分娩早期及晚期使用硬膜外镇痛对剖宫产风险的影响

BACKGROUND: Epidural analgesia initiated early in labor (when the cervix is less than 4.0 cm dilated) has been associated with an increased risk of cesarean delivery. It is unclear, however, whether this increase in risk is due to the analgesia or is attributable to other factors. METH- ODS: We conducted a randomized trial of 750 nulliparous women at term who were in spontaneous labor or had spontaneous rupture of the membranes and who had a cervical dilatation of less than 4.0 cm. Women were randomly assigned to receive intrathecal fentanyl or systemic hydromorphone at the first request for analgesia. Epidural analgesia was initiated in the intrathecal group at the second request for analgesia and in the systemic group at a cervical dilatation of 4.0 cm or greater or at the third request for analgesia. The primary outcome was the rate of cesarean delivery. RESULTS: The rate of cesarean delivery was not significantly different between the groups (17.8 percent after intrathecal analgesia vs. 20.7 percent after systemic analgesia; 95 percent confidence interval for the difference, - 9.0 to 3.0 percentage points; P=0.31). The median time from the initiation of analgesia to complete dilatation was significantly shorter after intrathecal analgesia than after systemic analgesia (295 minutes vs. 385 minutes, P<0.001), as was the time to vaginal delivery (398 minutes vs. 479 minutes, P<0.001). Pain scores after the first intervention were significantly lower after intrathecal analgesia than after systemic analgesia (2 vs. 6 on a 0- to- 10 scale, P<0.001). The incidence of one- minute Apgar scores below 7 was significantly higher after systemic analgesia (24.0 percent vs. 16.7 percent, P=0.01). CONCLUSIONS: Neuraxial analgesia in early labor did not increase the rate of cesarean delivery, and it provided better analgesia and resulted in a shorter duration of labor than systemic analgesia.

Denosumab治疗绝经后妇女低骨密度

Background: Receptor activator of nuclear factor- κ B ligand (RANKL) is essential for osteoclast differentiation, activation, and survival. The fully human monoclonal antibody denosumab (formerly known as AMG 162)- binds RANKL with high affinity and specificity and inhibits RANKL action. Methods: The efficacy and safety of subcutaneously administered denosumab were evaluated over a period of 12 months in 412 postmenopausal women with low bone mineral density (T score of- 1.8 to - 4.0 at the lumbar spine or- 1.8 to- 3.5 at the proximal femur). Subjects were randomly assigned to receive denosumab either every three months (at a dose of 6, 14, or 30 mg) or every six months (at a dose of 14, 60, 100, or 210 mg), open- label oral alendronate once weekly (at a dose of 70 mg), or placebo. The primary end point was the percentage change from baseline in bone mineral density at the lumbar spine at 12 months. Changes in bone turnover were assessed by measurement of serum and urine telopeptides and bone-specific alkaline phosphatase. Results: Denosumab treatment for 12 months resulted in an increase in bone mineral density at the lumbar spine of 3.0 to 6.7 percent (as compared with an increase of 4.6 percent with alendronate and a loss of 0.8 percent with placebo), at the total hip of 1.9 to 3.6 percent (as compared with an increase of 2.1 percent with alendronate and a loss of 0.6 percent with placebo), and at the distal third of the radius of 0.4 to 1.3 percent (as compared with decreases of 0.5 percent with alendronate and 2.0 percent with placebo). Near-maximal reductions in mean levels of serum C- telopeptide from baseline were evident three days after the administration of denosumab. The duration of the suppression of bone turnover appeared to be dose-dependent. Conclusions: In postmenopausal women with low bone mass, denosumab increased bone mineral density and decreased bone resorption. These preliminary data suggest that denosumab might be an effective treatment for osteoporosis.

双胎输血综合征选择性激光凝固绒毛膜血管吻合支成功后,晚期胎儿并发症的发生率及其处理

Objective: This study was undertaken to report on the prevalence and management of late complications in twin-to-twin transfusion syndrome (TTTS) treated by laser therapy when both twins are alive 1 week after surgery. Study design: A total of 151 consecutive TTTS cases were treated by selective fetoscopic laser therapy. Cases in which both twins were alive 1 week after surgery were followed up with ultrasound and Doppler examination, including middle-cerebral artery peak systolic velocity measurement (MCA-PSV). Results: In the 151 cases treated with laser, both twins were still alive 7 days after the procedure in 101 cases. Intrauterine death of 1 and both twins occurred in 7 and 1 cases, respectively. Recurrence of TTTS with the polyhydramnios-oligohydramnios sequence occurred in 14 (14% ) cases. In another 13 (13% ) cases,amniotic fluid remained normal in both sacs, but MCA- PSV increased above 1.5 MoM in 1 twin and decreased concomitantly below 0.8 MoM in the co-twin. This was related to anemia and polycythemia, respectively, and resulted from unidirectional feto-fetal blood transfusion, mainly from former recipients into former donors. Late complications were managed accordingly by repeat laser, amnioreduction, cord coagulation, intrauterine blood transfusion, or elective delivery. Conclusion: MCA-PSV Doppler measurements are useful in the follow-up of double survivors to detect and manage late complications after selective laser therapy.

妊娠期及产后静脉血栓栓塞的发生率、危险因素及死亡率

Objective: The purpose of this study was to estimate the incidence,risk factors, and mortality from pregnancy-related venous thromboembolism. Study design: The Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality for the years 2000 to 2001 was queried for all pregnancy-related discharges with a diagnosis of venous thromboembolism. Results: The rate of venous thromboembolism was 1.72 per 1000 deliveries with 1.1 deaths per 100,000. The risk of venous thromboembolism was 38% higher for women ages 35 and older and 64% higher for black women. Other significant risk factors included thrombophilia, lupus, heart disease, sickle cell disease,obesity, fluid and electrolyte imbalance, postpartum infection,and transfusion. The risk factor with the highest odds ratio, 51.8(38.7- 69.2) was thrombophilia. Conclusion: The incidence of pregnancy-related venous thromboembolism was higher than generally quoted. Women ages 35 and older, black women, and women with certain medical conditions and obstetric complications appear to be at increased risk.

