2017年 · 第52卷第09期

In this consensus, premature ovarian insufficiency (POI) refers to the decrease of ovarian function in women before the age of 40, mainly manifested by abnormal menstruation (amenorrhea, thin or frequent menstruation), elevated gonadotropin levels (FSH>25 U/L), and fluctuating decrease in estrogen levels^[1]。 In this consensus, POIs are classified into primary POIs and secondary POIs based on whether spontaneous menstruation has ever occurred.

Cervical cancer is caused by high-risk HPV infection. Because sexually active women are susceptible to HPV infection, cervical cancer is the most common malignant tumor in women under 35 years old. High-risk HPV detection for cervical cancer screening has unique advantages because of its high sensitivity, high negative predictive value, high detection efficiency and suggestive effect of lesion outcome. It is recommended by WHO for primary screening of cervical cancer alone^[1]。 Worldwide, cervical cancer screening is undergoing a transition from cytology-based testing to HPV testing.

Postpartum uterine varus is a "catastrophic" obstetric complication commonly seen in the third stage of labor^[1]。 As with most critical obstetric emergencies, early recognition and proactive management are essential for reducing mortality in postpartum women with uterine varus. In order to explore the significance of reasonable obstetric clinical intervention to prevent postpartum uterine varus, the clinical data of 10 cases of postpartum uterine varus women admitted to the Hospital of Obstetrics and Gynecology affiliated to Zhejiang University School of Medicine are summarized as follows.

Sjögren's syndrome (SS) is a chronic inflammatory autoimmune disease that mainly involves the exocrine glands of the whole body. The incidence of Sjögren's syndrome is 0.20% ~0.70% in Chinese population, and it is significantly more female than male^[1]。 Although SS does not affect the fertility of female patients, it may interact with pregnancy and lead to abnormal fetal growth and development. Therefore, the clinical characteristics of pregnant women with SS, the treatment plan during pregnancy, the timing and mode of terminating pregnancy, and the treatment plan after delivery have become one of the focus of clinical attention in obstetrics. This study retrospectively analyzed the clinical data of 29 pregnant women with SS admitted to Xiamen No.1 Hospital affiliated to Xiamen University, which are reported below.

heterotopic pregnancy (HP) refers to a pregnancy disorder in which intrauterine pregnancy (single or multiple births) and ectopic pregnancy (ectopic pregnancy) at least one site coexist. However, multi-site pregnancy refers to the simultaneous implantation of embryos in multiple sites. Besides covering HP, it can also refer to the simultaneous existence of ectopic pregnancy in different sites. With the increasing incidence of pelvic inflammatory diseases, the increase of infertility and the development of assisted reproductive technology (ART), the incidence of abnormal pregnancy after ART increases, and the disease is complicated (including HP or multi-site ectopic pregnancy, etc.). This article reports four patients with intrauterine twins complicated with tubal interstitial pregnancy admitted to the Hospital of Obstetrics and Gynecology affiliated to Zhejiang University School of Medicine from January 2003 to December 2016. Through literature review, the existing treatment methods and obstetric interventions of HP are discussed, and at the same time, the understanding of abnormal pregnancy after ART is improved.

The average recurrence time of patients with epithelial ovarian cancer (ovarian cancer) is about 18 months. The recurrence is mainly in pelvic and abdominal cavity, and the distant metastasis is mainly in lung and pleura. This paper reports a patient with advanced ovarian cancer who had complete remission for 7 years after initial surgery and chemotherapy. The recurrence manifested as simple thoracic and rib metastases. After treatment, it recurred again as multiple bone metastases and lung metastases, without recurrence and metastasis in pelvic and abdominal cavities. The metastatic pattern of this ovarian cancer patient is rare, which is reported in conjunction with the literature review as follows.

