稽留流产、葡萄胎妇女使用Billings法避孕效果观察

目的:观察稽留流产和葡萄胎妇女刮宫术后采用Billings法避孕的效果。方法:观察组46例,为我院住院治疗的稽留流产和葡萄胎行刮宫术后采用Billings法避孕者,同时随机抽取我院Billings门诊避孕的妇女92例为对照组,观察两组对象24个月内的停用率、续用率和意外妊娠率。结果:138例妇女共观察1501个妇女月,24个月内观察组除6例计划妊娠外,无停用和意外妊娠者,净累积续用率86.95%。对照组24个月内停用17例(18.47%),意外妊娠1例(1.08%),净累积续用率81.52%。结论:稽留流产、葡萄胎妇女采用Billings法避孕,效果良好,值得推荐应用。     

长效高效可逆避孕方法在高危人工流产后的应用

目的探讨高危人工流产后落实长效高效可逆避孕措施(long acting reversible contraception,LARC)是否能降低非意愿妊娠及重复流产。方法对行人工流产的妇女中具有高危因素的妇女随访流产后第1、第3、第6个月LARC方法的使用情况和再次妊娠情况。结果 685例人工流产女性中,高危人工流产女性共372例(54.31%),其中年龄≤20岁64例(17.20%),1年内≥2次流产或半年内终止妊娠者共74例(19.89%),≥3次人工流产者213例(57.25%);带器妊娠7例(1.88%),哺乳期11例(2.96%),稽留流产3例(0.81%)。术后6个月随访结果显示:年龄≤20岁者,术后立即落实LARC的女性半年内未发生重复人工流产,而术后未立即落实LARC的女性半年内的重复流产率为57.70%(15/26)。两者比较,差异有统计学意义(P0.05)。1年内2次流产或半年内终止妊娠者术后立即落实LARC方法的女性半年内重复流产率为8.33%(2/24),未立即落实者半年内重复流产率为43.33%(13/30),两者比较,差异有统计学意义(P0.05)。≥3次人工流产者术后立即落实LARC者半年内重复人工流产率为1.82%(1/55),术后未立即落实者半年内重复人工流产率为26.14%(23/88),两者比较差异有统计学意义(P0.05)。结论提高人工流产术后LARC立即落实率,能有效提高避孕措施的持续使用率,降低重复人工流产及非意愿妊娠的发生。     

1945例稽留流产的流行病学及高危因素分析

目的:探讨稽留流产发生的高危因素。方法:通过病例-对照回顾性研究,收集稽留流产病例1 945例,同时与1 874例因非意愿妊娠20周内的单活胎要求终止妊娠者(包括妊娠12周自愿要求终止妊娠者以及妊娠12~20周内因内外科因素不宜妊娠者)的病例资料进行对比。分析与稽留流产发病相关的高危因素及环境等因素在稽留流产中可能产生的影响。结果:1Logistic多因素回归分析显示,与1 945例稽留流产发病正相关的危险因素包括:室外职业者(OR=1.777,95%CI=1.538~2.052),初产妇(OR=2.305,95%CI=2.013~2.638),自然流产史(OR=2.359,95%CI=1.703~3.268),贫血(OR=5.498,95%CI=2.243~13.473),乙肝病毒携带者(OR=8.126,95%CI=4.688~14.084);与稽留流产发病负相关的危险因素为人工流产≥3次(OR=0.726,95%CI=0.573~0.920)。2稽留流产独立因素构成变化显示,环境因素及一些未知因素等构成比升高(P0.05),与稽留流产发病数增加有关。结论:室外职业者、初产妇、自然流产病史、贫血和乙肝病毒携带者是稽留流产发生的独立危险因素,其中环境因素及一些未知因素的构成比随稽留流产发病数增加而升高。初步推论:基因、生育史、合并症不能解释稽留流产发病数的升高,而环境因素和一些未知因素可能是稽留流产病例数升高的重要原因之一。     

