负压吸宫终止早孕术前宫颈准备的临床观察

目的 探讨米索前列醇联合利多卡因用于人工流产手术的效果。方法 将331例无阴道分娩史并要求人工流产的早孕妇女随机分3组：A组（利多卡因组）116例，宫颈黏膜与阴道穹隆黏膜交界的3点与9点处注入2％利多卡因5ml，1min后手术；B组（米索前列醇组）105例，术前3h阴道放置米索前列醇400μg；C组（米索前列醇联合利多卡因组）110例，术前3h阴道放置米索前列醇400μg，术时宫颈注射利多卡因剂量与用法同A组。观察各组镇痛效果、宫颈扩张程度、出血量、人流综合征。结果 C组镇痛效果优于A组和B组（P〈0．05），C组扩宫程度优于A组。结论 米索前列醇联合利多卡因用于人工流产较单纯用药效果好，用药简单、安全，值得临床推广。     

米索前列醇用于人工流产术前宫颈扩张给药时间的观察

目的　探讨口服米索前列醇用于人工流产术前宫颈软化扩张适宜的给药时间。方法　采用前瞻性对比研究 ,将 1 97例早孕妇女随机分为米索前列醇 4 0 0 μg术前 1h服、米索前列醇 4 0 0 μg术前 2h服用、米索前列醇 4 0 0 μg术前 1h服用配伍 1 %利多卡因宫颈 3点、 9点各注射 2ml以及不采用任何药物的A、B、C、D四组。观察并比较各组宫颈松弛程度、扩宫难易度、手术效果、疼痛程度、术前术后宫腔长度差、手术时出血量及人流综合征等参数。结果　A、B、C组在术前宫颈松弛度和扩宫难易度方面差异无显著性 (P >0 0 5 )。而A、B、C组与D组比较差异具有极显著性 (P =0 0 0 0 )。手术效果以及疼痛评分比较 :A组与B组比较差异无显著性 (P >0 0 5 ) ,A、B组与C组之间差异有显著性 (P =0 0 0 9、P =0 0 0 8) ;A、B、C组与D组比较差异有极显著性 (P =0 0 0 0 )。宫腔长度差及出血量在A、B、C、D组之间差异均无显著性 (P >0 0 5 )。A、B、C组均无人流综合征发生 ,D组 1例人流综合征。结论　人工流产术前口服米索前列醇 4 0 0 μg可以有效地软化扩张宫颈 ,减少受术者痛苦 ;术前 1h和 2h用药同样可以有效地软化扩张宫颈 ;口服米索前列醇配伍利多卡因宫颈局部麻醉镇痛效果更佳。     

芬太尼联合米索前列醇用于人工流产镇痛效果观察

目的:探讨芬太尼联合米索前列醇用于无痛人流手术的效果。方法:将328例无阴道分娩史要求人工流产的早孕妇女随机分成3组:A组(芬太尼组)110例,静脉推注芬太尼针0.002mg/kg,注毕手术;B组(米索前列醇组)106例,术前3h阴道放置米索前列醇400μg;C组(芬太尼联合米索前列醇组)112例,术前3h阴道放置米索前列醇400μg。术时静推芬太尼,剂量同A组。观察各组镇痛效果、宫颈扩张程度、出血量、人流综合征及药物副反应。结果:C组镇痛效果及宫颈扩张程度均优于A组、B组(P<0.01),术中出血量及药物副反应无明显差异(P>0.05),无1例发生人流综合征。结论:芬太尼联合米索前列醇用于人工流产较单纯用药效果好。用药简单、安全,值得临床推广。     

无痛人工流产术加米索前列醇终止早孕

目的:探讨无痛人工流产前、后舌下含化米索前列醇终止早孕的临床效果。方法:将孕8～10周需终止妊娠并要求无痛人工流产的97例孕妇随机分为观察组(49例)和对照组(48例)。前者在用丙泊酚及芬太尼行无痛人工流产前半小时及其后分别舌下含化米索前列醇0 .4mg ;后者不用米索前列醇。观察两组术中宫颈松弛扩张情况、宫缩幅度、术中出血量及术后阴道流血时间。结果:两组宫颈松弛扩张情况无差异;观察组宫缩幅度明显大于对照组(P <0 .0 5 ) ;且易于手术操作,术中出血量、术后阴道流血时间均明显的小于或短于对照组(P分别为<0 .0 1和<0 .0 5 )。结论:无痛人工流产前、后舌下含化米索前列醇可增强子宫收缩、手术易于操作、术中出血少、术后阴道流血时间短,值得临床推广应用。     

