对阴道前壁脱垂修复手术的再认识

正阴道前壁脱垂是盆腔器官脱垂中最常见和术后复发率最高的部位。100年来,阴道前壁脱垂的发生机制经过了筋膜伸展薄弱理论、盆底整体理论的盆底结缔组织及韧带损伤机制和阴道三水平支持中一水平起决定作用理论认识的改变,手术治疗方案也相应发生了改变。从阴道前壁筋膜折叠缝合修补术、增强补片添加的盆底重建和自体组织修补阴道前壁强调同时重建阴道一水平支持的手术。目前手术方式在采用自体组织修补(native tissue repair, NTR)或增强组织添加修复(augmented repair, AR)的术式间仍存在争议,还有待于具有高级别证据、临床长     

脱细胞生物组织补片在盆底重建手术中的应用

目的初步探讨脱细胞生物组织补片在盆腔器官膨出患者盆底重建手术中的应用情况。方法选择北京大学人民医院妇科2006年5月至12月期间接受盆底修补和重建手术并应用脱细胞生物补片的盆腔器官膨出患者20例,其中子宫脱垂19例,子宫切除术后阴道穹隆脱垂Ⅱ度1例;合并存在膀胱膨出20例、直肠膨出17例。20例患者中17例同时行阴道前后壁修补术,3例行阴道前壁修补术;阴道前壁置入补片15例,阴道后壁置入补片2例,阴道前壁和后壁同时置入补片3例。结果20例患者总手术时间平均为113．1min（70～180min）,其中放置补片的时间平均为10min。术中出血平均为175ml（50～300ml）。术后恢复良好,平均随访9．3个月（6～12个月）,未发现补片侵蚀阴道黏膜情况,无感染发生。随访期间4例（20％）患者出现盆腔器官膨出复发,3例为膀胱膨出Ⅰ度,复发时间均为6个月复查时,其中2例随访12个月时仍为膀胱膨出Ⅰ度,另1例随访8个月时也为膀胱膨出Ⅰ度,未见加重;1例为膀胱膨出Ⅱ度,复发时间为6个月复查时;所有复发患者均无临床症状。结论脱细胞生物组织补片用于盆底重建手术,方法简单,操作容易,未见补片侵蚀发生,其长期效果有待进一步观察。     

猪小肠黏膜下层生物补片治疗盆腔器官脱垂的手术疗效分析

目的探讨应用猪小肠黏膜下层生物补片(SIS)治疗盆腔器官脱垂(POP)的临床效果及并发症。方法回顾性分析2012年3月-2013年12月在北京大人民医院应用SIS行盆底重建手术的44例POP-Q≥Ⅱ期患者的临床资料。比较手术前后POP-Q各指示点位置及生活质量相关问卷(PFIQ-7、PFDI-20和PISQ-12)评分,分析术后患者的主客观复发率及下尿路症状。结果 44例患者随访时间为(2.4±0.7)年。术后患者主观复发率为6.8%(3/44),远低于客观复发率(36.4%,16/44)。术后未发生补片暴露。1例因尿潴留行补片缝线松解;1例阴道后壁补片植入部位感染,伴阴道疼痛,外用雌激素软膏后症状缓解;1例术后阴道前壁复发性脱垂Ⅲ期行Avaulta补片植入手术。患者PDFI-20评分由术前(66.25±28.35)分降为术后(17.03±21.00)分,PFIQ-7评分由术前(61.15±49.23)分降为术后(1.41±23.20)分,PISQ-12评分由术前(15.50±2.61)分降为术后(13.20±4.25)分。手术前后比较,除性生活质量评分外,差异均有统计学意义(P0.05)。结论应用SIS对POP患者行盆底重建手术后,患者生活质量明显提高,性生活质量无明显变化。患者主观满意度高,并发症少。基于较高的阴道前壁脱垂复发率,需要特别注意阴道前壁的修补,远期效果尚待随访观察。     

