超声消融治疗子宫黏膜下肌瘤的安全性和疗效评价

目的 探讨超声消融治疗突入宫腔体积＜50%的子宫黏膜下肌瘤的安全性及疗效.方法 前瞻性选择2006年10月至2009年9月在解放军总医院妇产科就诊有明显临床症状的、经MRI确诊的突出官腔体积＜50%的子宫黏膜下肌瘤患者66例(68个肌瘤),行超声引导下的聚焦超声消融治疗,记录消融治疗过程中及消融治疗后出现的不良反应;消融治疗后即刻采用超声造影评价消融治疗的疗效,消融治疗后第3、6、12和24个月,超声评价肌瘤体积变化;采用子宫肌瘤相关症状评分表(SSS)和月经期症状评分表评估症状变化.结果 共66例患者的68个黏膜下肌瘤消融治疗前肌瘤平均体积为(151±134)cm3,消融治疗后即刻超声造影中无灌注区平均体积为(114±104)cm3,肌瘤体积消融率为(77±16)%.所有患者均顺利完成治疗,随访时间为6～44个月,中位随访时间24个月,至今未出现显著并发症.消融治疗后有52%(34/66)的患者出现阴道排液症状,均于消融治疗3～4个月经周期后自行恢复正常.消融治疗后第3、6、12和24个月时,SSS评分与消融治疗前比较,分别降低20.9%、38.0%、45.1%、47.1%;月经期症状评分与消融治疗前比较,分别降低42.0%、63.8%、64.2%、68.8%,分别与治疗前比较,差异均有统计学意义(P＜0.05),坏死肌瘤逐渐吸收缩小,肌瘤体积较消融治疗前平均缩小44.7%、66.0%、77.7%和89.8%.结论 超声消融治疗突入宫腔体积＜50%的子宫黏膜下肌瘤安全、有效,黏膜下肌瘤相关症状改善显著.

Abstract：

Objective To evaluate the efficacy and safety of focused ultrasound ablation in the treatment of submucosal fibroids which broke into uterine cavity less than 50%. Methods From Oct. 2006 to Sept. 2009, 66 patients with 69 submucosal fibroids broke into uterine cavity less than 50% diagnosed by MRI in Chinese People's Liberation Army General Hospital were enrolled in this study. They were treated by ultrasound-guided focused ultrasound ablation in the outpatient department, which using the contrast enhanced ultrasonography to assess the efficacy after ablation immediately, to measure reduction of fibroids volume and record adverse effect before and after ultrasound ablation. At 3, 6, 12 and 24 months after treatment, ablation outcome and fibroids volumes were evaluated by contrast ultrasound. The changes of clinical symptom were evaluated by the symptom severity score ( SSS) of the uterine fibroid quality-of-life instrument( UFS-QOL). Results The average volume of fibroids in 66 patients with 68 submucosal fibroids were (151 ±134) cm3 before treatment and (114 ± 104) cm3 no enhanced regional after treatment. The ablation rate of target fibroids was (77 ±16)%. All patients completed this treatment successfully, they were followed up for 6 - 44 months, the median follow-up time was 24 months. No serious complication was observed. However, there were 52% (34/66) patients presented vaginal discharge after ablation, it disappeared gradually after 3 to 4 menstrual cycles. The SSS and the menstrual period symptom scores were significantly lower than that before ablation at the follow-up of 3,6, 12 and 24 months, the rates were 20. 9% , 38. 0% , 45. 1% , 47. 1% and 42. 0% , 63. 8% , 64. 2% , 68. 8% , which all reached statistical difference (P ＜ 0. 05 ). The necrotic fibroids were absorbed gradually, the reduction rates of fibroid volume were 44. 7% ,66. 0% ,77. 7% and 89. 8% . Conclusion It was safe and efficacy that focused ultrasound ablation was used in treatment of submucosal fibroids which broke into the uterine less than 50%.     

妊娠期肝内胆汁淤积症胎儿胆汁酸水平与肺表面活性物质的相关性研究

Objective To explore the relationship between total bile acid(TBA)concentration and fetal pulmonary surfactant in intrahepatic cholestasis of pregnancy(ICP).Methods Fifry five patients with ICP(ICP group)who received cesarean section from April 2008 to February 2010 in Second Xiangya Hospital,Central South University,were recruited.The general conditions of the neonates within 7 days after birth in ICP group were recorded.Those with fetal distress,neonatal asphyxia,or neonatal respiratory distress syndrome were referred as pathological neonates, others were referred as normal neonates. Over the same period, 23 healthy gravidas were recruited as control group. Enzymatic method was used to detect the TBA concentrations in maternal blood, cord blood and amniotic fluid. ELISA was employed to measure the urfactant protein A (SP-A) concentration in cord blood. High performance liquid chromatography system was used to detect the concentrations of phesphatidylcholine (PC),phosphatidylinositol (PI),lysophosphatidylcholine ( LPC), and sphingomyelin(SM) in amniotic fluid. Results ( 1 ) The concentrations of TBA in maternal blood, cord blood and amniotic fluid were ( 30. 1 ± 7.9 ), (9. 3± 3. 3 ) and (4. 4 ± 1.5 ) mmol/L in ICP group, (4. 8 ± 2. 2), (4. 9 ± 0. 9) and ( 1.4 v 1.1 ) mmol/L in control group, respectively. The differences between the two groups were significant ( P ＜ 0. 05 ). ( 2 ) The SP-A concentration in cord blood in ICP group was ( 29. 5 ± 6. 4 ) μg/L, significantly higher than that in control group, which was ( 22. 6 ± 7. 4 )μg/L ( P＜ 0. 05 ). ( 3 ) There were 20 pathological neonates and 35 normal neonates in ICP group. In pathological neonates, the concentrations of TBA and SP-A in cord blood were (10.9 ± 2.2) mmol/L,(37.0 ± 5.9 ) μg/L, respectively; and were ( 8.0 ± 2. 8 ) mmol/L, ( 26. 7 ± 4. 8 ) μg/L in normal neonates. The differences were significant (P＜ 0. 05 ). (4) There was a positive correlation between TBA concentration in cord blood and in maternal blood ( r1 = 0. 706, P＜0. 05 ). The TBA concentration in cord blood was positively correlated with SP-A concentration as well ( r3 = 0. 494,P ＜ 0. 05 ). (5) The PC and PI concentrations in amniotic fluid were (65.4 ± 7.2) mg/L and ( 3. 8 ± 0. 6 ) mg/L in ICP group, ( 69. 7 ±3.7) mg/L and (4. 3 ± 0. 7 ) mg/L in control group, respectively. The differences were significant (P ＜0. 05 ). The concentration of LPC in amniotic fluid in ICP group was (4. 8 ±0. 9) mg/L, significantly higher than that in control group (P＜0. 05), which was (4. 2 ±0. 6) mg/L. The concentration of SM in amniotic fluid was (3.5±0. 8) mg/L in ICP group, (4. 0 ± 0. 5 ) mg/L in control group, with no significant difference ( P＞0. 05 ). (6) The ratio of PC/LPC in ICP group ( 14. 2± 3. 2 ) was significantly lower than that in control group ( 16. 9 ± 2. 5 ) ( P＜ 0. 05 ). ( 7 ) The TBA concentration in cord blood was negatively correlated with PC and PI concentrations (r1 = -0. 561, r2 = -0. 407, P ＜ 0. 05 ), and had no correlation with LPC concentration (r3 = 0. 260, P＞ 0. 05). Conclusions ( 1 ) The fetal TBA concentrations in both cord blood and amniotic fluid of patients with ICP was higher than those of healthy gravidas, they were also positively correlated with maternal TBA concentration. (2) ICP resulted in the change of fetal pulmonary surfactant and this change was associated with TBA concentrations in both cord blood and amniotic fluid.     

