阴道残端切口感染的防治

阴道残端切口感染通常由阴道内源微生物引起的。当患者合并慢性疾病、阴道菌群失调、阴道残端积血时会增加感染的机会。术前预防应用抗生素、提高手术技巧可降低阴道残端切口感染率。一旦发现阴道残端切口感染,应给予合理抗生素治疗,必要时手术治疗。     

Significance of angiotensin sensitivity test for prediction of pregnancy-induced hypertension

In 48 normotensive women with epidemiologic high-risk factors for pregnancy-induced hypertension, the angiotensin sensitivity test was performed serially between 26 and 32 weeks of gestation. If an effective pressor dose of less than 12 ng/kg per minute was considered to be a positive test result, 20 subjects were positive at 30 weeks of gestation and destined to develop pregnancy-induced hypertension. Of ten subjects with a false-positive test result, seven patients developed proteinuria and/or clinically significant edema without apparent hypertension, and only three subjects remained normal throughout their pregnancy. Twenty-eight subjects with negative test results had uneventful pregnancies. Before 30 weeks' gestation, it was difficult to identify all patients destined for pregnancy-induced hypertension. Although high false-positive test results were detected, these results suggest that an angiotensin sensitivity test at 30 weeks' gestation represents an appropriate means of identifying women who remain normal throughout pregnancy. Careful follow-up should be undertaken in all patients with positive test results.     

Sonographic diagnosis of IUGR-macrosomia.

Many sonographic methods have been suggested for identification of the fetus with a growth abnormality. Clearly, optimal management depends on early diagnosis. In recent years, advances in sonography have improved the ability to identify abnormal growth patterns and evaluate fetal well-being. When abnormal fetal growth is suspected, a thorough sonographic evaluation should be performed. This evaluation includes measurements of the abdominal circumference, femur length,) BPD, HC, AC, FL, and amniotic fluid volume. If these measurements confirm the suspicion of abnormal fetal growth, careful search for anomalies is mandatory. If there is no evidence of fetal compromise that would warrant delivery, measurements should be repeated in 2-3 weeks to evaluate interval growth. The following conclusions could be drawn from this literature review: 1. Intrauterine growth retardation and macrosomia are multifactorial diseases with varying degrees of severity. It is unlikely that a single sonographic parameter will allow an accurate diagnosis of all cases. 2. The type and degree of growth retardation and macrosomia depend on the intensity and duration of the underlying disease. Thus, an ultrasound assessment performed long before delivery may be of limited value. 3. Most of the sonographic parameters reviewed in this chapter are gestational age dependent. Unfortunately, gestational age is often unknown. Gestational age independent indices such as the amniotic fluid volume, FL/AC ratio, and the rate of fetal growth should be helpful in this situation. 4. The constitutionally small infant whose only problem is low birth weight should not be expected to present with any abnormal indices other than a low EFW. On the other hand, newborns who appear to be malnourished but whose birth weight is at or slightly above the tenth percentile for gestational age, may present with abnormal indirect indices indicating growth retardation (ie, HC/AC, FL/AC, Doppler velocimetry or oligohydramnios) despite a normal estimate of fetal weight. In addition, if the diagnosis of IUGR is made only with the use of birthweight for gestational age criteria, these infants are likely to be misclassified and labelled AGA. However, an abnormal ponderal index would indicate that these neonates are growth retarded. It can be concluded from this review that the use of sonographic measurements for diagnosing IUGR or macrosomia is associated with a high specificity and a somewhat lower sensitivity. Therefore, it would seem that the current ultrasound methods are more useful for excluding the possibility of abnormal fetal growth rather than for confirming it.     