补片在女性盆底重建手术的应用-18例临床分析

目的初步探讨补片(mesh)在女性盆腔脏器脱垂手术重建盆底功能中的应用情况。方法我院妇科2004年3月～2005年4月期间共有18名患者因盆腔器官脱垂应用补片(mesh)进行盆底修补和重建。平均年龄68.6岁(48～78岁)。阴道前壁膨出17例,子宫脱垂15例,阴道后壁膨出12例。18例患者中14例行经阴式子宫切除术,1例行开腹全子宫切除术,1例保留子宫,2例已行子宫切除手术。同时行阴道前后壁修补术17例,单行阴道后壁修补术1例。单独置入阴道前壁补片11例,同时置入阴道前壁和后壁补片6例,单独置入阴道后壁补片1例。2例术中同时行阴道穹隆骶棘韧带悬吊术,4例术中行后路吊带阴道穹隆骶骨固定术。结果18例患者总手术时间平均为116.2min(85～150min),其中放置补片的时间平均15min。术中出血平均176ml(100～300ml)。术后恢复良好,术后住院时间5.4d(5～9d)。平均随访13.1个月(6～19个月),发现4例补片侵蚀阴道黏膜,发生率为22.2%,其中1例为前壁补片,此补片较大,为梯形补片,大小为5cm×12cm;3例为后壁补片。无补片感染发生。3例(16.7%)患者出现脏器膨出复发,1例阴道前壁膨出复发Ⅲ期,1例阴道前壁膨出复发Ⅰ期,1例阴道后壁膨出复发Ⅰ期。结论补片在女性盆底重建手术中的应用,方法简单,操作容易,不延长手术时间,患者耐受性好,但补片放置方法有待进一步探讨。     

猪小肠黏膜下层补片植入兔膀胱阴道间隙的转归研究

目的观察猪小肠黏膜下层(SIS)补片植入兔膀胱阴道间隙的转归,探讨SIS补片在妇科盆底手术中的应用价值。方法以家兔作为动物模型,16只雌性家兔随机(抽签法)分为4组,即7 d组、30 d组、90 d组和180 d组,每组4只家兔。4组家兔均通过手术方式于膀胱阴道间隙内植入SIS补片,分别于术后7、30、90、180 d处死各组家兔,并同时整块取出补片及其周围的膀胱阴道组织。标本均制成蜡块后切片,采用HE染色观察补片内部及周围组织产生的形态学变化,采用Masson染色观察补片组织内胶原形态和数量的变化。结果(1)HE染色后光镜下观察,7 d组SIS补片周围可见大量以嗜酸性粒细胞和淋巴细胞为主的炎性细胞浸润,并可见新生血管形成;30 d组炎性细胞浸润区域进一步增大;90 d组炎性细胞浸润区域明显缩小;180天组炎性反应基本消退。(2)Masson染色后光镜下观察,7 d组4只家兔SIS补片胶原结构清晰,保留完整;30 d组4只家兔SIS补片已有部分降解,但仍可见SIS胶原结构;90 d组有2只家兔尚可见少量残留SIS碎片结构,另2只家兔的SIS补片已被完全降解;180 d组4只家兔的SIS补片均被完全降解,其中1只家兔似可见部分有排序的胶原结构。结论SIS补片植入兔膀胱阴道间隙后可导致一过性的非感染性炎症反应,植入180 d后可被完全降解并有少量新生胶原结构产生。SIS补片用于盆底重建手术需谨慎。     

第五届北京大学妇科泌尿学与盆底重建手术研讨会会议通知

由北京大学人民医院、《中国妇产科临床杂志》社联合北京大学第一医院、第三医院于2009年11月26日～30日在北京举办第五届北京大学妇科泌尿学与盆底重建手术研讨会（国家卫生部继续教育项目I类学分10分）。研讨会特邀瑞典Karolinska大学专家著名盆底专家ChristianFalconer和DanielAltman教授及国内著名盆底专家进行专题讲座和重点演示常用的各种盆底重建手术。手术方式包括TVT—O、TVT—secure、改进的阴道前后壁修补术、补片加固术、阴道穹隆骶棘韧带悬吊术（SSLF）、阴道旁修补术、子宫脱垂保留子宫的手术、盆底整体悬吊术以及腹腔镜下盆底修复手术等。     

后盆腔缺陷疾病的手术治疗

现代解剖学根据矢状面将盆底结构分为前盆腔（ante-rior compartment）、中盆腔（middle compartment）、后盆腔（posterior compartment）.前盆腔包括阴道前壁、膀胱及尿道;中盆腔包括阴道顶部及子宫;后盆腔包括阴道后壁及直肠.后盆腔功能障碍主要指直肠膨出和会阴体组织的缺陷,表现为结直肠功能障碍的疾病.近年来更关注对后盆腔解剖结构缺陷的手术恢复方法,并认识到了会阴体或直肠阴道筋膜损伤可导致整个盆腔连接组织系统的薄弱退化.后盆腔的矫正或重建手术包括经肛门和经阴道两条途径施术,除经典的阴道后壁修补术和肛提肌加固缝合术外,对于重度阴道后壁膨出和修补术后复发者还可行加用补片（mesh）的阴道后壁修补术等.     