妊娠期肝内胆汁淤积症胎儿胆汁酸水平与肺表面活性物质的相关性研究

Objective To explore the relationship between total bile acid(TBA)concentration and fetal pulmonary surfactant in intrahepatic cholestasis of pregnancy(ICP).Methods Fifry five patients with ICP(ICP group)who received cesarean section from April 2008 to February 2010 in Second Xiangya Hospital,Central South University,were recruited.The general conditions of the neonates within 7 days after birth in ICP group were recorded.Those with fetal distress,neonatal asphyxia,or neonatal respiratory distress syndrome were referred as pathological neonates, others were referred as normal neonates. Over the same period, 23 healthy gravidas were recruited as control group. Enzymatic method was used to detect the TBA concentrations in maternal blood, cord blood and amniotic fluid. ELISA was employed to measure the urfactant protein A (SP-A) concentration in cord blood. High performance liquid chromatography system was used to detect the concentrations of phesphatidylcholine (PC),phosphatidylinositol (PI),lysophosphatidylcholine ( LPC), and sphingomyelin(SM) in amniotic fluid. Results ( 1 ) The concentrations of TBA in maternal blood, cord blood and amniotic fluid were ( 30. 1 ± 7.9 ), (9. 3± 3. 3 ) and (4. 4 ± 1.5 ) mmol/L in ICP group, (4. 8 ± 2. 2), (4. 9 ± 0. 9) and ( 1.4 v 1.1 ) mmol/L in control group, respectively. The differences between the two groups were significant ( P ＜ 0. 05 ). ( 2 ) The SP-A concentration in cord blood in ICP group was ( 29. 5 ± 6. 4 ) μg/L, significantly higher than that in control group, which was ( 22. 6 ± 7. 4 )μg/L ( P＜ 0. 05 ). ( 3 ) There were 20 pathological neonates and 35 normal neonates in ICP group. In pathological neonates, the concentrations of TBA and SP-A in cord blood were (10.9 ± 2.2) mmol/L,(37.0 ± 5.9 ) μg/L, respectively; and were ( 8.0 ± 2. 8 ) mmol/L, ( 26. 7 ± 4. 8 ) μg/L in normal neonates. The differences were significant (P＜ 0. 05 ). (4) There was a positive correlation between TBA concentration in cord blood and in maternal blood ( r1 = 0. 706, P＜0. 05 ). The TBA concentration in cord blood was positively correlated with SP-A concentration as well ( r3 = 0. 494,P ＜ 0. 05 ). (5) The PC and PI concentrations in amniotic fluid were (65.4 ± 7.2) mg/L and ( 3. 8 ± 0. 6 ) mg/L in ICP group, ( 69. 7 ±3.7) mg/L and (4. 3 ± 0. 7 ) mg/L in control group, respectively. The differences were significant (P ＜0. 05 ). The concentration of LPC in amniotic fluid in ICP group was (4. 8 ±0. 9) mg/L, significantly higher than that in control group (P＜0. 05), which was (4. 2 ±0. 6) mg/L. The concentration of SM in amniotic fluid was (3.5±0. 8) mg/L in ICP group, (4. 0 ± 0. 5 ) mg/L in control group, with no significant difference ( P＞0. 05 ). (6) The ratio of PC/LPC in ICP group ( 14. 2± 3. 2 ) was significantly lower than that in control group ( 16. 9 ± 2. 5 ) ( P＜ 0. 05 ). ( 7 ) The TBA concentration in cord blood was negatively correlated with PC and PI concentrations (r1 = -0. 561, r2 = -0. 407, P ＜ 0. 05 ), and had no correlation with LPC concentration (r3 = 0. 260, P＞ 0. 05). Conclusions ( 1 ) The fetal TBA concentrations in both cord blood and amniotic fluid of patients with ICP was higher than those of healthy gravidas, they were also positively correlated with maternal TBA concentration. (2) ICP resulted in the change of fetal pulmonary surfactant and this change was associated with TBA concentrations in both cord blood and amniotic fluid.     

