两种不同剂理米非司酮治疗子宫肌瘤的疗效观察

目的：观察两种不同剂量米非司酮治疗子宫肌瘤的效果。方法：将４３例有症状的子宫肌瘤患者非随机分为两组进行前瞻怀研究。甲组２８例，每天服用米非司酮１０ｍｇ；乙组１５例，每天服用米非司酮２０ｍｇ。从月经第１－３天开始服用，连续服用３个月。于治疗前以治疗期间的每个月行Ｂ超测量子宫和子宫肌瘤的体积；检查血红蛋白及肝、肾功能。结果：两组患者在治疗期间均闭经，痛经和下腹坠、胀痛症状消失。所有患者的贫血均得以纠正     

观察不同剂量米非司酮治疗子宫肌瘤的疗效

目的分析不同剂量米非司酮治疗子宫肌瘤的效果。方法选择116例患者,作为本次研究的对象,按照随机划分原则,分为对照组和研究组,各58例。对照组采用常规剂量治疗方案;研究组采取小剂量治疗方案。通过对比两组患者治疗后的瘤体体积和子宫体积以及不良反应率,获得研究结果。结果采取小剂量治疗方案的患者,即研究组,经过治疗后瘤体体积和子宫体积变化、不良反应发生情况,显著优于对照组,P<0.05。结论对患有子宫肌瘤的患者,使用米非司酮进行治疗,采用小剂量治疗方案,可提高患者的血清激素以及血红蛋白水平,并不良反应发生率比较低,具有推广应用价值。     

促性腺激素释放激素激动剂与米非司酮治疗子宫肌瘤的临床对照研究

目的比较促性腺激素释放激素激动剂（ＧｎＲＨ－ａ）与米非司酮治疗子宫肌瘤的临床疗效及副作用。方法将７５例根据临床症状、妇科检查及Ｂ超诊断为子宫肌瘤患者,随机分为两组,ＧｎＲＨ－ａ组３０例,每天用ＧｎＲＨ－ａ１５０μｇ肌内注射或皮下注射３个月;米非司酮组４５例,用米非司酮每天１２．５ｍｇ口服３个月,比较两组治疗的疗效与副反应。结果两组患者临床症状均有明显改善。肌瘤体积,ＧｎＲＨ－ａ组缩小２０．０％以上者有２７例,占９０．０％;米非司酮组肌瘤缩小２０．０％以上者有４１例,占９１．１％。复发率,ＧｎＲＨ－ａ组为４０．０％,米非司酮组为１７．８％。结论米非司酮较ＧｎＲＨ－ａ对子宫肌瘤有更好的治疗效果     

米非司酮对子宫肌瘤间隙连接蛋白43表达的影响

目的 :研究间隙连接蛋白 4 3(Cx4 3)在子宫肌瘤中的表达及米非司酮作用后Cx4 3蛋白表达的改变 ,探讨子宫肌瘤的生长及治疗的相关机制。方法 :用免疫组化法检测 30例子宫肌瘤组织 ,2 0例术前 3d给予米非司酮的子宫肌瘤及 2 0例正常子宫肌组织中Cx4 3蛋白的表达。结果 :子宫肌瘤Cx4 3蛋白表达高于正常子宫肌组织 (P <0 .0 5 )。子宫肌瘤Cx4 3蛋白表达增生期高于分泌期 (P <0 .0 5 )。米非司酮作用后Cx4 3蛋白表达在增生期无明显改变 (P >0 .0 5 ) ,分泌期明显增高 (P <0 .0 5 )。结论 :子宫肌瘤中Cx4 3蛋白表达水平与月经周期相关 ,米非司酮对Cx4 3蛋白表达的上调可能是其治疗子宫肌瘤的机制之一。     

米非司酮对子宫肌瘤组织中表皮生长因子基因表达的影响

目的探讨米非司酮对子宫肌瘤组织中表皮生长因子（ＥＧＦ）基因表达的影响。方法２０例子宫肌瘤患者随机被分为对照组和观察组,观察组从月经周期第１～３天开始,每日服用１０ｍｇ米非司酮,连续服用３个月后行子宫全切术。对照组在不同月经周期行子宫全切术。用半定量反转录聚合酶链反应法测定子宫肌瘤组织和周围正常肌层组织中ＥＧＦｍＲＮＡ含量。结果对照组分泌期肌瘤组织中ＥＧＦｍＲＮＡ含量高于周围正常组织,而增生期肌瘤组织中ＥＧＦｍＲＮＡ含量与周围正常组织比较,差异无显著性。观察组子宫肌瘤组织ＥＧＦｍＲＮＡ含量低于对照组分泌期,而与对照组增生期比较,差异无显著性。结论米非司酮可能是通过阻断孕激素刺激肌瘤组织中ＥＧＦ基因的表达,使肌瘤细胞生长受到抑制。     

