2017年 · 第52卷第11期

Fetal edema refers to fetal soft tissue edema and body cavity effusion. Ultrasound findings are 2 or more abnormal body cavity effusion, including pleural effusion, peritoneal effusion, pericardial effusion and skin edema (skin thickness>5 mm)^[1]Other commonly used clinical assisted ultrasound indicators include placental thickening (placental thickness ≥4 cm in the second trimester^[2,3]) and polyhydramnios. Fetal edema can be divided into immune and nonimmune hydrops fetalis (NIHF), among which NIHF accounts for more than 90%, and the incidence is (1~3) / (1 700~3 000)^[4,5,6]。 Because many fetuses with edema in the first and second trimester of pregnancy have died in the uterus before being diagnosed, the actual incidence may be higher^[7]。 The etiology of NIHF is complex and requires the formulation of individualized clinical diagnosis and treatment process; At the same time, fetal edema will be accompanied by serious complications during pregnancy, and clinical management is difficult. Based on evidence from evidence-based medicine, this guide explains the etiology of NIHF, the diagnostic process during pregnancy, the management of maternal complications during pregnancy, the possible intrauterine intervention and perinatal management, and provides help and guidance for clinicians. The recommended levels of evidence for this guide are presented inTable 1。

Now advocating integrated medicine, as integrated medicine, is to integrate all disciplines of medicine to form a new medical system. This new medical system should include philosophy, literature, art, etc. Of course, there should be other science and technology related to medicine, but also social, political and humanities. We should try to integrate medicine and literature, expounding literature in medicine and medicine in literature, narrative of medicine and narrative medicine, physicians and writers with writers and doctors. A doctor should not only be a reader of literature, but also an author of literature.

The screening of cervical cancer and the correct management of cervical lesions are of great significance for the prevention of cervical cancer and the detection of early cervical cancer. At present, there are some problems in the screening of cervical cancer and the treatment of cervical lesions in China. Only by facing and gradually solving these problems can we do a better job in the prevention and control of cervical cancer. This paper analyzes the main problems existing in the screening of cervical cancer and the management of cervical lesions, in order to seek the countermeasures to solve these problems.

Placental implantation can lead to postpartum hemorrhage, hysterectomy and even maternal death. The incidence of placental implantation reported in the literature ranges from 1/1 000 to 2/1 000. Pregnant women with previous history of cesarean section have a significantly increased risk of placenta previa or placental implantation in re-pregnancy^[1,2,3]。 With the implementation of China's "comprehensive two-child policy", the number of pregnant women with advanced age (delivery age ≥35 years) and scar uterus repregnancy has increased greatly, which may lead to the increase of the number of pregnant women with placental implantation. At present, the timing and surgical method of pregnancy termination in pregnant women with placenta implantation are controversial, and there is a lack of research on placenta implantation in elderly pregnant women at home and abroad; Therefore, this study will analyze the clinical characteristics, treatment measures and pregnancy outcome of pregnant women with complete placenta previa and placenta implantation at different delivery ages, so as to provide assistance for clinical management decision-making of pregnant women with complete placenta previa and placenta implantation.

Granulosa cells are the main functional cells of ovary and play an important role in the development of follicles. The normal proliferation and differentiation of ovarian granulosa cells directly affect the basic functions of ovary such as follicular growth, development, ovulation, luteal formation and hormone secretion^[1]。 Ovarian granulosa cell damage can seriously affect ovarian function and may even lead to premature ovarian failure. Some clinically used anti-tumor drugs have cytotoxic effects while exerting therapeutic effects, which can destroy normal ovarian granulosa cells and cause apoptosis^[2]。 Triptolide, also known as triptolide, is a kind of epoxy diterpene lactone compound extracted from roots, leaves, flowers and fruits of Tripterygium wilfordii. It is the main active ingredient of Tripterygium wilfordii extract. In vivo and in vitro studies have proved that triptolide has good anti-tumor activity on many kinds of tumors such as leukemia, breast cancer, pancreatic cancer and lung cancer^[3,4]； But it can also cause damage to normal human cells, including granulosa cells^[5]。 epigallocatechin gallate (EGCG) is the main active and water-soluble component of green tea, and it is the highest component in catechins, accounting for 9% ~13% of the gross weight of green tea. Because of its special stereochemical structure, EGCG has very strong antioxidant activity and is one of the compounds with strong antioxidant activity in tea. Its antioxidant activity is at least 100 times that of vitamin C and 25 times that of vitamin E. It can protect cells and DNA damage, so it has been applied to tumors, heart diseases and other major diseases^[6,7]。 In this study, triptolide was used to induce the injury and apoptosis of ovarian granulosa cells in rats, and the protective effect of EGCG on the injury and apoptosis of granulosa cells was observed, which provided experimental evidence for the application of EGCG in reducing the side effects of anticancer drugs.

