应用彩色多普勒四维超声诊断胎儿先天性心脏病

近几年发展起来的时间-空间相关成像技术(STIC)能静态或动态地显示胎儿心脏的容积图像,彩色多普勒血流显像与STIC相结合的四维重建可获取二维超声心动图所无法获得的胎儿心脏解剖及病理特点的某些信息,并且图像直观,有助于判断心内血流及心血管系统的空间位置关系~([1]).     

时空关联成像-超声断层成像技术与二维超声进行产前胎儿心脏筛查的质量及效率比较

目的 探讨如何提高产前胎儿心脏超声筛查的效率.方法 以心尖四腔心为起始切面,使用时空关联成像(spatio-temporal image correlation,STIC)技术采集83例正常胎儿心脏的容积数据,利用超声断层成像(tomographic ultrasound imaging,TUI)技术进行脱机分析,获取胎儿心脏筛查所需要的9个切面,并与二维(two-dimensional,2D)超声检查的图像进行质量及分析效率的比较.结果 83例均获取满意的图像.(1)TUI对大动脉短轴的合格率显著高于2D(94.0％与84.3％,x2 =5.57,P=0.042),对其他8个切面,TUI合格率高于2D,差异无统计学意义.(2)TUI对于四腔心、五腔心、左室流出道、右室流出道和大动脉短轴切面的显示和2D达到了极好的一致性(Kappa分别为0.79、0.90、0.92、0.93和0.77);对于主动脉弓、动脉导管弓腔静脉长轴和心室短轴切面的显示和2D的一致性较好(Kappa分别为0.72、0.67、0.74和0.70).(3)STIC采集时间短于2D检查时间[(0.85±0.18) min与(5.80±1.58) min,t=3.500,P=0.000],STIC采集+TUI分析时间亦短于2D检查时间[(3.29±1.13) min与(5.80±1.58)min,t=2.877,P=0.001].结论 STIC联合TUI能方便、快捷、清晰地显示胎儿心脏筛查的9个切面,有助于提高胎儿心脏超声筛查工作的质量及效率.     

脉冲组织多普勒成像技术评价胎儿心脏功能

胎儿超声心动图检查是一种无创性的检查,可在正常或异常妊娠时对胎儿血液动力学变化及胎儿心血管病理生理学变化进行研究.但早期评价胎儿心脏功能成为临床重要问题.组织多普勒成像技术已作为无创性评价心室功能的方法用于成人,该技术用于胎儿超声心动图检查中,为评价胎儿心脏功能提供了新途径.该技术评价胎儿心肌运动简便、可行,有广阔的应用前景.可提供实时动态心室各部位和各层次的运动信息,有助于揭示局部心肌运动与心室壁心肌结构间的动态和立体关系.与实时三维、四维成像技术一起成为评价胎儿心脏形态和功能的超声新技术.     

脉冲组织多普勒成像技术评价胎儿心脏功能

胎儿超声心动图检查是一种无创性的检查,可在正常或异常妊娠时对胎儿血液动力学变化及胎儿心血管病理生理学变化进行研究。但早期评价胎儿心脏功能成为临床重要问题。组织多普勒成像技术已作为无创性评价心室功能的方法用于成人,该技术用于胎儿超声心动图检查中,为评价胎儿心脏功能提供了新途径。该技术评价胎儿心肌运动简便、可行,有广阔的应用前景。可提供实时动态心室各部位和各层次的运动信息,有助于揭示局部心肌运动与心室壁心肌结构间的动态和立体关系。与实时三维、四维成像技术一起成为评价胎儿心脏形态和功能的超声新技术。     

三维及四维超声在胎儿医学中的应用

早在二十多年前三维超声就已问世,但发展较快、产科临床应用较多的时期还是在最近5 ～ 10年,这与三维超声仪器的重大改进密切相关.目前,我国很多医院均拥有了三维和(或)四维(以下简称三维)超声仪,三维超声技术用于产前检查也已经非常普遍.因此,结合本人多年经验,认为有必要进行探讨,究竟三维超声与二维超声有何不同,三维超声比二维超声好多少,到底能对产前诊断起到些什么作用. 无可否认,三维的成像与二维有很大的不同.三维图像是由多幅二维图像通过计算机重建而成,而四维图像则是三维图像的动态形式.三维不仅可能获得某些二维难以获得的平面,还可进行胎儿体表成像和体积测量、多平面断层扫查、薄层三维、动态Z平面、四维超声、心脏STIC技术、血管立体结构图、血管分布百分比等.     