米索前列醇用于负压吸宫术前宫颈准备疗效评价

目的:对不同剂量米索前列醇用于吸宫术前促宫颈软化效果及药物不良反应进行评价.方法:采用多中心随机双盲对照临床试验,比较在术前3小时服用米索前列醇600μg与米索前列醇400μg对宫颈的软化作用及观察两组的药物不良反应情况.结果:米索前列醇600μg组宫颈扩张平均值6.70±1.23 mm高于米索前列醇400μg组6.44±1.20 mm(P=0.03),两组的初孕妇女宫颈扩张平均值差异明显(6.85±1.58 mm vs 6.51±1.16 mm,P=0.01);同时,未行静脉麻醉的孕妇中米索前列醇600μg初孕组宫颈扩张平均值高于400μg初孕组(P=0.02),米索前列醇600μg的初孕组宫颈扩张平均值也高于有1次人工流产史组(P=0.002);两组服药后主要的药物不良反应为阴道流血、恶心及腹痛等,均无大出血的情况发生,未作特殊处理.结论:负压吸宫术前3小时口服米索前列醇能安全、有效促进宫颈软化,600 μg较400 μg效果好,尤其对于初孕的妇女.     

米索前列醇在终止早孕的促宫颈成熟作用

早孕人工流产对于将来的生育能力存在重要影响,很多医院早孕吸宫术前需扩张宫颈,机械性强制扩张宫颈可引起宫颈裂伤及子宫穿孔的危险。为评价口服米索前列醇,阴道放置Gemeprost或宫颈管内放置吸湿塞条(Dilapan)三种不同方法作为宫颈     

笑气吸入人工流产术前直肠给药米索前列醇扩张宫颈的剂量观察

目的 探讨早孕妇女在笑气无痛人流术前直肠给药米索前列醇扩张宫颈口的适宜剂量，了解用药后扩宫效果及不良反应。方法 选择900例未经阴道分娩，自愿行笑气无痛人工流产、无禁忌证、孕40～60天的妇女，随机分为3组。每组在笑气吸入无痛人流术前直肠给药米索前列醇分别为200μg、400μg、600μg，观察不同剂量给药后孕妇腹痛、阴道流血、流产、术中宫颈口扩张程度、镇痛效果及术中出血情况。结果 米索前列醇用量越大，宫颈口扩张越好，但术前腹痛、阴道流血、流产等不良反应越重，各组术中疼痛及出血量无明显差异。400μg组宫颈扩张效果满意、并发症少、安全。结论 笑气吸入人工流产术前2～3h直肠给药米索前列醇400μg，扩宫满意，镇痛效果好，并发症少，受术者易接受，设备及方法简单。安全可靠，价格便宜，稳定性好，值得推广。     

米索前列醇在负吸术前的临床应用

目的 探讨米索前列醇在负吸术前对宫颈的扩张作用，减少人流综合征的发生。方法 将100例初孕的早孕妇女随机分为两组，试验组负吸术前4h将米索前列醇400μg置于阴道，对照组确诊后直接行负吸术。结果 试验组宫颈明显软化、扩张，可顺利通过6～8号吸管，无阻力、痛苦小、出血少、人流综合征反应发生率明显减轻。对照组常规使用金属扩宫棒后方可手术，痛苦大、手术时间长、出血量较多。结论 米索前列醇对扩张宫颈、减少人流综合征及术中术后出血量有显著的效果。     

初孕人工流产术前不同剂量米索前列醇阴道内置入的随机对照研究

目的探讨人工流产术前米索前列醇阴道内置入的最佳有效剂量.方法将99例早孕(停经≤70天)要求负压吸宫术终止妊娠的初孕妇女,按阴道内置药剂量的不同,随机分为3组200 μg组35例,400μg组32例及600 μg组32例,分另于施术前3 h阴道后穹窿置米索前列醇200 μg、400μg及600 μg,观察各组有效宫颈扩张度(≥7.0 mm)比率、术中出血情况及用药后副反应发生率.结果三组有效宫颈扩张度比率,以400μg组93.75%(30/32)及600μg组96.88%(31/32)显著高于200μg组34.29%(12/35)(P＜0.005),其中400 μg与600 μg组相比,差异无显著性(P＞0.05),三组中术中出血量200μg组18.67±3.24 ml,400μg组16.38±3.52 ml及600 μg组17.60±2.73 ml,各组间差异均无显著性(P＞0.05),用药后副反应发生率,以600μg组15.63%(5/32)显著高于400μg组3.15%(1/32).结论400 μg米索前列醇阴道内置入可作为人工流产术前扩张宫颈的最佳有效剂量和理想的给药途径.     