两种补片在前盆底重建术中的应用比较

目的:比较两种补片(聚丙烯合成网片和生物补片)在前盆底重建术的围手术期情况及近期疗效,探讨更为适宜的前盆底重建手术方式及材料。方法:40例行前盆底重建术的患者分为两组,其中25例采用聚丙烯网片的骨盆底修复系统(Prolift)的前盆底重建系统行前盆底重建术(Prolift组),余15例采用美国Cook公司研发的百得塞(Biodesign)生物补片行前盆底重建术(Cook组)。比较两组患者围手术期和随访情况,并进行统计学分析。结果:Cook组手术时间和术中出血量高于Prolift组,差异有统计学意义(P0.05);两组术后最高体温、尿管留置时间、术后残余尿比较,差异无统计学意义(P0.05)。Prolift组术后2例(8.0%)发生补片侵蚀,2例(8.0%)出现阴道疼痛,1例(4.0%)出现复发;Cook组术后1例(6.7%)出现阴道壁血肿,无补片侵蚀及复发。结论:生物补片与聚丙烯网片比较,手术时间较长,术中出血量较多,但生物补片在术后近期疗效和手术并发症方面有一定优势。     

合成材料盆底修补术后阴道侵蚀8例诊治分析

目的探讨合成材料盆底修补术后阴道侵蚀的临床特点、诊断、治疗及预后。方法回顾性分析南京军区福州总医院1999年1月至2006年12月盆底修补术后出现阴道侵蚀的8例患者临床资料。结果合成材料盆底修补术后阴道侵蚀发生率为3.2%。TVT术后2例,占TVT术2.1%,TOT术后2例,占TOT术10.5%,补片相关4例,占补片修补术3.0%。7例位于阴道前壁正中,1例位于左后壁。病理证实慢性炎症7例,单纯增生1例;8例均经阴道侵蚀修补术治愈。结论阴道侵蚀为合成材料盆底修补术后的并发症之一,出现后宜及早修补,多预后良好。     

猪小肠黏膜下层补片在盆底重建手术中的应用进展

盆底重建手术的替代材料大体可分为合成补片和生物补片。由于合成补片有临床并发症的发生,人们开始探索生物补片的应用。猪小肠黏膜下层是近年来应用于临床的一种生物补片,国外已应用于盆底重建手术,国内尚无该补片治疗盆腔器官脱垂的临床报道。本文概述了猪小肠黏膜下层补片的组织结构特性,动物实验结果及临床应用效果。     

Differences in female and male perception of information and decision-making in single-embryo transfer in in vitro fertilization in Sweden

Purpose The aim of this study was to evaluate the information and the factors that contribute to the decision to accept and choose single embryo transfer (SET) in females and males. Materials and methods Fifty-four females and males undergoing SET were interviewed separately using a structured questionnaire. Results The women were significantly more satisfied with the information than the men (odds ratio 3.3), but the decision to accept SET was nevertheless more difficult for women (OR 3.1). Only one-third of both female and males were aware of the increased maternal risks with twin pregnancies. There was a tendency that the women who accepted SET had previous children, shorter duration of infertility, and were younger. Cryopreservation of embryos and a good pregnancy chance were important irrespective of gender. Conclusion The female needs more support to choose SET. The male needs better information and further involvement in decision-making. The females were more aware of the fetal risks, but the awareness of the increased maternal risks with twin pregnancies was low. The female need more support to accept and choose single embryo transfer, compared to the male and information should in some areas be directed differently to females and males.     

Non-persistent pesticides in breast milk in an agricultural area in Turkey

Background: Organophosphates, pythyreoids, carbamate pesticides and fungicides are heavily used in agriculture. They may have dangerous effects on newborn health especially on immune system and growth via prenatal transmission by placenta or postnatal transmission by breastfeeding.

Methods: In 2015, 144 non-persistent pesticides in 64 milk samples of 32 mothers were studied by OuEChERS method in liquid chromatography/tandem mass spectrometer in neonatal Intensive Care Unit in Adana, a city in Cukurova region which is an important agricultural area in Turkey.

Results: Pesticides were detected in milk samples of 11 mothers (34.3%) and 21 (32.8%) of milk samples. In five mothers, fungicides (in 5/10 samples propicanozole-PP, in 4/10 samples bromucanozole-BM), in five mothers, organophosphates (in 10/10 samples primyphosphomethyl-PPM), in one mother, both organophosphates and fungicide (in 1/2 samples PPM and in 1/2 samples buprimate) were detected. However, the estimated daily intakes (EDI) were less than acceptable daily intakes (ADI) for PPM, PP and BM, respectively.

Conclusions: Although pesticides levels in human milk did not exceed the ADIs, we suggest monitoring pesticides in human breast milk especially for newborn health.     