产科领域内核磁共振成像技术的应用

磁共振成像(MRI)技术是近年发展起来的重要检查技术,通过检索国外相关文献,总结MRI技术于产科的应用,包括原理、安全性、优缺点、相关技术改进、注意事项、应用指征及MRI的三维成像技术和体积计算技术.MRI技术不涉及放射线的问题,妊娠期间应用对妊娠妇女和胎儿均安全.诊断胎儿畸形MRI较B超技术有更多优点,由于设备复杂,价格昂贵,尚难普及,仅作为B超技术的辅助技术,同时MRI技术还有许多问题需要进一步解决.     

背景抑制磁共振弥散成像技术对宫颈癌的诊断价值(附160例分析)

目的 探讨背景抑制弥散成像(diffusion weighted imaging with background suppression,DWIBS)技术在宫颈癌及转移淋巴结成像的应用.方法 对2007年1月至2008年7月哈尔滨医科大学附属肿瘤医院160例宫颈癌患者术前行常规MRI及DWIBS检查,分别测量肿瘤实质、转移淋巴结及正常宫颈实质的表观弥散系数值(ADC值).行3D最大密度投影(MIP)重组及黑白翻转技术观察瘤体与淋巴结的信号特点,以术后病理诊断为金标准,采用病例自身对照法将临床及影像学进行对比,评价DWIBS在宫颈癌及其转移淋巴结的表现作用.结果 DWIBS瘤灶显示率96.88%.淋巴结显示率90.90%.瘤灶与肿大淋巴结呈高信号,反转图呈低信号.结论 DWIBS可以通过ADC值对宫颈癌及转移淋巴结量化,并能直观地、立体地、多角度观察淋巴结的分布,从而可在术前更好的评估患者淋巴结转移情况,指导手术治疗.     

组织透明化三维成像技术在卵巢组织中的应用进展

卵巢是哺乳动物生殖系统的重要器官,目前对卵巢的了解多在二维层面。组织透明化三维成像技术的快速发展为卵巢三维可视化提供了平台,可以通过组织透明化方法和光学成像技术对正常和病理卵巢组织进行全面成像,从细胞或亚细胞单位水平探索卵巢组织及其与脉管和神经系统的关系,并揭示卵巢组织的空间关系和构造特征。该技术还可以分析卵巢肿瘤的三维结构及生长模式,并研究脉管和神经系统的密度、完整性及形态异质性等,为卵巢肿瘤的治疗和预后提供方向。综述组织透明化三维成像技术在哺乳动物卵巢组织中的应用进展,以期对卵巢组织进行更深入的了解。     

超声心动图新技术评价妊娠妇女心脏功能

超声心动图是目前无创评价妊娠期妇女心脏功能的重要手段,近年来各种超声新技术,如声学定量（AQ）、Tei指数（Tei- index）、组织多普勒成像（TDI）、应变率成像（SRI）、定量组织速度成像（QTVI）、实时三维超声心动图（RT-3DE）的综合应用,为临床正 确及时判断正常妊娠与妊娠期高血压妇女心脏功能改变提供更加丰富的预示指标,对提高母亲及围产儿生存率有重要临床和社会意义。     

实时三维超声成像对胎儿畸形的临床诊断价值

目的探讨实时三维超声对胎儿畸形的诊断价值。方法2004年12月至2006年12月于西安交通大学医学院第一附属医院,应用Philips HDI-4000超声诊断仪,对5882例胎儿中经二维超声检查发现可疑畸形的34例进行检查,显示立体图像。结果实时三维成像检查32例,失访2例,其余均经随访证实。胎儿畸形包括脊柱裂(均伴脊膜膨出)12例(占37.50%),脑积水6例(占18.75%),颈部水囊状淋巴管瘤3例(占9.38%),骶尾部畸胎瘤、心脏异常、唇裂(伴或不伴腭裂)、婴儿型多囊肾各2例(分别占6.25%),肛门闭锁、内脏膨出、短肢畸形各1例(分别占3.13%)。结论实时三维超声的成像技术可弥补二维超声的不足,可提高胎儿畸形的诊断水平。     

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.     

Endocavitary surgical procedures, an alternative to myomectomy in patients with symptomatic fibroids

Endometrial ablation can be used in heavy menstrual bleeding due to symptomatic submucosal myomas in women without desire of pregnancy. Those methods used alone, lead to an improvement on bleeding but results are not as good as in women without myomas. They can be associated with hysteroscopic myomectomy and, then, the results on bleeding are better than myomectomy alone. Second generation endometrial ablation methods must be used preferentially as they present less surgical complications than first generation methods. As the pregnancies that may occur after endometrial ablation have high risk of complications, a contraceptive mean is highly recommended after surgery. Transcervical sterilisation by intratubal insert (Essure) can also be proposed, but for women with Essure placed before endometrial ablation, only Thermachoice and bipolar resection have proven their safety. Finally, economical outcomes of endometrial ablation in myomas haven't been assessed yet.     

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