剖宫产术后瘢痕处妊娠15例临床分析

目的:探讨剖宫产术后瘢痕处妊娠(CSP)的临床特点、诊断及治疗方法.方法:对15例CSP患者的临床资料进行回顾性分析.结果:15例患者均有剖宫产术后人工流产史,平均2.57±1.32次;除一般早期妊娠的临床表现外,13例(86.7%)有妊娠早期阴道少量不规则流血,3例(20.0%)有下腹隐痛;术前分别误诊为宫内早孕及(或)伴先兆流产7例,稽留流产4例,宫颈妊娠1例,侵蚀性葡萄胎1例,只有2例术前B超检查明确诊断,另13例是在人工流产或刮宫手术时大出血后B超检查明确诊断;15例中13例行甲氨蝶呤和(或)氟尿嘧啶全身或局部应用,配合米非司酮口服药物保守治疗,1例行子宫动脉栓塞(UAE)配合药物治疗,1例行子宫全切术.结论:CSP一般超声检查可确诊,应提高临床医生对CSP的认识;禁止刮宫,误行刮宫大出血时纱条压迫宫颈止血有效;甲氨蝶呤和(或)氟尿嘧啶全身或局部应用,配合米非司酮口服是有效、简便的治疗方法.     

稽留流产与生殖道感染的关系分析

目的:探讨生殖道解脲支原体(UU)和沙眼衣原体(CT)感染与稽留流产的关系及其临床意义。方法:应用培养法分别对150例稽留流产患者(实验组)、120例正常妊娠人工流产孕妇(对照组)进行UU及CT的检测,并行统计分析。结果:实验组中UU、CT、UU+CT的感染率分别为38.00%、24.67%、17.33%,时照组中UU、CT、UU+CT的感染率分别为17.50%、13.33%、7.50%,两组间分别比较差异有统计学意义(P<0.05)。结论:生殖道解腺支原体和沙眼衣原体感染对稽留流产有一定的影响,是其病因之一。     

232例早期妊娠稽留流产患者心理障碍症状与孕产史的关系

目的 探讨早期妊娠稽留流产患者心理障碍症状与孕产史的关系。方法 选取232例早期妊娠稽留流产患者,采用90项症状自评量表（SCL-90）评测患者心理障碍症状。分析早期妊娠稽留流产患者心理障碍症状的影响因素,并分析妊娠结局不良史对早期妊娠稽留流产患者心理障碍症状发生率的影响。结果 早期妊娠稽留流产患者心理障碍检出率为26.29%。与早期妊娠稽留流产患者的心理障碍症状相关因素：不良生活习惯（吸烟、饮酒史）、产次和妊娠结局不良史次数（P<0.05）。Logistics回归分析模型分析（校正混杂因素后）显示：产次较少（OR=6.249,95%CI:3.096,12.612）及妊娠结局不良史（OR=0.133,95%CI:0.070,0.253）的早期妊娠稽留流产患者心理障碍症状的发生率明显较高（P<0.05）。结论 产次及妊娠结局不良史是早期妊娠稽留流产患者发生心理障碍症状的主要危险因素。     

稽留流产与宫颈解脲支原体感染的相关性研究

目的:讨论稽留流产与宫颈解脲支原体感染之间的相关性。方法:采用培养法对65名稽留流产患者和同期82名产科正常妊娠者进行宫颈解脲支原体培养,并进行相关性研究。结果:稽留流产组患者的宫颈解脲支原体阳性检出率明显高于正常妊娠组(P<0.05);宫颈解脲支原体感染与稽留流产间存在相关关系,r=1.087。结论:宫颈解脲支原体是导致稽留流产的原因之一。     

米非司酮配伍米索前列醇治疗稽留流产和终止10～16周妊娠的效果比较

目的:米非司酮配伍米索前列醇治疗稽留流产和终止10～16周妊娠的的疗效观察。方法:回顾性分析我院因孕10～16周稽留流产和要求终止妊娠者259例,分为稽留流产组151例,终止正常妊娠组108例,两组均以相同的剂量顿服米非司酮、第3日加服米索前列醇进行药物流产,对2组的治疗效果及副反应进行比较。结果:稽留流产组与终止正常妊娠组比较,两组从开始用药到胎体排出时间以及副反应差异无统计学意义(P>0.05),但稽留流产组的24小时不完全流产率和排胎后2小时内阴道流血量显著高于终止妊娠组(P<0.01)。结论:口服米非司酮配伍米索前列醇治疗稽留流产有较好的临床效果,但出血多和需清宫的患者则多于要求终止妊娠者。     