米非司酮对子宫肌瘤组织中孕激素受体基因表达的影响

目的研究子宫肌瘤组织中孕激素受体（ＰＲ）基因的表达情况,从ＰＲ基因的转录及翻译水平探讨米非司酮治疗子宫肌瘤的作用机理。方法采用Ｎｏｒｔｈｅｒｎ印迹法和羟基磷灰石（ＨＡＰ）单点饱和分析法,分别测定２７例单纯手术治疗（单纯手术组）及６例术前口服米非司酮每天２５ｍｇ共３个月（米非司酮组）的子宫肌瘤患者的肌瘤瘤心、瘤边缘及子宫体正常肌组织中ＰＲｍＲＮＡ和ＰＲ蛋白。结果单纯手术组瘤心和瘤边缘中ＰＲｍＲＮＡ及ＰＲ蛋白水平在卵泡期和黄体期均显著高于子宫体肌组织（Ｐ＜０．０１）,呈持续高表达,而瘤心和瘤边缘间差异无显著性（Ｐ＞０．０５）;米非司酮组４例术前未停药者,肌瘤及子宫体肌组织中ＰＲｍＲＮＡ和ＰＲ蛋白水平均明显降低,２例术前停药１月者,上述组织中ＰＲｍＲＮＡ与单纯手术者相似,但ＰＲ蛋白仍处于低水平。结论子宫肌瘤中ＰＲ基因呈持续高表达。米非司酮能抑制ＰＲ基因的表达,在ｍＲＮＡ水平上的影响是可逆的,在蛋白水平上的影响持续时间较长。     

盆腔子宫内膜异位症术后应用不同剂量米非司酮治疗的疗效观察

目的 探讨服用不同利量米非司酮治疗盆腔子宫内膜异位症术后患者的临床疗效，并观察其对内分泌功能的影响、方法 2003-01—2005-09上海市长宁区妇幼保健院选择进行保守性手术后盆腔子宫内膜异位症患者100例，随机分为3组：观察1组40例，服用米非司酮6．25mg／d；观察2组40例，服用米非司酮12．5mg/d，两组均于手术后第一次月经来潮5d内开始用药，疗程6个月：对照组20例患者，不用药物巩固治疗，定期随访。比较应用不同剂量米非司酮治疗子宫内膜异位症的疗效、副反应情况及对内分泌功能的影响。结果 3组病人痛经症状均得到不同程度缓解，观察1组和观察2组完全缓解率分别为85．0％和87．5％，明显高于对照组的55．0％，差异有统计学意义（P〈0．05）；观察1组和观察2组累积复发率分别为7．5％和5．0％，显著低于对照组的20．0％（P〈0．05）。观察1组和观察2组骨质密度均无明显变化．观察1组恶心症状发生率（32．5％）明显低于观察2组（62．5％）。观察1组血清性激素水平均无明显变化，但观察2组服用米非司酮后血清孕酮水平明显降低（P〈0．05）.结论 米非司酮用于盆腔子宫内膜异位症手术后巩固治疗．安全、有效，而且副反应小，对内分泌功能影响小.     

米非司酮与子宫平滑肌瘤

米非司酮具有孕激素受体（PR）和糖皮质激素受体拮抗剂的作用。近年来米非司酮抗肿瘤作用受到重视，研究表明其在子宫平滑肌瘤治疗中是很有前途的药物之一。现就米非司酮治疗子宫平滑肌瘤的临床应用及其机理加以综述。     

经导管子宫动脉栓塞术治疗子宫肌瘤的临床观察

目的 探讨经导管子宫动脉栓塞（TUAE）治疗子宫肌瘤的疗效及安全性。方法 对38例子宫肌瘤患者经导管子宫动脉注射碘油－平阳霉素乳剂行TUAE治疗,其中5例于栓塞后1－3周行全子宫切除或肌瘤剔除术,标本送病理检查;对33例随访6－12个月者,观察肌瘤与子宫体积变化及卵巢内分泌功能改变。结果 行TUAE后,患者总的症状改善率为90．6％（29／32）,其中月经完全恢复正常为90．3％（28／31）,下腹部、腰腿胀痛消失为83．3％（25／30）,尿频、尿急等压迫症状消失为45．5％（5／11）。栓塞6个月后,肌瘤与子宫体积平均缩小为59．1％和49．3％,栓塞12个月后平均缩小为61．8％和49．9％。卵巢内分泌功能栓塞前后无显著变化。手术标本病理学检查,碘油仅分布于肌瘤组织,栓塞2周后肌瘤组织出现点状坏死,3周后出现大量片状坏死,而正常子宫肌组织未见异常。结论 行TAUE治疗子宫肌瘤,近期疗效明显,对卵巢内分泌功能及正常子宫肌组织无明显影响。     

米非司酮对子宫肌瘤血管生成的影响

目的探讨米非司酮对子宫肌瘤组织中血管生成的影响。方法 采用免疫组化方法对米非司酮治疗组的子宫肌瘤组织及子宫内膜处于增殖期或分泌期的、未治疗的子宫肌瘤组织及其周围的正常肌层组织中Ⅷ因子相关抗原(vWF)进行检测,以观察子宫肌瘤与其周围正常肌层间及米非司酮治疗后肌瘤组织的微血管密度(MVD)的变化。结果子宫肌瘤组织中的MVD较其周围的正常肌层低(P<0.05),肌瘤与肌层的MVD随月经周期改变而变化,增殖期高于分泌期(P<0.05)。米非司酮治疗有效与无效患者间的MVD差异无显著性(P>0.05),但治疗有效患者较对照组有明显降低(P<0.05)。结论米非司酮对子宫肌瘤治疗有效者可减少血管生成。     

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

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

Laparoscopic Morcellator-Related Complications

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

宫腔镜下清宫术治疗剖宫产瘢痕妊娠前不同预处理方式的疗效分析

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

Fístula cutáneo-uterina poscesárea

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

The gynecologist and the melanoma: breast and endometrial metastases

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

Anticoagulación en gestantes portadoras de prótesis mecánicas

Objective

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

Subjects and methods

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

Results

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

Conclusions

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