缩宫素对超声消融治疗子宫肌瘤效果的影响

目的 探讨缩宫素对超声消融治疗子宫肌瘤效果的影响.方法 采用MRI引导下的超声消融肿瘤治疗系统,以单点辐照的方式,选择确诊的26例子宫肌瘤患者的29个肌瘤中的82个靶点进行研究,比较使用缩宫素前、后辐照单点达到60℃时所需的能量、时间及升高单位温度(1℃)所需的能量.结果 使用缩宫素前,辐照单点温度达到60℃所需的能量为(5320±910)J,时间为(21±20)s,升高1 ℃所需的能量为(255±302)J;静脉滴注缩宫素后,辐照单点温度达到60℃所需的能量为(2890±325)J,时间为(12±7)s,升高1℃所需的能量为(126±94)J.使用缩宫素前、后,各指标间比较,差异均有统计学意义(P值分别为0.002、0.001、0.002).结论 缩宫素能明显降低超声消融治疗子宫肌瘤所需的能量,缩短治疗时间,从而提高治疗效率,具有很好的临床应用价值.

Abstract：

Objective To explore the effect of oxytocin on uterine fibroids treated by ultrasound ablation. Methods Eighty-two single points in 29 uterine fibroids from 26 patients were sonicated with magnetic resonance imaging guided by high intensity focused ultrasound before and after using oxytocin. The required total energy, sonication time required to reach 60 ℃ and the acoustic energy for increasing 1 ℃ of temperature at the single point before and after using oxytocin were compared. Results Before intravenous infusion of oxytocin, the average total sonication energy required to reach 60 ℃ was (5320 ±910) J and it took (21 ±20) seconds for sonicating a single point, the energy required for increasing 1 ℃ was (255 ± 302) J. In contrast, after intravenous infusion of oxytocin, the average total sonication energy required to reach 60 ℃ was (2890 ±325) J, and it took (12 ±7) seconds for sonicating a single point, the energy required for increasing 1 ℃ was ( 126 ± 94 ) J. Those three index all reached statistical difference ( P = 0.002, P = 0.001, P= 0.002, respectively). Conclusion It seemed that Oxytocin could significantly decrease the energy required for ablating uterine fibroids, shorten treatment time and improve the treatment efficiency.     

妊娠期肝内胆汁淤积症胎儿胆汁酸水平与肺表面活性物质的相关性研究

目的 探讨妊娠期肝内胆汁淤积症(ICP)胎儿总胆汁酸水平与胎儿肺表面活性物质(PS)的关系.方法 选择2008年4月至2010年2月在中南大学湘雅二医院住院行剖宫产分娩的ICP孕妇55例(ICP组),记录ICP组孕妇的新生儿出生至产后7 d的一般情况,凡符合胎儿窘迫、新生儿窒息、新生儿呼吸窘迫综合征其中1项者为病理围产儿,无上述情况为正常围产儿.另选同期健康孕妇23例为对照组.采用循环酶法测定两组孕妇血、脐血及羊水中总胆汁酸水平;ELISA法测定两组胎儿脐血肺表面活性蛋白A(SP-A)水平;高效液相色谱法测定两组羊水中磷脂酰胆碱(PC)、磷脂酰肌醇(PI)、溶血卵磷脂(LPC)、神经鞘磷脂(SM)的含量.结果 (1)ICP组孕妇血、脐血及羊水中总胆汁酸水平分别为(30.1±7.9)、(9.3±3.3)及(4.4 ±1.5)mmol/L,明显高于对照组的(4.8±2.2)、(4.9±0.9)及(1.4±1.1)mmol/L,两组分别比较,差异均有统计学意义(P＜0.05).(2)ICP 组胎儿脐血SP-A水平为(29.5±6.4)μg/L,明显高于对照组的(22.6±7.4)μg/L,两组比较,差异均有统计学意义(P＜0.05).(3)ICP组中病理围产儿20例,健康围产儿35例,病理围产儿脐血总胆汁酸及SP-A水平分别为(10.9±2.2)mmol/L及(37.0±5.9)μg/L,健康围产儿分别为(8.0±2.8)mmol/L及(26.7±4.8)μg/L,两者比较,差异有统计学意义(P＜0.05).(4)脐血总胆汁酸水平分别与孕妇血、羊水总胆汁酸水平呈正相关(r1=0.706,r2=0.763,P＜0.05);脐血SP-A水平与脐血总胆汁酸水平呈正相关(r3=0.494,P＜0.05).(5)ICP组羊水中PC及PI的含量分别为(65.4±7.2)及(3.8±0.6)mg/L,均明显低于对照组的(69.7±3.7)及(4.3±0.7)mg/L,两组比较,差异有统计学意义(P＜0.05);ICP组羊水LPC的含量为(4.8±0.9)mg/L,明显高于对照组的(4.2±0.6)mg/L,两组比较,差异有统计学意义(P＜0.05);ICP组羊水SM的含量为(3.5±0.8)mg/L,与对照组的(4.0±0.5)mg/L比较,差异无统计学意义(P＞0.05).(6)ICP组羊水PC/LPC比值(14.2±3.2)明显低于对照组(16.9±2.5),差异有统计学意义(P＜0.05).(7)脐血总胆汁酸水平与羊水PC、PI的含量均呈负相关(r1=-0.561,r2=-0.407,P＜0.05);与LPC含量无相关性(r3=0.260,P＞0.05).结论 ICP孕妇的胎儿脐血及羊水中总胆汁酸水平均明显高于健康孕妇,其胎儿PS的改变与胎儿体内高总胆汁酸水平有关.