The patient was 51 years old, pregnant with 4 births and 1 births. She was admitted to hospital on May 23, 2016 due to irregular vaginal bleeding for 1 year after total hysterectomy for more than 1 year. The patient had regular menstruation in the past and no history of pain. On July 30, 2014, I underwent total abdominal hysterectomy in an external hospital due to "multiple uterine fibroids". The details are unknown. Postoperative pathological examination showed: multiple uterine leiomyomas, endometrial proliferative phase changes, and adenomyosis. In May 2015, irregular vaginal bleeding began to appear, dark brown, and periodic lower abdominal pain with painful intercourse and anal distension gradually appeared. In August 2015, I went to another hospital. Gynecological examination showed a blue nodule in the vaginal stump. I was treated with microwave, but there was no improvement. In March 2016, B-ultrasound examination in a foreign hospital showed "echo mass at the top of vaginal stump", and a small amount of vaginal stump mass was removed. The pathological examination reported: (vaginal stump) endometriosis (endometriosis). For further diagnosis and treatment, see our hospital. Gynecological examination after admission: vagina is unobstructed, with a little blood stain, and a mass about 4 cm ×3 cm in size is seen on the vaginal stump, partially purple-blue, brittle in texture, and easy to bleed when touched; There were no obvious abnormalities in bilateral adnexes. Triple diagnosis: the vaginal stump can be palpable with a hard mass about 4 cm ×3 cm in size, obvious tenderness, poor movement, and the tumor protrudes toward the rectum with unclear boundary; But the intestinal wall is smooth, and the finger cuffs are not stained with blood. MRI examination showed: uterus was absent, and vaginal stump showed 3 to 4 star-shaped hyperintensity with short T₁Long T₂Signal, 3-6 mm in diameter, not shown in bilateral ovaries; There were no abnormal swollen lymph nodes and fluid signal shadows in the pelvic cavity; Combined with medical history, it is consistent with endometriosis changes. Colonoscopy return: Whole colon roughly normal. Abdominal plain film showed: bilateral kidney shadows were normal. No significant abnormalities were observed on intravenous pyelography. No abnormalities were found in the detection of tumor markers. Admission diagnosis: vaginal stump endometriosis after total hysterectomy. Laparoscopic endometriosis lesion resection of vaginal stump + bilateral adnexectomy + intestinal adhesions and pelvic adhesiolysis under general anesthesia was performed on 2 Jun 2016. During the operation, the vaginal stump was adhered to the omentum and intestinal tube and covered, and the posterior wall of the vagina was adhered to the rectum; The left ovary is normal in size, adhered to the left pelvic wall, and endometriosis lesions can be seen on the surface; The right ovary is normal in size and adheres to the right pelvic wall; Bilateral fallopian tubes appeared normal; The nodular bulge of the vaginal stump was observed after the separation of adhesions, and no endometriosis lesions were observed in the uterosacral ligament, rectovaginal septum and other pelvic peritoneum. Postoperative pathological examination reported: (vaginal stump) endometriosis nodule, (left ovary) endometriosis, left fallopian tube no special, right ovary no special, right fallopian tube mild inflammation. Postoperative diagnosis: vaginal stump endometriosis. He recovered well after operation, without complaint of vaginal bleeding, abdominal pain and anal distension disappeared, and has been followed up with no special complaint so far.