Management options for penetrating injuries to the great veins of the neck and superior mediastinum

Between January 1984 and January 1986, 74 patients were treated for stab or gunshot injury to the great veins in the neck and superior mediastinum. Veins involved in the neck were the subclavian and internal jugular and in the mediastinum, the brachiocephalic and subclavian vein and the superior vena cava. Most patients presented in a state of shock. Twenty-nine were bleeding too rapidly to resuscitate adequately and required emergency operation while in a moribund state. Twenty-five had arteriovenous fistulas and were hemodynamically stable. Direct venous repair was attempted if simple lateral suture or end to end anastomosis could be rapidly done. If complex repairs were required, ligation was performed. Fifty-five veins were ligated on this basis, including 14 brachiocephalic trunks, nine proximal subclavian veins and one superior vena cava cephalad to the azygos. Nineteen were repaired. Two patients died after ligation and one patient after repair, all as a result of the effects of massive hypovolemia. Edema of the upper limb developed in two patients in each treatment group in whom the distal part of the subclavian vein had been involved. The edema resolved within five to seven days. Chronic venous stasis problems did not develop in any patient during the two to 26 month follow-up period.     

Outcomes in the absence of the ductus venosus diagnosed in the first trimester

Purpose: To clarify the outcomes of the absence of the ductus venosus (DV) diagnosed in fetuses suspected to have a structural abnormality during a morphological assessment in the first trimester.

Methods: Infants in whom ultrasound fetal morphological assessments were attempted in the first trimester (11 to 13–6 weeks of gestation) and who were subsequently delivered between 2013 and 2015 at Showa University Hospital were enrolled. In cases in which the absence of the DV was diagnosed in the first trimester, the prognosis was assessed.

Results: First-trimester ultrasound screening was performed in a total of 2610 cases between 2013 and 2015. Fetal edema (n?=?38), hydrops (n?=?16), abnormal four-chamber view findings (n?=?2), and tricuspid regurgitation (n?=?1) were observed in a total of 52 cases (2.0%). In 4 of the 52 cases with abnormal ultrasound findings, the absence of the DV was detected.

Conclusion: If fetal edema or hydrops in early pregnancy is found without any other structural abnormalities, not only chromosomal abnormalities should be suspected but also an evaluation for the absence of the DV should be included. In addition, absence of the DV with fetal edema may be associated with the outcomes of cardiac dysfunction, chromosome abnormalities, and intrauterine sudden death. Severe fetal edema is associated with a poor prognosis, and the family must be carefully informed of the potential outcomes.     

Value of arterial pressure measurements in the proximal and distal part of the thigh in arterial occlusive disease

A prospective study was carried out comparing two techniques of segmental arterial pressure measurements of the leg to detect, localize and quantify regional arterial occlusive disease. The measurement of pressures of the proximal and distal parts of the thigh with the narrow cuff technique permitted correct anatomic localization of aortoiliac, femoropopliteal or combined disease in 78 per cent of diseased extremities, including all limbs with isolated aortoiliac or femoropopliteal disease. A single wide cuff arterial pressure measurement of the thigh correctly localized arterial obstructions in only 19 per cent of diseased extremities. Although a wide cuff is associated with less artifactual elevation in measured arterial pressure at the thigh, this advantage is outweighed by the limitation of diagnostic accuracy in localizing segmental arterial occlusive disease. We recommend that segmental arterial pressure measurements of the limb be made at four levels on the lower extremity, including arterial pressures of the proximal and distal parts of the thigh to achieve maximal diagnostic accuracy.     

Can ultrasound be used to screen uterine malformations?

Eighty-nine patients were examined by ultrasound during the second phase of the menstrual cycle. The operators were not aware of the patients' history or results of previous ultrasonographic or radiologic investigations. The operators' aim was to diagnose uterine malformations graded as normal, suspected, or abnormal. Ultrasound identified 7 of 9 patients with a didelphic or complete septate uterus and 2 out of 3 with a bicornuate or partial septate uterus. Two other cases were suspected (one with a unicornuate, the other with a didelphic uterus). One false-positive case occurred, and 10 patients were not identified as having a malformed uterus (sensitivity, 42.9%; specificity, 97.8%). False-negatives involved mainly minor malformations.     