子宫腺肌病UAE治疗后妊娠及分娩的研究

目的:了解子宫腺肌病子宫动脉栓塞治疗(UAE)后患者的妊娠情况及结局,探讨该治疗方法对生育功能的影响。方法:对我院所完成的252例因子宫腺肌病行UAE的病例进行追踪观察,了解治疗后妊娠情况及结局。结果:①252例患者中有13例共16次妊娠,均为自然受孕。受孕时间为术后3~43个月,平均为13个月。②没有生育要求的208例患者中,有4例(4次)意外受孕:2例(2次)药物流产,2例(2次)行人工流产术。其中1例行人工流产术的患者取其绒毛组织作染色体检查正常。③有生育要求的44例患者中有9例12次妊娠(妊娠2次者1例,妊娠3次者1例),受孕率为27.3%(12/44)。其中足月顺产分娩3例,足月要求剖宫产和术中切除子宫1例,因胎膜早破早产要求行剖宫产1例,此5例均未发生产后出血,新生儿常规体格检查均未发现异常。自然流产4例(4次),均为孕4个月内胚胎停止发育。目前正在妊娠中患者1例,该患者行血液唐氏综合征筛查风险值为1/780,B超符合孕周,发育良好。结论:子宫腺肌病UAE治疗后可以正常受孕和分娩,但可能存在流产和早产的高危因素。     

甲状腺功能异常与稽留流产的相关性研究

目的:探讨甲状腺功能异常与稽留流产的相关性。方法:选取妊娠12周内的95例稽留流产患者为研究对象(观察组),并选择同期正常妊娠的92例妇女作为对照组,应用化学发光法检测2组患者血清中促甲状腺素(TSH)、游离甲状腺素(FT4)、甲状腺过氧化物酶抗体(TPOAb)水平。结果:2组甲状腺功能亢进、甲状腺功能减退、低T4血症发生率差异无统计学意义(均P>0.05);观察组亚临床甲状腺功能减退、TPOAb(+)发生率均高于对照组,差异有统计学意义(P<0.05),与稽留流产有弱相关性(列联系数分别为0.21和0.22)。结论:甲状腺功能异常中的亚临床甲状腺功能减退、TPOAb(+)与稽留流产有一定的关系,提示开展妊娠早期甲状腺功能相关检查对降低稽留流产的发生率有一定临床意义。     

Studies on the viability of trophoblast after termination of various kinds of pregnancies (author's transl)

Although normal value of hCG (LH level) does not necessarily indicate eradication of viable trophoblast, its confirmation has been demonstrated as a clinically useful guide for the probable prevention of choriocarcinoma after hydatidiform mole by Takeuchi et al. Choriocarcinoma preceded by other pregnancies than hydatidiform mole which has the highest risk for choriocarcinoma has drawn more attention than before in connection with the decrease of postmolar choriocarcinoma. So that I have studied the regression rate of urinary gonadotropin (hCG) after the termination of various kinds of pregnancies. In 2,433 cases of induced abortion, 695 cases of spontaneous abortion, 1,724 cases of term delivery and 43 cases of hydatidiform mole, their urinary hCG were determined to the level of physiological range of LH. The rate of hCG regression was in the order of term delivery, spontaneous abortion, induced abortion and hydatidiform mole. The younger was the gestational age of trophoblast, the slower was the regression of hCG. At one month after the termination of pregnancy, 80.1%, 11%, 0.3%, 8% and 4.1%, and at two month 55.8%, 1.6%, 0.5%, 4% and 0.5% for hydatidiform mole, induced abortion of less than 12 week of gestation, spontaneous abortion of less than 12 week of gestation, spontaneous abortion of between 13 and 20 week of gestation respectively still showed abnormal hCG value. One percent of induced abortion at 5 month, 4% of spontaneous abortion at 3 month, 0.3% of term delivery at 4 month still maintained abnormal titer. No malignant sequelae in patients under the investigation have ever been observed in the follow up period between 3 and 8 years.     

Gestational trophoblastic disease in women aged 50 or more

Twenty cases of gestational trophoblastic disease in women aged 50 or more are reported. The lesions were 7 hydatidiform mole (35%), 8 invasive mole (40%), and 5 choriocarcinoma (25%). The most common presenting symptom was abnormal vaginal bleeding. Three choriocarcinoma patients were postmenopausal and all of them had choriocarcinoma. None of the patients with hydatidiform mole or invasive mole died of the disease, but 4 of 5 choriocarcinoma patients died of the disease. Because of the high rate (56.3%) of malignant sequelae after molar evacuation, a primary hysterectomy for the treatment of hydatidiform mole in this age group is recommended. It is important to maintain a high level of suspicion for the diagnosis of gestational trophoblastic disease in the elderly women.     