The 37-year-old patient was admitted to the hospital on May 13, 2016 because 48 days after embryo transfer and no gestational sac was seen for 18 days. Two frozen embryos were transferred to the patient on 26 March 2016. Serum β-hCG was 10 477 U/L 30 days after transfer, and 88 165 U/L 48 days after transfer. No gestational sac was found in the uterus and outside the uterus after multiple ultrasound examinations. On May 3, 2016, the other hospital was treated with mifepristone combined with misoprostol. The patient discharged a small amount of blood clots but was not sent for pathological examination. After that, the blood β-hCG level was still rising, so I went to our hospital. In the past, induced abortion and medical abortion were carried out once each. In 2012, due to "fallopian tube factor infertility", laparoscopic hysteroscopy was performed in an outside hospital, and bilateral fallopian tubes were removed during the operation. After in vitro fertilization-embryo transfer (IVF-ET), a boy was delivered by term cesarean section in 2013. Gynecological examination: There was no tenderness in the uterus and bilateral appendages. The diagnosis of admission was: ectopic pregnancy after IVF-ET, and trophoblastic disease was not excluded. On the day of admission, serum β-hCG: 88 165 U/L, blood routine, liver and kidney function, coagulation function and thyroid function were normal. Gynecological ultrasound examination showed that the endometrium was 5 mm thick, no gestational sac was seen both inside and outside the uterus, and no mass was seen in the bilateral adnexal area. No obvious abnormalities were found in chest radiographs. Considering the special condition of the patient, the scope of ultrasound examination was expanded. On May 16th, ultrasound examination showed that a gestational sac was seen in front of the lower pole of the left kidney, 42 mm ×42 mm, and fetal heart rate was seen inside, which was closely related to the abdominal aorta. Report of CT angiography (CTA) results of the abdominal aorta: Retroperitoneal mass of the second lumbar vertebra left side, considered gestational sac, with placenta attached to the abdominal aorta side. Serum β-hCG on 16 May: 92 079 U/L.

The 69-year-old patient was admitted to the hospital on July 8, 2016 due to menopause for more than 10 years and vaginal bleeding for 20 days. The patient developed vaginal bleeding without obvious trigger 20 days ago, and went to an external hospital for diagnosis and curettage. Pathological examination showed: endometrial adenosarcoma. For further diagnosis and treatment, see our hospital. Gynecological examination: no abnormalities in vulva and vagina, cervical atrophy; The uterine body is anterior, atrophic; There were no abnormalities in bilateral adnexal areas. Laparoscopic total hysterectomy + bilateral adnexectomy was performed under general anesthesia. Intraoperative exploration showed that there were no adhesions and effusion in the pelvic cavity, and the uterus and bilateral adnexes showed postmenopausal changes. Postoperative pathological examination: The tumor consists of two parts: typical adenosarcoma area and pure sarcoma area. Benign endometrioid glands and low-grade malignant mesenchymal sarcoma components can be seen in adenosarcoma area. The glands vary in size, some are cystic dilatation, and there are red-stained secretions in the gland cavity, seeFigure 1； Mesenchymal sarcoma cells are moderately atypical, and mitotic images are visible. There are no glands in the pure sarcoma area, the cell atypia is obvious, and there are many strange heteronuclear and tumor giant cells, and the mitotic image is more common, seeFigure 2。 Tumor tissue necrosis can be seen in some areas; There was no tumor infiltration in myometrium and vessels, and there were no other heterologous components in the tumor. Cytokeratin (CK) and epithelial membrane antigen (EMA) were detected by immunohistochemistry in benign glandular epithelial cells and tumor-covered epithelial cells; Vimentin positive in mesenchymal sarcoma cells, CD₁₀Partially positive, alpha smooth muscle actin (SMA), desmin, inhibin alpha, myomodulin (MyoD1), S-100, CD₆₈actin (actin) negative. Pathological diagnosis: Mullerian adenosarcoma of the uterus with sarcoma overgrowth (MASO). The patient did not receive radiotherapy or chemotherapy after operation, and has been followed up for 7 months with no progression.

pelvic organ prolapse (POP) is the weakness of pelvic floor supporting tissues caused by various reasons, which causes the descent and displacement of pelvic organs to trigger abnormal position and function of organs. Although POP is not fatal, it has adverse effects on the patient's body image and sexual life. The incidence of symptomatic POP is 3% ~6%; However, according to the definition and grading of gynecological examination results, the incidence of POP is as high as 41% to 50%. This is because patients with mild POP often have no obvious clinical symptoms^[1]。 The study of Chinese women also found that the incidence of POP among women>60 years old is close to 25%, of which 43% to 76% of POP patients need surgery, and 1/3 of POP patients who undergo surgery need reoperation^[2]。 The health care impact of POP is likely to increase based on the estimate that "the prevalence is also increasing among the increasing population of older women".

Cervical cancer screening remains a major public health issue that needs to be given priority. Meeting the basic requirements of high-quality screening includes high sensitivity and high negative predictive value of primary screening, and reasonable triage of those with positive primary screening. In this way, the benefits of screening can be maximized and unnecessary intervention in transient HPV infection and its corresponding benign lesions can be avoided^[1]。