Pregnant woman 30 years old, pregnant 5 birth 2, Han nationality, due to "12 weeks of menopause⁺⁵The pregnant woman gave birth to a baby girl by full-term cesarean section in 2007, with normal growth and development; in 2011, she was induced by "fetal death intrauterine" at 38 weeks of pregnancy; in 2012 and 2013, she was found to be induced by "fetal edema" at 27 and 24 weeks of pregnancy, respectively. No fetal autopsy was performed, and no fetal, maternal Rh blood type, and antibodies outside the maternal ABO blood group system (i.e. irregular antibodies) were detected. No abnormalities were found in the karyotype and thalassemia gene tests of both couples. Before this pregnancy, the ABO blood type of pregnant women was B and the Rh blood type was CCDee in Guangzhou Blood Center; Her husband's ABO blood type is O and Rh blood type is ccDEE; The titers of anti-E and anti-C antibodies in pregnant women were 1:512 and 1:64, respectively, and the antiplatelet-related antibodies were negative. During this pregnancy, the anti-E antibody titer fluctuated from 1:512 to 1:256, and the anti-C antibody titer was 1:64. 17 weeks gestation⁺³The peak systolic blood flow of middle cerebral artery (MCAPSV)>1.5 times median multiple (MoM) of normal value measured by ultrasound, suggesting moderate to severe fetal anemia; Three days later, umbilical vein puncture was performed. The fetal hemoglobin (Hb) level was 83 g/L, hematocrit (HCT) was 25.4%, and platelet count was 99×10⁹/L, no abnormality in chromosome karyotype, positive direct anti-human globulin (Coombs) test (3+), Rh free emission test (+), fetal ABO blood type B, Rh blood type CcDEe. Consider the diagnosis: (1) maternal-fetal Rh alloimmunity (anti-E, anti-C type); (2) Moderate fetal hemolytic anemia.

The patient was 27 years old, pregnant and delivered 0. Due to the prolongation of menstrual cycle for 3 years and menopause for more than 6 months, he went to Sun Yat-sen Memorial Hospital of Sun Yat-sen University in January 2017. The patient had regular menstruation in the past, and had prolonged menstrual cycle for 5 d/ (3~4) months at the end of 2013. He only went to another hospital at the beginning of 2015. The pregnancy test was negative (-), and no obvious abnormalities were found in gynecological B-ultrasound examination. There was bleeding in the progesterone test. On the third day of withdrawal bleeding, blood prolactin was 1.656 nmol/L (i.e. 36.39 ng/ml), FSH was 4.01 U/L, LH was 1.82 U/L, and estradiol was 56.0 pmol/L, which was considered hyperprolactinemia. Since September 2015, other hospitals have been treated with cyproterone acetate-ethinyl estradiol tablets (other name: Diane-35) plus bromocriptine. During this period, menstruation was regular and menstrual volume was small, and the drug was stopped spontaneously after 3 cycles. Amenorrhea occurred again in 2016. Blood prolactin was 1.419 nmol/L (i.e. 31.18 ng/ml) in a different hospital. B-ultrasound examination showed that the endometrium was 3 mm thick, and no large follicles or corpus luteum were seen. Pregnancy test (-). In January 2017, I came to our hospital for treatment. In the past 3 years, my shoe size increased by 3 sizes and my body weight increased by 20 kg. Admission physical examination: height 163 cm, body weight 65 kg, body mass index (BMI) 24.4 kg/m²The skin of the face is rough, a small amount of spotted acne grows, the eyebrow arch and cheekbones are thick, the nose is thick, the lips are thick, the bilateral breast development is normal and symmetrical, there is no galactorrhea, the hands and feet are thick and rough, and the ends of the toes are slightly enlarged. urine pregnancy test (-); Hormone test: FSH 4.31 U/L, LH 1.19 U/L, estradiol 87.8 pmol/L, progesterone 0.7 nmol/L, prolactin 1.284 nmol/L (i.e. 28.21 ng/ml), basal growth hormone (GH)>40 μ g/L, somatomedin C [i.e.: insulin-like growth factor 1 (IGF-1)] 916 μ g/L, insulin-like growth factor binding protein 3 (IGF-BP3) 10.70 mg/L, 75 g oral glucose tolerance test (OGTT) 0, 30, 60, 90 and 120 min blood GH levels>40 μ g/L; There were no abnormalities in androgen, thyroid function and gynecological B-ultrasound examination; Pituitary MRI findings: Pituitary macroadenoma, approximately 29 mm ×29 mm ×22 mm. Admitted to the neurosurgery department of our hospital, admission diagnosis: (1) pituitary macroadenoma; (2) acromegaly; (3) Secondary amenorrhea. In February 2017, transnasal sphenoidal pituitary tumor microresection was performed, and the pathological examination result: pituitary growth hormone macroadenoma. Two months after the operation, the patient's pituitary MRI reexamination showed no residual tumor, the roughness of the skin improved compared with before, the menstruation returned, the menstrual flow was less, the blood FSH on the third day of menstruation was 5.52 U/L, LH was 3.78 U/L, and estradiol was 73.2 pmol/L. At present, the neurosurgery department and gynecology department of our hospital are in regular follow-up.

