation, the patient was dehydrated. Physical examination: blood pressure 126/84 mmHg (1 mmHg =0.133 kPa), heart rate 118 beats/min, body temperature 37.9 ℃, 34 breaths/min, blood oxygen saturation 100%, bilateral pupils of unequal size (slightly smaller on the left side, obtuse in light reflex, normal size on the right side, sensitive to light reflex), decreased muscle tone of the limbs, and negative pathological signs. Arterial blood gas analysis: pH 7.33, CO2 partial pressure 38.9 mmHg, oxygen partial pressure 74.2 mmHg, Na⁺207.1 mmol/L, K⁺3.1 mmol/L, Cl^-152.9 mmol/L, Ca²⁺1.41 mmol/L, extracellular residual base-5.5 mmol/L, residual base-4.3 mmol/L, standard carbon dioxide concentration 20.8 mmol/L, carbonate concentration 20.7 mmol/L. Intraoperative and 17 h postoperative intake of 4 000 ml and urine volume of 6 000 ml. Preliminary consideration is hypernatremic coma.

The patient was 39 years old, pregnant 3 and gave birth 1. Due to menopause for more than 40 days, I went to another hospital in July 2014. B-ultrasound examination showed ovarian cyst and endometrium thickness of 5 mm. I was given an artificial cycle for one course of treatment (details unknown). Later, I complained that my menstruation had not resumed. For further diagnosis and treatment, I went to our hospital on August 12. The patient usually had regular menstruation, contraception with intrauterine device (IUD), last menstruation on 8 June 2014. The urine pregnancy test was negative, and the B-ultrasound examination showed abnormal echo of the uterine wall, thin endometrium, a small amount of fluid accumulation in the uterine cavity, and intrauterine IUD. Considering that she was using an artificial cycle, she was recommended to follow up, but her menstruation never resumed, so she went to our hospital again on October 31st. B-ultrasound examination showed: abnormal echo in the right uterine horn (intestinal embedding?), local thickening of the endometrium (considering endometrial polyps), and intrauterine IUD. After medical history was asked, the patient complained of no abdominal pain, abdominal distension, nausea and vomiting, and constipation except menopause. It was recommended that he underwent IUD removal + curettage and pelvic MRI examination. One IUD was removed and curettage was performed on November 14th. The pathological examination results showed that the endometrial tissue was broken (proliferative stage). MRI showed thickening of the endometrium (postoperative view), and no other abnormalities were found. After operation, anti-infection and hemostatic treatment, normal sexual life, no contraception. On January 12, 2015, the patient developed lower abdominal distension and pain without obvious trigger, which was persistent and severe, without nausea and vomiting, accompanied by vaginal bleeding for 2 days, and the amount was small. He thought that it was menstrual recovery. He went to the doctor on January 16. B-ultrasound examination showed that there was a mass from the right adnexus to the uterine corner, about 40 mm ×10 mm ×17 mm in size, which was considered to be inflammatory changes in the fallopian tube, a small amount of pelvic effusion, and an endometrium thickness of 9 mm. Laboratory tests: LH 3.23 U/L, FSH 8.44 U/L, estradiol 182.8 pmol/L; Close follow-up B-ultrasound is recommended. Half a month later, the patient was followed up. During the complaint period, vaginal bleeding was 1 d, the amount was not large, there was no abdominal pain and other discomfort, and the blood hCG was tested at 2 540 U/L. B-ultrasound examination showed that the right adnexal mass was about 22 mm ×13 mm ×15 mm in size. First, ectopic pregnancy was considered; Abnormal echo in the proximal right uterine horn (changes after uterine perforation?), small effusion in the pelvic cavity. Then she was admitted to the hospital on January 28th with "ectopic pregnancy" in the emergency department.

congenital anomalies of the kidney and urinary tract (CAKUT) cover a series of diseases caused by abnormal development of renal parenchyma and collecting duct system and abnormal migration of embryonic kidney during embryonic development. During pregnancy ultrasound examination found that 1:500 fetuses developed CAKUT, accounting for 20% to 30% of fetal malformations during pregnancy. More importantly, 50% of children with CAKUT eventually developed chronic renal insufficiency^[1]。 This article aims to guide prenatal consultation, early diagnosis and treatment, and long-term intervention with multidisciplinary involvement through an overview of the development of kidney and ureter, the pathogenesis of CAKUT, different phenotypes of common CAKUT, and clinical management.

Endometrial stem cells are a kind of adult stem cells existing in the basal layer of endometrium. They have the potential of self-renewal, infinite proliferation and multidirectional differentiation of general adult stem cells. They participate in the periodic regeneration of endometrial epithelial and mesenchymal cells, and play a vital role in the dynamic regeneration and repair of endometrium. Studying the pathophysiological process and related molecular mechanism of endometrial stem cells involved in endometrial regeneration and repair can provide theoretical basis for clinical treatment of endometrial repair after injury. In recent years, the involvement of endometrial stem cells in endometrial regeneration and repair has been reported from time to time. New progress has been made in the molecular mechanism and in vivo research of their involvement in endometrial regeneration and repair, which are summarized as follows.

It was found that there are epithelial precursor cells and mesenchymal stem cells (MSC) -like adult stem cells (endometrial stem cells) in the endometrium. endometrial stem cells have multi-directional differentiation potential, such as osteogenic differentiation, odontogenic differentiation, cardiovascular cells and liver-like cells, etc. The labeling methods for endometrial stem cells are also being continuously updated and improved. This article will review the above contents.