丙泊酚配伍米索前列醇用于人工流产镇痛效果观察

目的:探讨无痛人工流产术前应用米索前列醇对宫颈的扩张效果。方法:将330例自愿要求行无痛人工流产术终止妊娠的早孕健康妇女随机分为观察组(A组)和对照组(B组)。A组于手术前3h口服米索前列醇0.2～0.4mg,然后在丙泊酚静脉麻醉下行人工流产手术;B组直接在丙泊酚静脉麻醉下行人工流产手术,观察两组宫颈扩张、手术时间、术中出血量、术后阴道流血时间、用药量及用药后副作用。结果:两组手术麻醉效果无显著差异(P<0.05)。但A组宫颈松弛度明显好于B组,手术时间A组也较B组明显缩短,且手术易于操作,术中出血量、术后阴道流血时间均明显少于B组,丙泊酚用药量减少(P<0.01)。两组均无人工流产综合症及无一例呼吸抑制发生。结论:丙泊酚静脉麻醉下实施人工流产,术前3h口服米索前列醇0.2～0.4mg,有较好的宫颈扩张作用,可增强子宫收缩,手术易于操作,术中出血少,术后阴道流血时间短,丙泊酚用量减少,值得临床推广应用。     

腹主动脉球囊预置术与髂内动脉球囊预置术在植入型凶险性前置胎盘治疗中的比较研究

目的:比较研究腹主动脉球囊预置术与髂内动脉球囊预置术在植入型凶险性前置胎盘治疗中的临床疗效。方法:选择2014年1月至2015年4月住院治疗的植入型凶险性前置胎盘患者64例,随机分为两组,择期剖宫产术前行腹主动脉球囊置管32例(腹主动脉组)和双侧髂内动脉球囊置管32例(髂内动脉组),观察比较两组孕妇术中、术后情况及新生儿出生和婴儿期生长发育情况。结果:两组患者在手术时间、术中出血量、术后最高体温、输血率、子宫切除率、住院时间、球囊预置术后穿刺部位出血率、感觉障碍发生率、新生儿Apgar评分、新生儿身高、出生体质量等方面比较,差异均无统计学意义(P0.05);而腹主动脉组球囊预置时间、透视时间、放射剂量均显著低于髂内动脉组(P0.05)。术后1年内随访,两组婴儿在42天、3个月、6个月、1年的体质量及身高情况比较,差异均无统计学意义(P0.05)。结论:腹主动脉球囊预置术与髂内动脉球囊预置术在植入型凶险性前置胎盘的治疗中均能安全、有效减少术中出血。而腹主动脉球囊预置术X线暴露时间更短、预判效果无需造影剂,对母胎保护性更强,可在临床推广。     

Laparoscopic Morcellator-Related Complications

Morcellation at laparoscopy is a commonly used minimally invasive method to extract bulky tissue from the abdomen without extending abdominal incisions. Despite widespread use of morcellation, complications still remain underreported and poorly understood. We performed a systematic review of surgical centers in the United States to identify, collate and update the morcellator-related injuries and near misses associated with powered tissue removal. We searched articles on morcellator-related injuries published from 1993 through June 2013. In addition, all cases reported to MedSun and the FDA device database (MAUDE) were evaluated for inclusion. We used the search terms “morcellation,” “morcellator,” “parasitic,” and “retained” and model name keywords “Morcellex,” “MOREsolution,” “PlasmaSORD,” “Powerplus,” “Rotocut,” “SAWALHE,” “Steiner,” and “X-Tract.” During the past 15 years, 55 complications were identified. Injuries involved the small and large bowels (n = 31), vascular system (n = 27), kidney (n = 3), ureter (n = 3), bladder (n = 1), and diaphragm (n = 1). Of these injuries, 11 involved more than 1 organ. Complications were identified intraoperatively in most patients (n = 37 [66%]); however, the remainder were not identified until up to 10 days postoperatively. Surgeon inexperience was a contributing factor in most cases in which a cause was ascribed. Six deaths were attributed to morcellator-related complications. Nearly all major complications were identified from the FDA device database and not from the published literature. The laparoscopic morcellator has substantially expanded our ability to complete procedures using minimally invasive techniques. Associated with this opportunity have been increasing reports of major and minor intraoperative complications. These complications are largely unreported, likely because of publication bias associated with catastrophic events. Surgeon experience likely confers some protection against these injuries. Understanding and implementing safe practices associated with the use of the laparoscopic morcellator will reduce these iatrogenic injuries.     