With the development of assisted reproductive technology, the incidence of twin pregnancies is increasing^[1]。 An epidemiological study in the United States showed that the incidence of twin pregnancies increased by 34 percent from 1995 to 2008^[2]。 Twin pregnancy has received widespread attention because of its significantly increased rate of preterm birth and neonatal mortality^[3]； Whether different delivery modes of twin pregnancy have different effects on the outcome of mother and child, and how to make individual choices for the delivery modes of pregnant women with twin pregnancy, have been the hot issues of scholars. Although many studies have shown that the prevalence and mortality of the second fetus delivered naturally in twins are significantly higher^[4,5]However, a multicenter, large-sample randomized controlled study showed that elective cesarean section did not reduce the incidence of death or serious disease in their fetuses or newborns compared with natural delivery in twin pregnancies with the first fetus in the cephalic position^[6]。 In 2014, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine A consensus was issued that vaginal trial delivery may be considered when the first fetus of a pregnant woman with twin pregnancy is in the head position^[7]。 In 2015, my country also formulated clinical management guidelines for twin pregnancy^[8]In support of the above view. However, the rate of cesarean delivery in pregnant women with twin pregnancies is still high. A study in the United States showed that the rate of cesarean delivery in pregnant women with twin pregnancies reached 44%^[9]。 So what factors are related to natural delivery of pregnant women with twin pregnancy? This article summarizes the relevant research as follows.

Assisted reproductive technology (ART), as the main means of treating infertility, often uses ovulation-inducing drugs to stimulate the ovaries to obtain more oocytes. Therefore, whether ART will increase the risk of ovarian epithelial tumors, especially ovarian borderline epithelial tumors (BOT), while benefiting countless families, is a matter of great concern for reproductive physicians and gynecologists. BOT accounts for about 10% ~15% of ovarian epithelial tumors^[1]It is more common in women of reproductive age, and about 30% of patients<40 years old. Patients with BOT who have not yet given birth are often treated with fertility-preserving surgery. Whether BOT patients who have postoperative fertility requirements but cannot conceive naturally can choose ART-assisted fertility treatment and whether ART will increase the risk of postoperative recurrence of BOT makes the relationship between ART and BOT highly concerned.

Recently, domestic violence against medical staff has occurred frequently, and even attracted the attention of foreign professional media and mass media. Under this background, it is necessary to rational discuss and speculate on the relationship between doctor and patient beyond emotional catharsis and objective opposition. defensive medicine, as a prevalent medical behavior at this stage, provides a good entry point for analyzing physician practice and doctor-patient relationship. In a survey of American neurosurgeons, the seemingly joking phrase "every patient is a possible lawsuit" was approved by 69 percent of physicians^[1]。 The American Academy of Medicine (IOM) estimates that approximately $765 billion in health care costs (equivalent to 30% of medical expenditures) are wasted in the United States each year to the detriment of patients, of which $210 billion is related to unnecessary medical practices by physicians, including overuse or misuse of diagnostic tests and treatments^[2]。 It is the practice of defensive medicine to change the diagnosis and treatment norms in order to avoid litigation. This paper discusses the concepts, causes, effects and solutions of defensive medicine, especially the influence of defensive medicine on medical practice (including obstetrics and gynecology) by taking cesarean section as an example.