Pre- and postmenopausal high-risk women undergoing screening for ovarian cancer: anxiety,risk perceptions,and quality of life

OBJECTIVE: Recommendations for women at high risk of ovarian cancer include prophylactic salpingo-oophorectomy (PSO) or screening with transvaginal ultrasonography (TVUS) and CA125 levels. The best strategy for improving survival and maintaining quality of life in high-risk women is not known. Premenopausal women may be more reluctant than postmenopausal women to undergo PSO. However, the risk of false-positive screening results may be more likely in premenopausal women, posing potential psychological risk for those enrolled in high-risk ovarian cancer surveillance programs. We sought to determine whether anxiety, depression, perception of ovarian cancer risk, and false-positive test frequency differed between high-risk premenopausal and postmenopausal women initiating ovarian cancer screening. METHODS: High-risk women aged > or = 30 years enrolling in a TVUS plus CA125 ovarian cancer screening study completed standard QOL (SF-36), cancer-specific anxiety (IES), depression (CES-D), and ovarian cancer risk perception measures. CA125 > 35 and TVUS showing solid or complex cystic ovarian masses were considered abnormal. Abnormal tests were repeated after 4-6 weeks. Persistently abnormal tests prompted a search for malignancy. Tests that normalized on repeat were considered false positive. RESULTS: One hundred forty-seven high-risk women, median age 46 (range, 30-78), 78 premenopausal and 69 postmenopausal, had > or = 1 TVUS/CA125/outcome assessment. Premenopausal women were more likely than postmenopausal women to consider themselves at higher risk of ovarian cancer compared with women their age (P < 0.001) and compared with women with similar family histories (P < 0.001). Mean personal perception of lifetime risk of ovarian cancer among premenopausal women was 37% (range, 0-90%) versus 26% (range, 0-60%) among postmenopausal women (P = 0.02). While general QOL and depression scores were similar, 38% of premenopausal women reported high anxiety versus 27% of postmenopausal women (P = 0.03). Thirty percent of women required repeat CA125 or TVUS after first screening; 10.8% of premenopausal women versus 4.6% of postmenopausal women required repeat CA125; and 23.3% of premenopausal and 20.6% of postmenopausal women required repeat TVUS. One postmenopausal woman with persistently rising CA125 >100 had negative mammography, colonoscopy, and dilation and curettage/bilateral salpingo-oophorectomy. All other abnormal tests normalized on repeat. Two premenopausal women withdrew due to anxiety following false-positive CA125 results. Five women (2 premenopausal, 3 postmenopausal) with normal TVUS/CA125 screening tests elected PSO, with benign findings. CONCLUSION: Premenopausal women perceive their ovarian cancer risk to be higher, report greater ovarian cancer risk-related anxiety, and are more likely to have false-positive screening results than postmenopausal women. Few high-risk women elect PSO in the short term. Knowledge of the frequency of false-positive screening results and psychosocial outcomes is important for high-risk women choosing strategies for managing ovarian cancer risk.     

Treatment with a metallic endovascular stent in a patient with iliac venous stenosis due to endometrial cancer

There are few cases, to our knowledge, that report the successful treatment of iliac venous stenosis due to gynecologic malignancies with the use of self- expanding metallic endovascular stents. Our patient, who had right lower limb edema, had iliac lymph node metastases which caused iliac vein stenosis by direct invasion from endometrial cancer. The patient was not considered to be a good surgical candidate. A 10-mm diameter self-expanding metallic endovascular stent was placed in the external iliac vein. The patient’s symptoms of right lower limb edema improved dramatically, and she was discharged at 3 weeks after stent placement. The patient had no further symptoms, with continued resolution of the right leg edema during the 10 months following stent placement, at which time she died from the primary disease. The treatment to this patient with a self-expanding metallic endovascular stent proved to be very efficacious and less stressful than direct venous reconstruction or femorofemoral venous bypass grafting. In addition, this procedure dramatically improved the patient’s quality of life. Received: 10 January 2000 / Accepted: 8 February 2000     