Malignant potential of gestational trophoblastic disease at the extreme ages of reproductive life

The effect of maternal age on the incidence and significance of hydatidiform mole in 2202 patients studied at the Southeastern Regional Trophoblastic Disease Center during 1978 to 1982 is analyzed. Results are compared with a contemporary control group that comprised all types of pregnancy events. A significant increase (P less than .001) in the incidence of hydatidiform mole was seen in women 15 years of age or less and 40 years of age or more. A significant decrease (P less than .001) in the incidence of hydatidiform mole was seen in women in the 20 to 29-year age group. The greatest relative risk of hydatidiform mole occurred in women 50 years of age and older (relative risk = 519). The malignant sequelae rate from hydatidiform mole was 21.7% for the entire group. The relative risk of malignant gestational trophoblastic disease was lowest among patients 15 years of age and less (13.9%) and highest in patients 50 years of age and more (37.5%), but the differences were not significant (P greater than .05). The findings of the present study are compared with the previous literature and management recommendations are made.     

Epidemiology of hydatidiform mole in Finland, 1975 to 2001

PURPOSE: Broad variations in the incidence of gestational trophoblastic diseases have been reported in different parts of the world. Recent time trends in the incidence of hydatidiform mole in Western countries have not been elucidated. We studied the epidemiology of hydatidiform mole in Finland over a period of 27 years. METHODS: Women reported to have hydatidiform mole from 1975-2001 were identified from the National Research and Development Center for Welfare and Health. Women with choriocarcinoma were identified from the Finnish Cancer Registry. RESULTS: We identified 1659 cases of hydatidiform mole between 1975 and 2001. This gives an incidence of 73/10(6) women or 984/10(6) deliveries. The overall incidence remained fairly constant over the study period. The incidence was higher in women below 20 years and above 39 years than in women in the other age groups. Forty-nine percent of choriocarcinomas identified during the study period were associated with a preceding hydatidiform mole. The risk of choriocarcinoma after a hydatidiform mole was 2.2%. CONCLUSIONS: The incidence of hydatidiform mole in Finland follows the same patterns as in other Western countries. The incidence has not changed considerably in recent decades.     

Clinicopathologic characteristics and subsequent pregnancy outcome in 139 complete hydatidiform moles

OBJECTIVE: The most common form of gestational trophoblastic disease is the complete hydatidiform mole (CHM). The study reports our experience of clinicopathologic characteristics and subsequent pregnancy outcome of patients with CHM. STUDY DESIGN: One hundred fifty-one subsequent cases with initial diagnosis of CHM were re-evaluated histopathologically. Clinical characteristics, the need for chemotherapy and subsequent pregnancy outcome were evaluated. RESULTS: Twelve out of 151 cases were re-evaluated as hydropic abortion, as partial hydatidiform moles or were insufficient for morphologic examination and therefore excluded from further analysis. The leading clinical symptoms of the remaining 139 cases were irregular vaginal bleeding (67%) and uterine enlargement (41%). Twenty-six patients (19%) required chemotherapy because of gestational trophoblastic neoplasia (GTN; low-risk: 23 out of 26). All patients were cured successfully. The subsequent pregnancy rate was 15% (21/139). Five patients suffered from abortions, 12 women delivered a healthy offspring. Four women presented with recurrent CHM with a spontaneous normalization of HCG levels after D&C. CONCLUSIONS: The clinical and morphologic diagnosis of CHM is a challenge, and diagnosis as well as treatment should be multidisciplinary and centralised. One fifth of CHM are at risk of a GTN, but the cure rate is 100% with adequate management. Pregnancy outcome following CHM is complicated by an increased risk of abortion.     

P63 expression in hydropic abortion and gestational trophoblastic diseases

Gestational trophoblastic diseases are a group of interrelated diseases of trophoblastic tissue that include partial hydatidiform mole, complete hydatidiform mole, invasive mole, choriocarcinoma, and placental site trophoblastic tumor. P63 is a p53 homologue that, in normal placentas, is expressed in the cytotrophoblast cells. The role of p63 in gestational trophoblastic diseases, however, merits further investigation. Immunohistochemistry with the p63 antibody (clone 4A4) was performed in formalin-fixed paraffin-embedded samples of hydropic abortion (n=10), partial hydatidiform mole (n=12), complete hydatidiform mole (n=12) and choriocarcinoma (n=5). P63 expression was quantitatively assessed as 0 (no stained cells), + (less than 10% positive cells), ++ (10-50% positive cells), and +++ (more than 50% positive cells). The intensity was scored as 0 (absence), + (weak), ++ (moderate), or +++ (strong). Statistical analysis was carried out by the Fisher test. In contrast to the other diagnoses, none of the choriocarcinomas analyzed exhibited p63-positive cells. There was no difference in distribution of p63 positive cells between hydropic abortion, partial hydatidiform mole, and complete hydatidiform mole. Concerning the intensity of immunostaining, there was difference only between partial hydatidiform mole and complete hydatidiform mole. According to our results, p63 might be useful to differentiate a choriocarcinoma from other gestational trophoblastic diseases. Besides, since the intensity of p63 expression was much stronger in partial hydatidiform mole and complete hydatidiform mole than in hydropic abortion, this feature may be helpful in distinguishing these two diagnoses in challenging cases.     