Abstract：

Objective To explore the relationship between total bile acid(TBA)concentration and fetal pulmonary surfactant in intrahepatic cholestasis of pregnancy(ICP).Methods Fifry five patients with ICP(ICP group)who received cesarean section from April 2008 to February 2010 in Second Xiangya Hospital,Central South University,were recruited.The general conditions of the neonates within 7 days after birth in ICP group were recorded.Those with fetal distress,neonatal asphyxia,or neonatal respiratory distress syndrome were referred as pathological neonates, others were referred as normal neonates. Over the same period, 23 healthy gravidas were recruited as control group. Enzymatic method was used to detect the TBA concentrations in maternal blood, cord blood and amniotic fluid. ELISA was employed to measure the urfactant protein A (SP-A) concentration in cord blood. High performance liquid chromatography system was used to detect the concentrations of phesphatidylcholine (PC),phosphatidylinositol (PI),lysophosphatidylcholine ( LPC), and sphingomyelin(SM) in amniotic fluid. Results ( 1 ) The concentrations of TBA in maternal blood, cord blood and amniotic fluid were ( 30. 1 ± 7.9 ), (9. 3± 3. 3 ) and (4. 4 ± 1.5 ) mmol/L in ICP group, (4. 8 ± 2. 2), (4. 9 ± 0. 9) and ( 1.4 v 1.1 ) mmol/L in control group, respectively. The differences between the two groups were significant ( P ＜ 0. 05 ). ( 2 ) The SP-A concentration in cord blood in ICP group was ( 29. 5 ± 6. 4 ) μg/L, significantly higher than that in control group, which was ( 22. 6 ± 7. 4 )μg/L ( P＜ 0. 05 ). ( 3 ) There were 20 pathological neonates and 35 normal neonates in ICP group. In pathological neonates, the concentrations of TBA and SP-A in cord blood were (10.9 ± 2.2) mmol/L,(37.0 ± 5.9 ) μg/L, respectively; and were ( 8.0 ± 2. 8 ) mmol/L, ( 26. 7 ± 4. 8 ) μg/L in normal neonates. The differences were significant (P＜ 0. 05 ). (4) There was a positive correlation between TBA concentration in cord blood and in maternal blood ( r1 = 0. 706, P＜0. 05 ). The TBA concentration in cord blood was positively correlated with SP-A concentration as well ( r3 = 0. 494,P ＜ 0. 05 ). (5) The PC and PI concentrations in amniotic fluid were (65.4 ± 7.2) mg/L and ( 3. 8 ± 0. 6 ) mg/L in ICP group, ( 69. 7 ±3.7) mg/L and (4. 3 ± 0. 7 ) mg/L in control group, respectively. The differences were significant (P ＜0. 05 ). The concentration of LPC in amniotic fluid in ICP group was (4. 8 ±0. 9) mg/L, significantly higher than that in control group (P＜0. 05), which was (4. 2 ±0. 6) mg/L. The concentration of SM in amniotic fluid was (3.5±0. 8) mg/L in ICP group, (4. 0 ± 0. 5 ) mg/L in control group, with no significant difference ( P＞0. 05 ). (6) The ratio of PC/LPC in ICP group ( 14. 2± 3. 2 ) was significantly lower than that in control group ( 16. 9 ± 2. 5 ) ( P＜ 0. 05 ). ( 7 ) The TBA concentration in cord blood was negatively correlated with PC and PI concentrations (r1 = -0. 561, r2 = -0. 407, P ＜ 0. 05 ), and had no correlation with LPC concentration (r3 = 0. 260, P＞ 0. 05). Conclusions ( 1 ) The fetal TBA concentrations in both cord blood and amniotic fluid of patients with ICP was higher than those of healthy gravidas, they were also positively correlated with maternal TBA concentration. (2) ICP resulted in the change of fetal pulmonary surfactant and this change was associated with TBA concentrations in both cord blood and amniotic fluid.     

三维超声自动体积测量技术在多囊卵巢综合征诊断中的应用价值

Objective To investigate clinical significance of counting follicles classification by three-dimensional imaging with sonography based automated volume calculation(SonoAVC)in the diagnosis of polycystic ovary syndrome(PCOS).Methods Eighty cases with PCOS were counted classified follicles and determined ovarian volume by three-dimensional(3D)imaging with SonoAVC method matched with 60 infertile women with fallopian tube or male factors as control.Main clinical.biological and other ultrasonographic markers were assessed during the early follicular phase,and the relationship between the follicle number range per ovary or the volume per ovary and the major hormonal features of PCOS was studied.Results Three-dimensional ultrasound imaging with SonoAVC methed provides a new path for objective quantitative assessment of follicle count.ovarian volume,total follicle numbers.The volume of (11 ±8)ml,total numbers of 27 ±14 follicle and number of22 ±19 follicle with diameter of≥2-＜6 mm in PCOS patients were significantly higher than(6 ±4)ml in ovarian volume.6 ±4 in total follicles and 2 ±3 in follicle with diameter of≥2-＜6 mm in controls(P＜0.05).while follicles were similar for the≥6-≤9mm range(P＞0.05).Total follicle numbers and follicles≥2-＜6 mm had significantly positive relationships with ovarian volume ( r= 0. 600, 0. 618, P＜0. 01 ) and level of testosterones ( r= 0. 364,0. 291, P＜0.05), follicles ≥2-＜6 mm also had significantly positive relationships with total follicle number (r=0. 916,P＜0. 01 ). The follicles within the ≥6 - ≤9 mm range was significantly and negatively related to ovarian volume and total follicle numbers ( r = - 0. 618, - 0. 263, all P = 0. 001 ), but no significantly related to the major hormonal features of PCOS. The ovarian volume was significantly positively related with luteinizing hormone ( LH)/follicle stimulating hormone (FSH) ratio ( r= 0. 282, P = 0. 010)but negatively related to FSH level (r = - 0. 226, P = 0. 042). Conclusions Ovarian volume, total follicle numbers and follicles ≥2 - ＜6 mm in PCOS patients were significantly higher than those in controls. The larger ovarian volume might produce more total follicle and follicles ≥ 2 - ＜6 mm. The higher level of testosterone might produce more total follicle probably, which mainly result in more follicles ≥2 -＜6 mm.These morphologically ultrasonographic characteristics could reflect pathophysiological changes in PCOS. Obviously, it has important clinical significance to count follicles in patients with PCOS by the threedimensional ultrasound imaging with SonoAVC method.     

