2018年 · 第53卷第04期

Sun Tzu's Art of War is the oldest and most outstanding military book. It can be said that it is a must-read for military strategists and generals in ancient and modern times. It is rich in strategies, strategies, and restrained politics and philosophy. Sun Tzu's Art of War was initiated by Sun Wu in the Spring and Autumn Period (5th century BC), and was revised by later generations. It was translated into French in 1772 and in English in 1910. It can be said that the whole world came to learn the Art of War. It was an absolute achievement of military strategy and tactics, and it influenced many professions, such as commerce, sports, law, and even medicine. In 2016, a new book was published in the UKSurgical Philosophy(Philosophy of Surgery), combined with the modern concepts of medicine and surgery, it is quite interesting to regard it as the implementation art of surgery.

With the comprehensive adjustment of the "two-child" policy, the proportion of pregnant women who are elderly and suffer from internal and surgical diseases has increased significantly, and the proportion of those who are pregnant again with uterus damage and scar uterus caused by various surgical operations is also increasing, which makes obstetricians with insufficient human resources face greater challenges. In addition, studies have shown that those who have suffered from obstetric complications such as gestational diabetes mellitus (GDM), pre-eclampsia (PE) and premature delivery have a significant risk of recurrence of the above complications when they are pregnant again. Therefore, in the "two-child" era, how to identify high-risk factors before or in the early trimester of pregnancy and take corresponding measures to prevent them is one of the problems that should be paid attention to at present.

Uterine rupture during pregnancy is one of the serious complications during pregnancy, with an incidence of about 0.14%, which not only causes fetal death, but also causes hemorrhagic shock and even death in pregnant women. Scarred uterus is the most common cause of uterine rupture. Common uterine rupture during pregnancy is more common in uterine scar rupture after cesarean section and scar rupture after myomectomy, while uterine corner scar rupture during pregnancy secondary to salpingectomy is often neglected in clinic because of atypical symptoms and cannot be diagnosed and treated in time, with more serious consequences. This article analyzes and discusses the minimally invasive surgical techniques of fallopian tube diseases and the management of pregnancy after repregnancy, in order to reduce the risk of scar rupture at the uterine corner during pregnancy after salpingectomy.

With the progress of society and the development of medicine, people's life expectancy is prolonging, and the number of the elderly, especially the elderly, is increasing obviously. Elderly people often have multiple diseases. Osteoporosis and osteoporotic fractures in the elderly are the highest incidence populations^[1]。 Therefore, it is particularly important to study the health problems of skeletal muscles in the elderly. This study analyzed the characteristics of body composition, bone mineral density (BMD) and their correlation in older women to elucidate the influence of muscle and fat on bone mass.

The 39-year-old patient was admitted to the hospital on 26 May 2016 due to "1 week of discovery of a foreign body in the rectum". The patient underwent induced abortion in a foreign hospital 1 year ago and placed an intrauterine device (IUD) at the same time, but did not follow up regularly after the operation; The patient had no discomfort after surgery. Early pregnancy was diagnosed by ultrasound in an external hospital 2 months ago, but no IUD was seen in the uterus. Painless induced abortion was performed and the IUD was placed at the same time. Half a month ago, the patient developed diarrhea and worsened it, with loose stools 7 to 8 times a day. One week ago, gastroscopy and colonoscopy in our hospital showed that half of the annular metal foreign body was seen on the left wall of the rectum about 12 cm away from the anus, which was considered as intrarectal foreign body (IUD?) and rectovaginal fistula? SeeFigure 1。 The patient did not have vaginal exhaust or defecation. Admitted to hospital for further treatment. The patient had been in good health, regular menstruation, painless menstruation, last menstruation on May 5, 2016, pregnancy 7 and delivery 3, spontaneous abortion once in 1999, induced abortion once in 2001, 2015 and 2016, and natural delivery once in 2000, 2004 and 2013, respectively. In 2015 and 2016, IUDs were placed at the same time as induced abortion surgery. Admission gynecological examination: vagina is unobstructed and dome is smooth; The cervix is smooth, often large, without tenderness; The uterus is anterior, often large, mobile, without tenderness, and there is no mass or tenderness palpable in the bilateral adnexal area. Digital rectal examination: the lower edge of the foreign body protruding from the anterior wall of the rectum in the intestinal lumen can be accessed at about 9 cm from the anus. Admission diagnosis: Ectopic IUD.

