2017年 · 第52卷第07期

Since 1927 Sampson defined endometriosis (endometriosis)^[1]Since, it has been 90 years. In this long history, the diagnosis and treatment of endometriosis has undergone an extraordinary development process. People' s awareness of endometriosis, from common diseases of women of reproductive age to social problems and health problems worldwide; From ovarian "chocolate cyst" to widespread and varied "pelvic dust storm"^[2]； From the classical theory of menstrual blood reflux to eutopic endometrial determinism^[3]Then to "Source Cure"^[4], multiple doctrines complement each other; From "radical" surgery to "pain relief, fertility improvement^[5]These changes reflect the changes and progress of people's concepts of life, organs, fertility, human nature and individuals in recent years, and improving the quality of life of patients has become the core content of endometriosis treatment. The new concept of diagnosis and treatment is bound to change and optimize clinical practice and benefit more patients. In summary, there are mainly the following aspects.

Histone methylation modification is one of the important research contents in epigenetics, which is dynamically regulated by histone methylase and histone demethylase. Histone methylation modification can activate or inhibit gene expression, and abnormal changes in modification status are closely related to many kinds of tumors^[1]。 It was found that retinoblastoma-binding protein 2 (RBP-2) has the activity of histone demethylase, which can specifically demethylate the 2nd and 3rd methylation sites of the 4th lysine of histone H3^[2]Thus achieving the regulation of cell function. Studies have shown that RBP-2 is widely present in a variety of tissues and is closely related to the differentiation, proliferation, metastasis and drug resistance of tumor cells^[3,4,5]。 Epithelial ovarian cancer (ovarian cancer) is one of the gynecological malignant tumors with high mortality rate, and its 5-year survival rate is only 40%; The development of drug resistance in ovarian cancer cells during chemotherapy is one of the main reasons affecting the therapeutic effect^[6]。 In order to investigate whether the resistance of ovarian cancer cells to chemotherapeutic drugs is related to RBP-2, this study observed the effect of RBP-2 gene on the drug resistance of ovarian cancer cells by silencing the expression of RBP-2 gene in ovarian cancer cell lines.

The patient was 21 years old, pregnant and delivered 0, and had vaginal injury caused by multiple pelvic fractures due to a car accident in 2007; In 2008, there was a fecal overflow in the vagina, mainly loose stool; In 2011, he was diagnosed as rectovaginal fistula in a local hospital and underwent sigmoidostomy. There was no obvious fecal overflow in the vagina after the operation, and reexamination of colonoscopy showed rectovaginal fistula. In February 2016, he visited our hospital, and performed barium enema angiography, which showed the formation of vaginorectal fistula; Gynecological examination: there is scar stenosis 3 cm in the lower segment of the vagina, and there is an opening above the stenosis, which can allow the little finger to enter the vagina; Then, the auxiliary mold pressing method was performed in the outpatient department of our hospital to dilate the vaginal stenosis. After 10 months of pressing, the outpatient review showed that the vagina had been pressed to about 10 cm in length, and there was still a stenosis ring in the middle section. The posterior wall of the vagina was about 5 cm away from the hymen. There was a fistula with a diameter of about 1 cm, and the scar of the surrounding tissue was as thin as paper. Anal diagnosis: anal sphincter intact. After completing the relevant examinations, transvaginal rectovaginal fistula repair (modified Martius method) was performed on 18 January 2017. Surgical procedures: The bladder lithotomy position was taken during the operation, and the exploratory fistula was located about 5 cm above the vaginal opening. The surrounding vaginal tissue was scarred hard, and the rectovaginal septal space was weak. Fingers were extended into the rectum as guidance, and 0.5 cm of full-thickness tissue around the fistula was completely removed with a cold knife. At the same time, the peripheral tissue water separates the gap between vagina and rectum, continues to separate the left vaginal submucosal space and tunnels to the left labia majora space. The wound surface was repeatedly washed, and the rectal mucosa was intermittently inverted and sutured with 3-0 Vico line. The skin on the surface of the left labia majora was incised, and the lipid pad of the labia majora and the bulbocavernous muscle was free, 6 cm long and 1 cm wide, preserving the blood supply at the lower end. The free bulbocavernous muscle fat pad was implanted into the rectovaginal septum through a subcutaneous tunnel, and 4 needles on the upper, lower, left and right of the 3-0 absorbable thread were sutured and fixed at 0, 3, 6 and 9 points. The wound surface was washed, and the 1-0 absorbable thread was continuously locked to suture the vaginal mucosa layer. Vaginal fill oil gauze roll 1. The 3-0 absorbable thread was intermittently sutured to the adipose tissue of the left labia majora, and then the 3-0 absorbable thread was intermittently sutured to the skin. Antibiotics were used for 5 d to prevent infection after surgery, the urinary catheter was kept for 1 week, and the diet was gradually transitioned after 1 week of fasting, and the vulva was kept clean and dry. One week after surgery, the color of the intravaginal tissue flap was rosy.