Combined use of serial serum human chorionic gonadotropin testing, ultrasound and panoramic diagnostic microhysteroscopy in the early diagnosis of ectopic pregnancy

It is not always easy to make an early diagnosis of ectopic pregnancy in patients with suspected ectopic pregnancy who in any case appear to be clinically stable, and in whom the serial serum study of human chorionic gonadotropin (hCG) testing and ultrasound (US) showed an abnormal pregnancy without adding any useful information for obtaining a differential diagnosis between ectopic pregnancy and non-viable intrauterine pregnancy (IUP). Typical management of these patients comprises expectant observation or carrying out a diagnostic laparoscopy. The purpose of this study was to examine the value of microhysteroscopy as an adjunctive procedure in the above-mentioned patients; the results of this clinical test show that in these patients, the microhysteroscopy may represent a simple and valid alternative to expectant observation or immediate laparoscopy.     

Fetal breathing movements and the nonstress test in high-risk pregnancies.

Three hundred ninety-eight observations of fetal breathing movements (FBM) and the nonstress test (NST) were made in 223 patients. The presence of FBM was noted in a significantly higher proportion of tests with a reactive NST (88%) than a nonreactive NST (67%). Conversely, a significantly higher proportion of tests were reactive when FBM were present (82.6%) than when FBM were absent (49%). A significant relationship existed betweeen either test and the outcome of pregnancy as judged by the five minute Apgar score or the incidence of fetal distress in labor. Combining two normal tests did not improve the accuracy in predicting outcome; but the combination of both tests, when abnormal, produced a significant improvement in predicting fetuses likely to have an abnormal outcome. The combination of the normal with the abnormal test had a predictive accuracy similar to a single normal test in predicting a normal five-minute Apgar. This combination was associated with an incidence of fetal distress in labor intermediate between that seen with either the normal or abnormal test when alone. Neither a single test nor the combination of tests was helpful in identifying the small-for-gestational age (SGA) infants. These data indicate antepartum fetal evaluation may be improved when more than one biophysical variable is used.     

Diagnosis of deep venous thrombosis using a Doppler ultrasonic technique.

A consecutive series of 118 patients was studied postoperatively by Doppler ultrasonic techniques and by either venography or radioiodinated fibrinogen. When using the latter diagnostic measures, 22 patients were shown to have deep venous thrombosis, an incidence of 18.6 per cent. The Doppler ultrasonic technique showed that 21 patients had deep venous thrombosis, an incidence of 17.7 per cent. When the patients diagnosed as having deep venous thrombosis by two separate methods were compared, it was shown that the Doppler technique gave two false-positive results and three false-negative results. It is concluded that this technique is accurate, and because of its convenience, lack of complications and ability to be repeated frequently, it should be the preferred screening technique for the diagnosis of postoperative deep venous thrombosis.     

Diagnosis of deep venous thrombosis in the outpatient by venography

One hundred and two patients, presenting at the outpatient departments of two Boston teaching hospitals, underwent clinical examination and venography. History, physical examination and presence of risk factors were unreliable in the diagnosis of deep venous thrombosis. Seventy-two per cent of the patients with deep venous thrombosis had a proximal extension of the thrombus to the femoral vein or higher. The outpatient with deep venous thrombosis appears to differ from the more frequently studied inpatient in the time of diagnosis and its anatomic extent. The high incidence of false-positive clinical examination results has important cost-benefit implications.     