三维超声自动体积测量技术在多囊卵巢综合征诊断中的应用价值

Objective To investigate clinical significance of counting follicles classification by three-dimensional imaging with sonography based automated volume calculation(SonoAVC)in the diagnosis of polycystic ovary syndrome(PCOS).Methods Eighty cases with PCOS were counted classified follicles and determined ovarian volume by three-dimensional(3D)imaging with SonoAVC method matched with 60 infertile women with fallopian tube or male factors as control.Main clinical.biological and other ultrasonographic markers were assessed during the early follicular phase,and the relationship between the follicle number range per ovary or the volume per ovary and the major hormonal features of PCOS was studied.Results Three-dimensional ultrasound imaging with SonoAVC methed provides a new path for objective quantitative assessment of follicle count.ovarian volume,total follicle numbers.The volume of (11 ±8)ml,total numbers of 27 ±14 follicle and number of22 ±19 follicle with diameter of≥2-＜6 mm in PCOS patients were significantly higher than(6 ±4)ml in ovarian volume.6 ±4 in total follicles and 2 ±3 in follicle with diameter of≥2-＜6 mm in controls(P＜0.05).while follicles were similar for the≥6-≤9mm range(P＞0.05).Total follicle numbers and follicles≥2-＜6 mm had significantly positive relationships with ovarian volume ( r= 0. 600, 0. 618, P＜0. 01 ) and level of testosterones ( r= 0. 364,0. 291, P＜0.05), follicles ≥2-＜6 mm also had significantly positive relationships with total follicle number (r=0. 916,P＜0. 01 ). The follicles within the ≥6 - ≤9 mm range was significantly and negatively related to ovarian volume and total follicle numbers ( r = - 0. 618, - 0. 263, all P = 0. 001 ), but no significantly related to the major hormonal features of PCOS. The ovarian volume was significantly positively related with luteinizing hormone ( LH)/follicle stimulating hormone (FSH) ratio ( r= 0. 282, P = 0. 010)but negatively related to FSH level (r = - 0. 226, P = 0. 042). Conclusions Ovarian volume, total follicle numbers and follicles ≥2 - ＜6 mm in PCOS patients were significantly higher than those in controls. The larger ovarian volume might produce more total follicle and follicles ≥ 2 - ＜6 mm. The higher level of testosterone might produce more total follicle probably, which mainly result in more follicles ≥2 -＜6 mm.These morphologically ultrasonographic characteristics could reflect pathophysiological changes in PCOS. Obviously, it has important clinical significance to count follicles in patients with PCOS by the threedimensional ultrasound imaging with SonoAVC method.     

妊娠期糖尿病母鼠血清晚期糖基化终产物与子鼠心脏发育异常的关系

Objective To explore the effect of advanced glycation end product(AGE) in serum of maternal rats with gestational diabetes mellitus (GDM) on the heart development of their offsprings. Methods Fifty-four SD rats were randomly assigned into control group (n= 24) and GDM group (n=30) which were established by administration of streptozotocin intra-abdominally. On the gestational age of 13, 16, 19 days, all rats underwent hysterectomy to obtain the fetal heart tissues. Serum level of AGE and blood glucose level of maternal rats were tested. The expression of receptor AGE (RAGE) in fetal cardiac tissue were detected by immunohistoehemistry. Results The incidence of fetal heart defect in GDM group was significantly higher than the control group at each time point (P<0.01). Rats in GDM group had higher blood glucose level at each time point (P<0.01). The AGE levels of GDM group on gestational age of 13, 16 and 19 day [(5.72±0.68) U/mgpr, (7.31±0.29) U/mgpr and (7.77±0.39) U/mgpr] were significantly higher than those of the control group [(4.45±0.27) U/mgpr, (4.71±0. 35) U/mgpr and (4. 37±0. 44) U/rngpr] (t=6. 142, 16. 295, 0. 399,P<0. 01). The number of heart malformation in fetal rats (r=0.994,P=0. 000) and blood glucose (r=0. 717,P=0. 000) had the positive relationship with the maternal serum AGE level. The expression of RAGE in fetal heart was positively related with the number of fetal heart malformation (r= 0. 638,P= 0. 004). Conclusions The increased maternal serum AGE level in GDM rats may be an important factor in fetal heart dysplasia.     

Laparoscopic radiofrequency volumetric thermal ablation of fibroids versus laparoscopic myomectomy

Objective

To compare the mean hospital discharge times and perioperative outcomes for radiofrequency volumetric thermal ablation (RFVTA) of fibroids and laparoscopic myomectomy (LM).

Methods

The present postmarket, randomized, prospective, single-center, longitudinal, comparative study, conducted in Tübingen, Germany, evaluated the outcomes of RFVTA and the current standard of care (LM) for symptomatic uterine fibroids in women who desired uterine conservation. The surgeons were blinded to the treatment until all fibroids had been mapped by laparoscopic ultrasound.

Results

The mean hospitalization times were 10.0 ± 5.5 (median 7.8 [range 4.2–25.5]) hours for the RFVTA group and 29.9 ± 14.2 (median 22.6 [range 16.1–68.1]) hours for the LM group (P < 0.001, Wilcoxon test). Intraoperative blood loss was 16 ± 9 (median 20 [range: 0–30]) mL for the RFVTA procedures and 51 ± 57 (median 35 [range 10–300]) mL for the LM procedures. The percentage of fibroids imaged by laparoscopic ultrasound that were treated/excised was 98.6% for RFVTA and 80.3% for LM. Two complications were reported: vertigo (n = 1; RFVTA) and port site hematoma (n = 1; LM).

Conclusion

Radiofrequency volumetric thermal ablation resulted in the treatment of more fibroids, a significantly shorter hospital stay, and less intraoperative blood loss than laparoscopic myomectomy.ClinicalTrials.gov:NCT01750008     

超声消融治疗子宫肌瘤的安全性及有效性

目的 验证超声消融技术用于子宫肌瘤治疗的安全性、有效性.方法 采用前瞻性、非随机临床研究方法,对重庆医科大学附属第一医院和解放军第三○七医院就诊的99例子宫肌瘤患者(117个肌瘤,肌瘤直径≤10 cm)进行超声消融治疗.仪器为重庆海扶(HIFU)技术有限公司研制的JC型聚焦超声肿瘤治疗系统.治疗在镇静、镇痛下进行,实时超声声像图引导超声消融治疗全过程.治疗后随访期为6个月.治疗后1个月内,行增强磁共振成像(MRI)检查,评价靶肌瘤体积消融率.治疗后3、6个月时,行增强MRI检查,评价靶肌瘤体积缩小率及靶肌瘤体积缩小超过50%的肌瘤占所有肌瘤的百分比.根据子宫肌瘤症状量表(UFS)评价有症状患者的症状评分改善10分者所占比例.依照国际介入放射治疗学会(SIR)标准评价治疗相关的不良反应.结果 (1)有效性:治疗后1个月内,靶肌瘤体积消融率平均为(76±24)%;3、6个月时,靶肌瘤平均体积分别缩小了(45±21)%和(59±26)%,与治疗前比较,差异均有统计学意义(P<0.05).治疗后6个月时,靶肌瘤体积缩小≥50%共99个肌瘤,占84.6%(99/117);UFS症状评分改善10分者占92%(66/72).(2)安全性:全部患者治疗后2 h均可以正常活动.SIR标准中重要不良反应(SIR C～D级:延长住院时间,需要重要治疗,护理等级增加)及严重不良反应(SIR E～F级:永久性后遗症或死亡)的发生率均为0;一般不良反应(SIR A～B级:观察或简单治疗,无不良后果)的发生率为35%(35/99),SIR B级不良反应包括2例声通道皮肤浅Ⅱ度烧伤和2例发热,需要对症治疗及换药处理.其余包括臀部和(或)下肢酸胀痛、阴道分泌异常、排尿困难或疼痛等,均无需治疗,为SIR A级.结论 超声消融技术用于治疗子宫肌瘤是安全、有效的,可以单独用于子宫肌瘤的治疗.     