Fístula cutáneo-uterina poscesárea

A fistula is an abnormal communication between two epithelial surfaces. Although fistulas that wrap around the uterus are not infrequent, uterocutaneous fistula is rare. The treatment of choice is abdominal hysterectomy with excision of the fistula up to the skin. We report two cases of uterocutaneous fistula requiring surgical treatment.     

宫腔镜下清宫术治疗剖宫产瘢痕妊娠前不同预处理方式的疗效分析

目的:探讨宫腔镜下清宫术治疗剖宫产瘢痕妊娠(CSP)前不同预处理方式的临床效果。方法:回顾性分析2014年10月至2015年10月本院住院中B超检查提示妊娠囊下缘距子宫切口小于1.0 cm行宫腔镜下清宫术并确诊为CSP的患者170例作为研究对象。其中直接行宫腔镜下清宫术的患者23例(A组);行米非司酮+米索前列醇药物治疗后在宫腔镜下行清宫术的患者29例(B组);行米非司酮+甲氨蝶呤+米索前列醇杀胚治疗后在宫腔镜下行清宫术的患者40例(C组);行子宫动脉灌注+介入栓塞术后在宫腔镜下行清宫术的患者78例(D组),比较4组患者治疗效果。结果:①所有患者手术顺利,无一例发生术中大出血和组织残留,4组患者治疗后血β-HCG较治疗前明显下降,术后血β-HCG、术中出血量、手术时间两两比较,差异无统计学意义(P0.05)。②A组和D组住院时间较短,B组和C组较长,A组与D组住院时间差异无统计学意义(P0.05),但其余两两比较,差异有统计学意义(P0.05)。③A组住院费用最少,D组最多,B组住院费用与C组比较差异无统计学意义(P0.05),但其余两两比较,差异均有统计学意义(P0.05)。④术后不良反应情况:A组术后无一例发生不良反应,B组术后有2例肝功能受损,3例恶心、呕吐等胃肠道反应,C组术后有3例肝功能受损,26例发生胃肠道反应;D组1例发生肝功能受损,16例发热,57例疼痛,对症治疗后好转。结论:CSP的治疗应根据患者病情、经济条件、个人意愿和医院的技术设备条件选择合适的治疗方案。     

The gynecologist and the melanoma: breast and endometrial metastases

Melanoma has an important metastatic potential and its incidence is greatly increasing. Even after many years of negative follow-up, gynecologists should be aware that a gynecological tumor might be a secondary location for a woman with a medical history of melanoma. Because of a poor prognosis and a reduced life expectancy, it is necessary to make a disease staging in order to offer a prompt diagnosis and a personalized strategy of treatment. Considering the increasing incidence of melanoma, gynecologists will face more frequently with this situation.     

Anticoagulación en gestantes portadoras de prótesis mecánicas

Objective

To study distinct anticoagulation regimens in pregnant women with prosthetic heart valves.

Subjects and methods

We performed a systematic review of the literature to determine the required levels of anticoagulation prophylaxis, timing of the introduction of oral anticoagulation and its substitution by heparins, and the maternal and fetal risks associated with different anticoagulation regimens.

Results

A target international normalized ratio (INR) of 2.5-3.5 should be achieved. Although consensus on the heparin of choice is lacking, heparin dose requirements should be based on anti-factor Xa levels (around 1.0 U/mL) or activated partial thromboplastin time (aPTT) (2-3 times control value). The risk of thrombosis in heparin-treated patients is approximately 7%, while the incidence of heparin embryopathy ranges from 1.6-7.4%. The switch from oral anticoagulation to heparin should be made no later than at weeks 35-36 of pregnancy.

Conclusions

The nticoagulation therapy of choice in the first trimester of pregnancy cannot currently be established. Prospective and randomized studies are required to determine the advisability of one treatment over the other