Combined second-trimester biochemical and ultrasound screening for Down syndrome

OBJECTIVE: To evaluate the efficacy of a Down syndrome screening protocol that combines second-trimester maternal serum analytes and the continuous ultrasound measures of nuchal fold thickness and proximal long bone length. METHODS: Ultrasound measurements of nuchal fold, femur length, and humerus length were reviewed for 72 second-trimester Down syndrome and 7063 unaffected fetuses. Derived statistical variables for these parameters were entered into a multivariable Gaussian model together with the statistical variables used in the "quad" test (maternal serum alpha-fetoprotein, unconjugated estriol, human chorionic gonadotropin, and inhibin A). Maternal age-specific sensitivities, false-positive rates, and positive predictive values were generated together with receiver operating characteristic curves. Overall efficacy of ultrasound screening alone, the quad test, and the combination of the ultrasound and quad test were compared using a 1:270 second-trimester risk cutoff applied to 1999 US births. RESULTS: Using ultrasound, a sensitivity of 79.9% and false-positive rate of 6.7% may be achieved (positive predictive value: 1 in 42). The quad test has a sensitivity of 81.5% and false-positive rate of 6.9% (positive predictive value: 1 in 42). The combination of the quad test with nuchal fold and long bone measurements may achieve 90% sensitivity and a 3.1% false-positive rate (positive predictive value: 1 in 18). CONCLUSION: Combining second-trimester serum testing and fetal biometry is a feasible approach to Down syndrome screening, compatible with current obstetric practice. This modality is substantially more effective than either serum screening or ultrasound alone. Efficacy may be comparable to that reported for combined first- and second-trimester (integrated) screening.     

Clinical study of the cervical mucus and the post-coital tests: its role in sterility (authors transl)

Cervical mucus and post-coital test abnormalities are the most frequently observed in infertile couples. In most cases, such disorders reflect a hormonal dysfunction in the woman and also an alteration of spermiogram. This simple clinical examination reflects the fertility of the moment: its positivity is necessary but not sufficient for fecundation. When the result of this examination is normal, one may generally skip the spermiogram. If the result is abnormal, the test must be performed again until a clear positivity is obtained. If it is repeatedly negative, a spermiogram must be done.     

Transvaginal sonohysterographic evaluation of uterine malformations

OBJECTIVE: The aim of this study was to assess the diagnostic value and the usefulness of sonohysterography (SHG) in the detection of uterine anomalies, compared with other diagnostic methods. STUDY DESIGN: From January 2002 to December 2003, we collected 54 patients with a history of primary or secondary infertility or repeated spontaneous abortion and with a clinically or sonographically suspected abnormal uterus. All patients had previously undergone hysterosalpingography (ISG). All patients were examined by standard transvaginal ultrasound. Sonohysterography was then carried out by the intrauterine injection of an isotonic saline solution. Suspected uterine anomalies were also confirmed by hysteroscopy (HS) and/or laparoscopy. RESULTS: Sonohysterography was able to detect all the anomalies. The sensitivity and specificity of sonohysterography were the same as for hysteroscopy. However, there was no significant difference between the diagnostic capabilities of the methods analyzed. CONCLUSIONS: Transvaginal sonohysterography with saline solution is a low-cost, easy, and helpful examination method for uterine malformations. We propose that sonohysterography should be performed for the primary investigation of infertility and repeated miscarriages.     

Evidence-based medicine for diagnostic questions

When searching the medical care literature for evidence on a diagnostic test, three questions should be addressed each time a study is found: (1) Is this evidence about a diagnostic test valid? (2) Does the test accurately discriminate between patients who do and patients who do not have a specific disorder? (3) Can the test be applied to this patient who is right now sitting in front of me? We will discuss hysterosalpingography (HSG) as an example of a valid and accurate diagnostic test to be applied in a general population of subfertile couples to assess tubal patency (specificity 0.83). HSG is an unreliable test for diagnosing tubal occlusion however (sensitivity 0.65). If HSG were normal, other investigations could be pursued and diagnostic laparoscopy (LS) only performed if conception had not occurred by a later date. If HSG were abnormal, LS would be needed to confirm or exclude tubal occlusion. Patients with risk factors for pelvic or tubal disease, including an abnormal Chlamydia antibody test (CAT) and those showing abnormalities at pelvic examination, should proceed directly to LS because they are significantly more likely to have pelvic pathology. A completely different issue would be HSG as a prognostic test for the occurrence of pregnancy. In theory, the occurrence of pregnancy may be considered a gold standard; however, in reproductive medicine, with so many causes of subfertility other than tubal pathology, a diagnostic test for one single disorder, if normal, will never be able to accurately predict the eventual occurrence of pregnancy.     