Ovulation induction in in vitro fertilization

The main goal of an in vitro fertilization (IVF) program is to maximize the number of women who become pregnant in any treatment cycle. In order to achieve pregnancy, many steps should be successfully accomplished. The number of mature oocytes that are retrieved and fertilized in a treatment cycle has the major impact on the success rate of the IVF program. The chances of achieving conception increases dramatically when the number of embryos replaced into the uterus increases^1-3. Hence, most IVF treatment programs currently use some combination of ovulation induction agents in order to stimulate and aspirate as many follicles as possible.     

Heterogeneity in alpha-thalassemia interactions in Malays, Chinese and Indians in Malaysia

AIM: Interactions between different determinants of alpha-thalassemia raises considerable problems, particularly during pregnancies where antenatal diagnosis is necessary. This study aims to determine the different types of deletional alpha-thalassemia and Hemoglobin Constant Spring (HbCS), and their frequency in Malays, Chinese and Indians in Malaysia. METHODS: DNA from 650 pregnant women from the Antenatal Clinic of the University of Malaya Medical Center in Kuala Lumpur, Malaysia who showed mean cell volume < or =89 fL and/or mean cell hemoglobin < or =28 pg were analyzed for the double alpha-globin gene South-East Asian deletion (--SEA), the -alpha3.7 and -alpha4.2 single alpha-globin gene deletions and HbCS. RESULTS: One hundred and three (15.8%) of the pregnant women were confirmed as alpha-thalassemia carriers: 25 (3.8%) were alpha-thalassemia-1 carriers with the --SEA/alphaalpha genotype, 64 (9.8%) were heterozygous for the -alpha3.7 rightward deletion (-alpha3.7/alphaalpha), four (0.6%) were heterozygous for the -alpha4.2 leftward deletion (-alpha4.2/alphaalpha), nine (1.4%) were heterozygous for HbCS (alphaCSalpha/alphaalpha) and one (0.2%) was compound heterozygous with the -alpha3.7/alphaCSalpha genotype. The double alpha-globin gene --SEA deletion was significantly higher in the Chinese (15%) compared to the Malays (2.5%) and not detected in the Indians studied. The -alpha3.7 deletion was distributed equally in the three races. HbCS and -alpha4.2 was observed only in the Malays. CONCLUSION: The data obtained gives a better understanding of the interactions of the different alpha-thalassemia determinants in the different ethnic groups, thus enabling more rapid and specific confirmation of alpha-thalassemia in affected pregnancies where antenatal diagnosis is necessary.     

缺氧缺血性脑病的性别差异性研究进展

新生儿缺氧缺血性脑病(hypoxic-ischemic encephalopathy,HIE)是指围产期窒息缺氧导致的脑缺氧缺血性损害,可遗留不同程度的神经系统后遗症。动物研究表明,缺氧缺血性损伤后,炎性反应、氧化应激和细胞死亡途径等关键病理生理过程中存在明显的性别差异,雌性动物对亚低温、促红细胞生成素、脑源性营养因子和别嘌呤醇等治疗效果也明显优于雄性。临床研究发现男性HIE患儿病情更重、预后更差。基于性别的治疗干预很有可能在围产期脑损伤中提供更好的神经保护。本文总结了目前HIE性别差异性的相关证据,以期为临床治疗提供新思路。     

Trends in preterm birth in singleton deliveries in a Hong Kong population

Objective

To examine trends in preterm birth and its relationship with perinatal mortality in Hong Kong.

Methods

In a retrospective cohort study, data were reviewed from singletons delivered between 1995 and 2011 at a university teaching hospital. Trends in preterm birth (between 24 and 36 weeks of pregnancy), perinatal mortality, and subtypes of preterm birth (spontaneous, iatrogenic, and following preterm premature rupture of membranes [PPROM]) were examined via linear regression.

Results

There were 103 364 singleton deliveries, of which 6722 (6.5%) occurred preterm, including 1835 (1.8%) early preterm births (24–33 weeks) and 4887 (4.7%) late preterm births (34–36 weeks). Frequency of preterm birth remained fairly consistent over the study period, but that of spontaneous preterm birth decreased by 25% (β = –0.83; P < 0.001), from 4.5% to 3.8%. Frequency of preterm birth following PPROM increased by 135% (β = 0.82; P < 0.001), from 0.7% to 1.7%. The perinatal mortality rate decreased from 56.7 to 37.0 deaths per 1000 deliveries before 37 weeks (β = –0.16; P = 0.54). Early preterm birth contributed to 16.0% of all deaths.

Conclusion

Although the overall rate of preterm birth in Hong Kong has remained constant, the frequencies of its subtypes have changed. Overall perinatal mortality is gradually decreasing, but early preterm birth remains a major contributor.