剖宫产术后子宫瘢痕部位妊娠96例临床分析

目的 探讨剖宫产术后子宫瘢痕部位妊娠(CSP)的临床表现、诊断依据、治疗方法和卫生经济学特点.方法 回顾性分析复旦大学附属妇产科医院2005年1月至2008年12月收治的96例CSP患者的临床资料,按不同治疗方法分为A组33例,行甲氨蝶呤(MTX)50 mg/m2静脉滴注,其中18例MTX静脉治疗后5～10 d内行清宫术(MTX+清宫);15例先行清宫术,术后每48小时复查1次血人绒毛膜促性腺激素β亚单位(β-hCG)水平,3次均下降不足30%者,再用MTX 50 mg/m2静脉滴注治疗(清宫+MTX).B组60例,行MTX双侧子宫动脉介入栓塞治疗,每侧子宫动脉注入MTX 100 mg,术后2 d内行清宫术.C组3例,行子宫病灶切除术.比较各组出血量(M)、病灶直径(-x±s)、治疗前血β-hCG水平(M)、病灶距子宫浆膜层≤3mm的例数、病灶血流阻力指数(RI)≤0.5的例数、治疗费用(-x±s)、住院时间(-x±s)的差异,并分析出血量与病灶直径和血β-hCG水平的相关性.结果 (1)临床指标:出血量:A组MTX+清宫者为20 ml、清宫+MTX者为10 ml,B组为12 ml,C组为200ml,C组与A、B组比较,差异有统计学意义(P＜0.01);病灶直径:A组MTX+清宫者为(16±8)mm、清宫+MTX者为(23±15)mm,B组为(30±14)mm,显著高于A组MTX+清宫者,差异有统计学意义(P＜0.01),C组为(52±7)mm,3组分别比较,差异均有统计学意义(P＜0.01);治疗前血β-hCG水平:A组MTX+清宫者为21 592 U/L、清宫+MTX者为979 U/L,两者比较,差异有统计学意义(P＜0.05),B组为11 312 U/L,C组为101 U/L,C组与A、B组比较,差异均有统计学意义(P＜0.05);病灶血流RI0.5共28例,其中A组8例(24%,8/33)、B组18例(30%,18/60),C组2例(2/3),C组高于其他两组,差异有统计学意义(P＜0.05);病灶距子宫浆膜层≤3 mm共23例:A组2例(6%,2/33),B组21例(35%,21/60),C组0例,B组高于其他两组,差异也有统计学意义(P＜0.05);治疗费用:A组MTX+清宫者为(5578±3679)元、清宫+MTX者为(5346±2765)元,两者比较,差异无统计学意义(P＞0.05),B组为(7860±2104)元,C组为(5004±421)元,B组高于A、C组,差异有统计学意义(P＜0.05);住院时间:A组MTX+清宫者为(15±8)d、清宫+MTX者为(19±14)d,B组为(16±10)d,C组为(17±8)d,各组比较,差异均无统计学意义(P＞0.05).(2)相关性:出血量与子宫病灶直径(r=0.31,P＜0.05)以及治疗前血β-hCG水平(r=0.35,P＜0.05)均呈正相关关系.结论 MTX静脉治疗、动脉介入栓塞治疗和子宫病灶切除术用于治疗CSP,如应用恰当都能取得良好效果;病灶大、血β-hCG水平高、病灶距浆膜层近或子宫病灶血液供应丰富时,可选择MTX子宫动脉介入栓塞+清宫术治疗,但费用较高.     

超低出生体重儿脑室周围-脑室内出血的危险因素

目的 探讨超低出生体重儿(extremely low birth weight infant,ELBWI)脑室周围-脑室内出血(periventricular-intraventricular hemorrhage,PIVH)的危险因素.方法 研究对象为2001年1月至2008年8月我院新生儿重症监护病房收治的资料完整的ELBWI 41例,其中PIVH23例,无PIVH者18例.采用单因素及Logistic回归分析ELBWI发生PIVH的围产期高危因素.结果 PIVH的发生率为56.1%(23/41).单因素分析显示,PIVH组胎龄小于无PIVH组[(27.1±l.9)周和(28.7±1.6)周](t=2.834,P＜0.05),入院时平均血压低于无PIVH组[(28.9±4.8)mm Hg和(33.1±4.9)mm Hg](t=-2.747,P＜0.05),生后1周内最低平均血压值低于无PIVH组[(24.4±4.3)mm Hg和(31.4±6.6)mm Hg](t=-3.863,P＜0.05),血压波动值和最高PaCO2高于无PIVH组[分别为(19.0±5.2)mm Hg和(13.7±4.8)mm Hg;(60.2±19.4)mm Hg和(49.5±12.1)mm Hg](t分别=3.310和2.166,P均＜0.05);应用肺表面活性物质(73.9%,17/23)、新生儿呼吸窘迫综合征(60.9%,14/23)、休克(52.2%,12/23)、生后4 d内低血压(73.9%,17/23)、1周内高血糖(78.3%,18/23)和机械通气治疗(87.0%,20/23)的比例均高于无PIVH组[分别为27.8%(5/18)、27.8%(5/18)、5.5%(1/18)、33.3%(6/18)、44.5%(8/18)和44.5%(8/18)],差异均有统计学意义(P均＜0.05).Logistic回归分析显示,血压波动值(OR=1.260,95%CI:1.009～1.572,P=0.041)和最低平均血压(OR=0.805,95%CI:0.672～0.965,P=0.019)是PIVH发生的独立危险因素.对接受机械通气治疗的28例ELBWI发生PIVH的危险因素进行Logistic回归分析,结果发现最高吸气峰压(OR=2.086,95%CI:1.140～3.819,P=0.017)是PIVH的独立危险因素.结论 低血压和血压波动是ELBWI发生PIVH的危险因素.对于机械通气的ELBWI,最高吸气峰压过高,可能增加PIVH的发生风险.