The 8-year-old child was admitted to the hospital on 7 August 2016 due to abnormal vaginal bleeding for 7 months and adnexal mass found for 9 days. Physical examination at admission: vital signs were stable, weight 32 kg, height 140 cm, well developed breasts. Gynecological examination: vulva young girl type, see bloody discharge. B-ultrasound examination: the uterus size was 5.3 cm ×5.4 cm ×3.5 cm; The endometrium is 1.5 cm thick and has uneven echoes; A cystic-solid mass of 3.2 cm ×3.4 cm ×2.8 cm was seen in the right ovary, mainly solid hypoechoic. Serum estradiol levels (2 716.57 pmol/L) were significantly increased, and serum anti-Müllerian hormone (AMH) levels were>23.00 μ g/L. Blood hCG, AFP, carcinoembryonic antigen, CA₁₉₉CA₁₂₅All within the normal range. The chromosome karyotype was normal (46, XX), and no abnormal fragments were found. Hysteroscopy and multipoint endometrial biopsy were performed on August 10th. The uterine cavity was normal and the endometrium showed blister-like hyperplasia. Postoperative pathological findings showed that the intimal glands were cystic dilated (Figure 1）。 Laparoscopic right adnexectomy was performed on August 18th. During the operation, the uterus was like an adult, the right ovary was cystically enlarged, 4.0 cm ×3.0 cm ×3.0 cm, the surface was smooth, the capsule was intact, the right fallopian tube and left adnexal were not abnormal in appearance, and there were no metastatic lesions and enlarged lymph nodes in the pelvis and abdominal cavity. The specimens were sent for intraoperative rapid frozen pathological examination, and the results were rewarded: sexual cord-stromal tumors, tending to Sertoli cell (Sertoli cell) tumors. Postoperative pathological examination: Microscopically, the tumor consists of a mixture of germ cells and similarly immature sertoli cells or granulosa cells (Figure 2), consistent with gonadoblastoma changes. Immunohistochemical detection showed positive expression of inhibin-α and octamer-binding transcription factor 4 (OCT4) (Figure 3，Figure 4）。 Postoperative pathological diagnosis: Mixed germ cell-sex cord-stromal tumor of ovary (mixed germ cell-sex cord-stromal tumor, MGC-SCST).

Umbilical cord ligation is not only a symbol of separation between mother and child, but also a great physiological challenge for newborns, which has an important impact on the health of newborns. Centuries ago, scholars believed that cord blood could "rejuvenate" newborns^[1]。 1796, Darwin^[2]It is proposed that "premature ligation of umbilical cord is a kind of injury to newborns, and the umbilical cord should be ligated after the establishment of breathing or umbilical cord pulsation stops", and the relationship between breathing and umbilical cord ligation time and newborn health is proposed. In 1875, Bennet discovered that delayed cord clamping (DCC) transferred more blood from the mother to the newborn^[1]。 Therefore, in the following decades, DCC has been the mainstream of obstetric clinical practice. The standard is that umbilical cord ligation 1 min after newborn delivery is early cord clamping (ECC) and 5 min is DCC. After the mid-20th century, obstetricians began to actively deal with the third stage of labor in order to prevent postpartum bleeding, and the umbilical cord was ligated immediately after delivery; At the same time, some studies have suggested that ECC can reduce the occurrence of neonatal polycythemia and jaundice. Therefore, cord ligation was initiated within 15 to 20 s after delivery of the newborn^[3,4]。 However, debate about the timing of cord ligation persisted until 2006, when WHO guidelines first recommended DCC^[5]But obstetricians have been controversial on DCC-related issues^[6]。 This article reviews the clinical research progress of DCC as follows.

Due to the high sensitivity of gestational trophoblastic neoplasia (GTN) to chemotherapy and the ideality of blood hCG as a tumor marker, GTN is by far the best prognostic malignant tumor, among which the cure rate of high-risk GTN is 80% ~90%^[1]However, some high-risk patients still die due to ineffective treatment due to drug resistance, recurrence and metastasis at special sites. In this article, the research progress of high-risk GTN chemotherapy will be reviewed in order to provide reference for clinical diagnosis and treatment.