Compression ultrasonography as a reliable imaging monitor in deep venous thrombosis

Our experience at Hippokration Athens Hospital with high-resolution real-time ultrasonography of the deep veins of the lower extremities is described, drawn from the results of a prospective comparative study of 65 patients. We used a combination of sonography and contrast venography for the detection of deep venous thrombosis (DVT). Of the study group, 33 had clinically suspected DVT, 20 were asymptomatic high-risk patients, while 12 with varicosities of the leg and scheduled for saphenectomy were examined preoperatively for deep venous patency confirmation. For all patients, venography, the reference method, was performed within 12 hours of the ultrasound scan. Since 29 of the examinations were bilateral, the total number of extremities studied was 94. The sonographic criteria analyzed were the intraluminal echogenicity and the venous compressibility with the ultrasound transducer probe. In addition, the response of the common femoral vein to the Valsalva maneuver was studied. Among these three criteria, compressibility was by far the most accurate. Noncompressible abnormal veins were noted in all of the 24 extremities with proximal thrombosis and in six of the 12 with thrombosis limited to the calf veins. Thus, the sensitivity of the compressibility criterion was 100 per cent for proximal and 50 per cent for isolated calf venous thrombosis (83 per cent). All venographically patent veins were fully compressible (specificity, 100 per cent). Abnormal intraluminal echoes were found in 18 of the 36 extremities with thrombosis but not in those with negative findings on venography. Sensitivity of intraluminal echogenicity was, therefore, 50 per cent and specificity, 100 per cent. For the Valsalva criterion, the standard lower normal limit of 10 per cent was applied, leading to 40 per cent sensitivity and 93 per cent specificity rates. In comparison with venography, ultrasonography underestimated the extent of thrombosis in 60 per cent of the true-positive examinations, although never to a clinically significant degree. In conclusion, compression ultrasonography, a technique based upon the unique criterion of venous compressibility, is a highly accurate and objective noninvasive diagnostic method, and is also suitable as a screening test. We urge clinicians to support their therapeutic decisions concerning the management of DVT with it.     

Circulatory congestion in obese hypertensive women: a subset of pulmonary edema in pregnancy

We describe four obese, chronically hypertensive women presenting with antepartum pulmonary edema in whom invasive hemodynamic monitoring showed elevated wedge pressure, normal to high cardiac index, and normal systemic vascular resistance. Echocardiography revealed large chambers, thick walls, and increased left ventricular mass with normal systolic but abnormal diastolic function. These findings are indicative of intrinsic volume overload occurring in the presence of impaired left ventricular relaxation, a combination resulting in high filling pressures and pulmonary congestion. Diuretic therapy is indicated in this subset of patients, who could not be recognized by the usual clinical parameters such as history and physical examination, chest x-ray, and arterial blood gas.     

A 1-hour hCG radioimmunoassay detection kit for the management of suspected ectopic pregnancy

The value of a rapid hCG kit was assessed in 60 patients undergoing laparoscopy or laparotomy for suspected ectopic pregnancy, of whom 30 were subsequently proven to be pregnant. A high degree of specificity (93%) and sensitivity (97%) was found, with one false-negative and three false-positive results. If the kit had been used as a routine on admission three patients would not have been inadvertently discharged before the diagnosis of tubal pregnancy and 27 could have avoided a laparoscopy to exclude tubal pregnancy.