Lateral fusion disorder of Müllerian duct is a common malformation of female reproductive organ development; Two Müllerian ducts failed to fuse normally in the center, and one of them was underdeveloped. The larger one was called unicornuate uterus, and the corresponding underdeveloped Müllerian duct eventually became rudimentary horn. According to whether the stump uterus develops a uterine cavity covered by endometrium, it can be further divided into functional and non-functional stump uterus; According to whether the uterine cavity of the stump horn is communicated with the uterine cavity of the single horn, it is divided into two categories: communicative and non-communicative. 74% ~90% of single-horned uteruses are accompanied by stump uterus, and about 1/4 of them are functional non-communicating stump uterus with the most common complications^[1]One of the rare and serious complications is stump uterine pregnancy (rudimentary horn pregnancy, RHP). RHP belongs to one type of ectopic pregnancy, and its incidence is only 1/140 000~1/75 000, which is about 10 times lower than the incidence of abdominal pregnancy^[2]。 Because it is very rare, the vast majority of cases are difficult to get an accurate diagnosis when they are asymptomatic or even after the symptoms appear. Only 22% to 29% of cases can be correctly diagnosed before operation^[3]。 In view of the rarity and danger of RHP, this article provides a systematic review of the case reports of RHP published in the past 5 years, so as to provide a detailed explanation of the serious complications of this single-horned uterus with functional stump uterus.

pre-eclampsia (PE) is one of the leading causes of mortality in pregnant women, fetuses and newborns worldwide, with an incidence of 3% ~5%^[1]。 The prevention of PE is a hot topic in obstetrics. Focusing on different angles of its pathogenesis, scholars have conducted a number of interventional studies from anti-platelet aggregation agents, antioxidants, nutrition, diet, exercise, etc^[2,3]This provides some evidence-based medical evidence for the prevention of PE. As an anti-inflammatory factor, aspirin can block the production of thromboxane; Several studies have explored the preventive effect of low-dose aspirin on PE in different populations, such as normal pregnant women and PE pregnant women, and concluded that it is safe to use low-dose aspirin during pregnancy^[4,5]； Although different guidelines recommend different populations and doses, it is considered that low-dose oral aspirin is the primary preventive measure for PE in high-risk groups after 12 weeks of pregnancy^[3,6,7]But its preventive effect is limited. In fact, no intervention has been effective in preventing various types of PE to date.

Endometriosis (endometriosis) is one of the common benign gynecological diseases, and the incidence rate of women of childbearing age is 3% ~15%^[1]The incidence rate of postmenopausal women is 2% to 5%^[2]。 Endometriosis is a benign lesion, but it has the biological characteristics of malignant tumors, such as invasion, metastasis, recurrence, etc. A few patients can develop malignant transformation. About 80% of the malignant transformation of endometriosis occurs in ovarian endometriosis^[3]Some scholars refer to it as endometriosis-associated epithelial ovarian cancer (ovarian cancer). Recent studies have shown that endometriosis-associated ovarian cancer is closely related to endometriosis in epidemiology, and shows more benign biological characteristics than non-endometriosis-associated ovarian cancer, such as earlier termination and better survival prognosis^[4]。 Identification of people at high risk of endometriosis can be helpful to actively prevent the occurrence of malignant transformation of intervention, as well as early diagnosis of endometriosis-associated ovarian cancer. This article reviews the risk factors of malignant transformation of endometriosis and the latest progress in early diagnosis from epidemiological and clinical perspectives.

Cervical cancer is a common malignant tumor in women, and its morbidity and mortality are second only to breast cancer. About 85% of cervical cancer patients occur in developing countries^[1]。 For patients with locally advanced cervical cancer (tumor diameter>4 cm), external pelvic radiotherapy + post-loading intracavitary radiotherapy, combined with platinum-based concurrent chemotherapy, is the best treatment today. However, the 5-year survival rate of patients with locally advanced cervical cancer still hovers between 50% and 70%^[2]How to improve the survival rate of this kind of patients has been a hot spot at home and abroad. The recurrence of cervical cancer occurred within 1 year and 75% within 2 years after treatment^[2]。 Paraaortic lymph node metastasis is one of the main reasons for recurrence of cervical cancer patients. It is reported that the uncontrolled rate of paraortic lymph node after conventional concurrent chemoradiotherapy is as high as 10% ~25%^[3]。 Therefore, the recurrence of paraaortic lymph node may be the key factor affecting the prognosis of patients with cervical cancer, and how to improve the control rate of this area is crucial to improve the prognosis of patients. Back in 1984, Berman et al.^[4]The study found that 17% ~37% of patients with primary cervical cancer have micrometastasis in the abdominal para-aortic lymph node area in the field of radiotherapy. However, due to the large irradiation range of external pelvic radiotherapy + prophylactic irradiation in the para-aortic lymph node area (extended field radio therapy, EFRT), it will aggravate the side effects of radiotherapy. Therefore, the current indication of EFRT is those with para-aortic lymph node metastasis and/or common iliac lymph node metastasis diagnosed by imaging examination or pathology. However, for patients with locally advanced cervical cancer without evidence of para-aortic lymph node metastasis, even if there is a risk of para-aortic lymph node metastasis, the significance of EFRT has not been affirmed. The possible role of EFRT in improving the prognosis of patients with locally advanced cervical cancer is reviewed below.