On the results of hydatidiform mole managed by Niigata method

We have managed 518 cases of total mole patients in our Ob-Gyn clinic in the past 13 years by the Niigata postmole management method. Serial urinary hCG determination by sensitive assay (Higonavis and RIA) is the key examination in it. There are two critical points of urinary hCG determination: 1,000iu/L at the 5th week and 100iu/L at the 8th week after the termination of hydatidiform mole. The urinary hCG patterns are classified into type I if the hCG regression curve falls below both of them, and into type II if it follows curves other than type I. Among 89 cases of postmole patients who were administered no anti-cancer chemotherapy, 73 cases (82%) showed a type I hCG regression pattern, eight cases of which (11%) were complicated mole such as metastatic mole and invasive mole. Sixteen cases (18%) showed type II, but 8 of them (50%) were diagnosed as uncomplicated mole. The rate of complication among 118 cases of hydatidiform mole who had a molar pregnancy terminated and were followed up totally in our clinic was 24.6% and that of referral cases after molar evacuation was 21.3%, which is significantly higher than others reported in literature. There occurred no postmolar choriocarcinoma from uncomplicated mole patients who had their LH level confirmed in their urinary hCG determination, but 1 case (2.7%) did occur from LH level confirmed metastatic mole, and 3 cases (3.9%) from LH level confirmed metastatic invasive mole. It was shown that lung shadows on chest roentgenogram mostly take about 40 days to appear after D & C of hydatidiform mole and after surgery for uterine invasive mole.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evacuation of the gravid uterus by negative pressure (suction evacuation)

500 patients treated by suction evacuation of the gravid uterus are described. There were 80 therapeutic abortions, 375 early incomplete abortions, 21 late incomplete abortions, 18 missed abortions, and 6 cases of hydatidiform mole. The suction method was attempted to avoid the trauma of the curette. The 80 therapeutic abortions were done in Weeks 5-10 of pregnancy. To check results, an immediate curettage was made in 56 cases: this verified that no tissue remained in the uterus. In the 18 cases of missed abortion an adherent and fibrotic placenta was encountered in 9. A curettage was then needed to complete the procedure. The suction method was not used for subsequent cases of missed abortion. In the 375 cases of early incomplete abortion suction evacuation was 100% successful; in these cases the cervix was usually already adequately dilated. In the 21 cases of late incomplete abortion, 17 had the fetus already expelled. However, the remaining placenta tended to block the suction tube. Parts of the placenta were then left to be removed by curettage. In the 4 cases in which the fetus had not been expelled it could not be evacuated through the suction tube. Therefore suction evacuation was no longer done for late incomplete abortion. In all 6 cases of hydatidiform mole suction evacuation was quickly performed with minimal bleeding. Damage to the basal layer of the endometrium and the myocardium is avoided in the separation of the placenta by suction evacuation. The method is recommended as better than curettage for early therapeutic abortion, early incomplete abortion, and hydatidiform mole but not for late incomplete abortion or missed abortion.     

选择性动脉栓塞治疗妇产科大出血的临床应用

目的 研究选择性髂内动脉栓塞或子宫动脉栓塞技术在妇产科大出血中的临床应用。方法 选择性双侧髂内动脉或子宫动脉栓塞术治疗19例妇产科大出血患者，其中产后出血12例，功血3例，人工流产术后宫内残留2例，侵蚀性葡萄胎1例，绒癌子宫穿孔1例。产后出血、功血、宫内残留患者用明胶海绵栓塞，肿瘤患者用化疗药物加碘油混悬液、明胶海绵栓塞。结果 19例妇产科大出血患者栓塞后立即止血或出血明显减少，除1例出现右髂外动脉血栓形成，行右股动脉切开取栓术后好转外，余无严重并发症。结论 髂内动脉或子宫动脉栓塞技术的开展既避免了开腹手术，又不影响患者脏器功能，保留了年轻患者的生育功能，对抢救妇产科大出血是安全有效的。