Abstract：

Objective To study the risk factors of periventricular-intraventricular hemorrhage (PIVH) in extremely low birth weight infants(ELBWI). Methods A retrospective study was performed in 41 ELBWI hospitalized between January 2001 and August 2008. Univariate analysis and Logistic regression analysis were performed to detect the risk factors of PIVH. Results Of 41ELBWI, twenty-three suffered from PIVH with the incidence of 56.1%. Univariate analysis revealed that,in PIVH group,gestational age,mean blood pressure and the minimum values of blood pressure were lower than non-PIVH group[ ( 27.1 ± 1.9 ) weeks vs ( 28. 7 ± 1.6) weeks, t = 2. 834, P ＜ 0. 05 ;(28.9±4.8) mm Hg vs (33.1±4.9) mm Hg, t=-2.747,P＜0. 05; (24.4±4.3) mm Hg vs (31.4 ± 6.6) mm Hg,t= -3. 863, P＜0. 05], while blood pressure fluctuation and the highest values of PaCO2 during the first week of life were higher[(19.0 ± 5.2) mm Hg vs (13.7 ± 4. 8) mm Hg;(60. 2± 19. 4) mm Hg vs (49.5±12.1) mm Hg] (t= 3. 310 and 2. 166, P＜0. 05), the incidence of administration of pulmonary surfactant, neonatal respiratory distress syndrome, shock, hypotension before 4 days of age, hyperglycemia and mechanical ventilation therapy were higher[73. 9 % (17/23) vs 27. 8%(5/18), 60. 9%(14/23) vs 27.8%(5/18),52. 2%(12/23) vs 5.5%(1/18),73. 9%(17/23) vs 33.3%(6/18) ,78. 3%(18/23) vs 44. 5%(8/18),87. 0% (20/23) vs 44. 5% (8/18)]( all P＜0.05).Multivariate Logistic analysis revealed that blood pressure fluctuation (OR = 1. 260, 95% CI: 1. 009-1. 572, P = 0. 041 ) and lowest mean blood pressure(OR = 0. 805,95 % CI: 0. 672-0. 965, P = 0. 019)were risk factors of PIVH. Among twenty-eight ELBWI received mechanical ventilation, only peakinspiratory pressure(OR=- 2. 086,95% CI: 1. 140-3. 819, P= 0. 017) was the risk factor of PIVH by Logistic analysis. Conclusions Low blood pressure and blood pressure fluctuation may be risk factors of PIVH in ELBWI. The high values of peak inspiratory pressure is a risk factor of ELBWI with mechanical ventilation.     

三维超声自动体积测量技术在多囊卵巢综合征诊断中的应用价值

目的 探讨经阴道或直肠三维超声自动体积测量(SonoAVC)技术在多囊卵巢综合征(PCOS)诊断中的价值.方法 使用SonoAVC技术分级计数80例PCOS患者(PCOS组)卵巢内的卵泡数,并测量卵巢体积,以60例输卵管或男性因素的不孕症患者为对照组;测定观察对象早卵泡期的血生殖激素水平,并分析PCOS患者卵泡数、卵巢体积和血生殖激素水平之间的关系.结果 PCOS 组患者的卵巢体积[(11 ±8)ml]、总卵泡数[(27±14)个]及直径≥2～＜6 mm卵泡数[(22±19)个]显著高于对照组[分别为(6 ±4)ml、(6 ±4)个及(2±3)个],分别比较,差异均有统计学意义(P＜0.05);直径≥6～≤9 mm卵泡数与对照组类似,两组比较,差异无统计学意义(P＞0.05).总卵泡数及直径≥2～＜6 mm卵泡数与卵巢体积呈正相关(相关系数分别为0.600、0.618,P＜0.01),直径≥2～＜6 mm卵泡数与总卵泡数也呈正相关(相关系数为0.916,P＜0.01);直径≥6～≤9 mm卵泡数与卵巢体积及总卵泡数呈负相关(相关系数分别为-0.618、-0.263,P均=0.001);总卵泡数及直径≥2～＜6 mm卵泡数与血睾酮水平呈正相关(相关系数分别为0.364、0.291,P=0.001、P＜0.05);卵巢体积与卵泡刺激素(FSH)水平呈负相关(相关系数为-0.226,P=0.042),与黄体生成素(LH)/FSH比值呈正相关(相关系数为0.282,P=0.010).结论 PCOS患者的卵巢体积、总卵泡数、直径≥2～＜6 mm卵泡数显著高于对照人群.卵巢体积越大,总卵泡数及直径≥2～＜6 mm卵泡数增多的可能性越大;血睾酮水平越高,总卵泡数增多的可能性越大,主要以直径≥2～＜6 mm小卵泡绝对增加为主.这些超声特征在一定程度上反映了PCOS患者卵巢的病理生理变化及相应的临床生化改变.SonoAVC卵泡计数法为PCOS患者提供了一种新的客观的卵泡计数方法,使用SonoAVC技术分级计数卵泡数对PCOS的诊断具有重要的临床意义.

Abstract：

Objective To investigate clinical significance of counting follicles classification by three-dimensional imaging with sonography based automated volume calculation(SonoAVC)in the diagnosis of polycystic ovary syndrome(PCOS).Methods Eighty cases with PCOS were counted classified follicles and determined ovarian volume by three-dimensional(3D)imaging with SonoAVC method matched with 60 infertile women with fallopian tube or male factors as control.Main clinical.biological and other ultrasonographic markers were assessed during the early follicular phase,and the relationship between the follicle number range per ovary or the volume per ovary and the major hormonal features of PCOS was studied.Results Three-dimensional ultrasound imaging with SonoAVC methed provides a new path for objective quantitative assessment of follicle count.ovarian volume,total follicle numbers.The volume of (11 ±8)ml,total numbers of 27 ±14 follicle and number of22 ±19 follicle with diameter of≥2-＜6 mm in PCOS patients were significantly higher than(6 ±4)ml in ovarian volume.6 ±4 in total follicles and 2 ±3 in follicle with diameter of≥2-＜6 mm in controls(P＜0.05).while follicles were similar for the≥6-≤9mm range(P＞0.05).Total follicle numbers and follicles≥2-＜6 mm had significantly positive relationships with ovarian volume ( r= 0. 600, 0. 618, P＜0. 01 ) and level of testosterones ( r= 0. 364,0. 291, P＜0.05), follicles ≥2-＜6 mm also had significantly positive relationships with total follicle number (r=0. 916,P＜0. 01 ). The follicles within the ≥6 - ≤9 mm range was significantly and negatively related to ovarian volume and total follicle numbers ( r = - 0. 618, - 0. 263, all P = 0. 001 ), but no significantly related to the major hormonal features of PCOS. The ovarian volume was significantly positively related with luteinizing hormone ( LH)/follicle stimulating hormone (FSH) ratio ( r= 0. 282, P = 0. 010)but negatively related to FSH level (r = - 0. 226, P = 0. 042). Conclusions Ovarian volume, total follicle numbers and follicles ≥2 - ＜6 mm in PCOS patients were significantly higher than those in controls. The larger ovarian volume might produce more total follicle and follicles ≥ 2 - ＜6 mm. The higher level of testosterone might produce more total follicle probably, which mainly result in more follicles ≥2 -＜6 mm.These morphologically ultrasonographic characteristics could reflect pathophysiological changes in PCOS. Obviously, it has important clinical significance to count follicles in patients with PCOS by the threedimensional ultrasound imaging with SonoAVC method.     

High-intensity focused ultrasound for the targeted destruction of uterine tissues: experiences from a pilot study using a mobile HIFU unit

Background High intensity focused ultrasound (HIFU) is a novel method which offers the non-invasive ablation of tissues without harming overlying organs or skin. It has been introduced successfully in urology for the ablation of prostatic hyperplasia and seems to be promising in the treatment of uterine fibroids. In this study we aimed to examine the feasibility and possible side effects of HIFU treatment of uterine tissues using an experimental mobile HIFU unit with ultrasound guidance. Methods For these experiments, a 1.07 MHz ultrasound source was used which allows treatment depths between 0 and 10 cm. In 12 patients scheduled to have abdominal hysterectomy, 5–60 impulses of HIFU were applied through the intact skin upon uterine tissues directly prior to the surgical procedure. Tissue intensities lay between 3,200 and 6,300 W/cm2 and a fixed pulse length of 4 s was used. Results No side effects were encountered other than one first-degree skin burn and the treatment was well tolerated. Histology showed clearly demarcated coagulative necrosis in the targeted tissues. Treatment was concluded in less than 45 min for each patient. Conclusion Focused ultrasound is an effective method to selectively destroy tissue within the uterus and the transabdominal access route is very feasible. This study shows that a mobile ultrasound source can be used safely and effectively to destroy uterine tissues, such as fibroids, without major side effects.     

Decreasing margins to the uterine serosa as a method for increasing the volume of fibroids ablated with magnetic resonance-guided focused ultrasound surgery

Objective

To demonstrate the safety of magnetic resonance-guided focused ultrasound surgery (MRgFUS) treatments regardless of the distance between the treatment region and the uterine serosa.

Study design

83 pre-menopausal women with symptomatic uterine fibroids were treated with MRgFUS in 88 treatments. Treatment data was analyzed, measuring the distance between the treatment spots (sonications) and the serosa. Patients were followed up for 1 year and adverse events were collected.

Results

79% and 37% of the sonications were less than 15 mm and 10 mm from the serosa, respectively. Treatment was always confined to the fibroid capsule. There were no unexpected or serious adverse events.

Conclusion

Reducing the margin between the fibroid treatment area and the uterine serosa, when possible, enables MRgFUS treatment of greater fibroid volume, while maintaining a high safety profile. Special attention should be paid when the uterus lies adjacent to other sensitive organs to avoid unintentional heating of these organs, using the planning and real-time MR images.     

Feasibility of endometrial assessment after thermal ablation

Objective

To evaluate the feasibility of endometrial assessment after endometrial thermal ablation.

Study design

Prospective observational study. A total of 57 women (age 47–52 years), who had undergone endometrial thermal ablation as a treatment for heavy menstrual bleeding (HMB) 3–10 years (mean 6 years) earlier, were examined with transvaginal ultrasound and saline sonohysterography. Endometrial samples were collected with a Pipelle device. Visualisation of endometrium, access to uterine cavity, change in cavity length, success in outpatient endometrial sampling and success in sonohysterography were evaluated.

Results

Endometrial thickness was 4.5 mm in amenorrhoeic women (n = 17), 5.6 mm in eumenorrhoeic women (n = 37) and 6.6 mm in hypermenorrhoeic women (n = 3). An endometrial sample was successfully taken in 44 (77%) women, and in 13 (23%) women endometrial sample taking failed. The length of the uterine cavity compared to the length measured before endometrial thermal ablation was 0.5–5 cm (mean 2 cm) shorter in 34 women, unchanged in four women and longer in five women. The uterine cavity distended regularly in only nine (16%) women. In 14 (25%) women the cavity distended irregularly or only partly, and in 24 (42%) women the uterine cavity did not distend at all, but appeared as a narrow tube. In 10 (18%) women the sonohysterography catheter did not enter the uterine cavity at all.

Conclusion

Endometrial assessment is compromised after previous endometrial thermal ablation. Both endometrial sampling and sonohysterography fail quite often, causing problems in diagnosis of abnormal bleeding. Intrauterine adhesions may also decrease the reliability of the endometrial sampling.