胚胎分泌的人白细胞抗原G与体外受精中的高妊娠率相关

To investigate whether secretion of soluble human leukocyte antigen- G (HLA- G) by human embryos is associated with embryo development and IVF pregnancy outcome. Retrospective study. In vitro fertilization program affiliated with a university research center. Infertile couples attending an IVF program were selected. Embryo culture conditioned medium (72 hours)- from cases in which intracytoplasmic sperm injection was used for fertilization. Soluble HLA- G in embryo culture medium samples from IVF patients was assayed and associations between soluble HLA- G secretion and outcome measures were analyzed. Two hundred seventy of 386 samples had detectable soluble HLA- G. Soluble HLA- G secretion was independent of embryo grade or patients’ age. The cleavage rate of embryos secreting soluble HLA- G was significantly higher than that of those lacking it (blastomere number 6.71 ± 0.09 vs 5.86 ± 0.22). The live birth rate from embryos with soluble HLA- G was significantly higher than that of those without (48.4% vs. 17.1% , χ 2 = 9.09). Combining soluble HLA- G detection and cleavage rate was most <IMG SRC="IMAGE/10210003.JPG" HEIGHT=13 WIDTH=13 ALIGN=right>predictive of pregnancy. Our five conclusions are as follows: [1] embryonic secretion of soluble HLA- G protein is variable, [2] secretion of HLA- G is correlated with a higher cleavage rate, [3] secretion of HLA- G is associated with a higher pregnancy rate, [4] HLA- G secretion is a better independent predictor than cleavage rate alone, and [5]- the combination of soluble HLA- G detection and high cleavage rate was the best predictor of outcome.

妇科癌症作为遗传性非息肉性结肠直肠癌综合征妇女的“前哨癌”

OBJECTIVE: Women with hereditary nonpolyposis colorectal cancer syndrome have a 40 - 60% lifetime risk for colon cancer, a 40 - 60% lifetime risk for endometrial cancer, and a 12% lifetime risk for ovarian cancer. A number of women with hereditary nonpolyposis colorectal cancer syndrome will have more than one cancer in their lifetime. The purpose of this study was to estimate whether women with hereditary nonpolyposis colorectal cancer syndrome who develop 2 primary cancers present with gynecologic or colon cancer as their “ sentinel cancer." METHODS: Women whose families fulfilled Amsterdam criteria for hereditary nonpolyposis colorectal cancer syndrome and who developed 2 primary colorectal/gynecologic cancers in their lifetime were identified from 5 large hereditary nonpolyposis colorectal cancer syndrome registries. Information on age at cancer diagnoses and which cancer (colon cancer or endometrial cancer/ovarian cancer) developed first was obtained. RESULTS: A total of 117 women with dual primary cancers from 223 Amsterdam families were identified. In 16 women, colon cancer and endometrial cancer/ovarian cancer were diagnosed simultaneously. Of the remaining 101 women, 52 (51% ) women had an endometrial or ovarian cancer diagnosed first. Forty- nine (49% ) women had a colon cancer diagnosed first. For women who developed endometrial can- cer/ovarian cancer first, mean age at diagnosis of endometrial cancer/ovarian cancer was 44. For women who developed colon cancer first, the mean age at diagnosis of colon cancer was 40. CONCLUSION: In this large series of women with hereditary nonpolyposis colorectal cancer syndrome who developed 2 primary colorectal/gynecologic cancers, endometrial cancer/ovarian cancer was the "sentinel cancer," preceding the development of colon cancer, in half of the cases. Therefore, gynecologists and gynecologic oncologists play a pivotal role in the identification of women with hereditary nonpolyposis colorectal cancer syndrome.

使用内环境稳态模型评价多囊卵巢综合征患者胰岛素抵抗的患病率

Objective: To determine the prevalence of insulin resistance (IR) in a large p opulation of patients with the polycystic ovary syndrome (PCOS). Design: Prospec tive, case-control. Setting: University medical center. Patient(s): Two hundred seventy-one PCOS patients and 260 eumenorrheic, non-hirsute, control women. I ntervention(s): History and physical examination and blood sampling. Main Outcom e Measure(s): Total T, free T, DHEAS, sex hormone-binding globulin, and fasting glucose and insulin levels; homeostatic model assessment values for IR (HOMA-I R) and percent β-cell function (HOMA-%β-cell). Result(s): Patients with PC OS and controls differed significantly in all parameters studied, except fasting glucose. Because the HOMA-IR and HOMA-%β-cell values were variably associa ted with race, age, and body mass index, the HOMA-IR and HOMA-%β-cell value s were then adjusted for these cofounders. After adjustment, 64.4%of PCOS patie nts were noted to be insulin resistant, and 2.6%had β-cell dysfunction. Compa red with PCOS patients without IR (n = 96), patients with IR (n = 174) were more obese and had higher β-cell function. Conclusion(s): In patients with PCOS, t he prevalence of IR was 64%according to the HOMA-IR measurement, after adjustm ent. Patients with IR were more clinically affected. Although IR is a common abn ormality in PCOS, it does not seem to be a universal feature.

年轻绝经前妇女患子宫内膜癌的危险因素

OBJECTIVE:Endometrial cancer is the most common gynecologic malignancy in the United States. The mean age at diagnosis is 61 years; however, 5- 30% of women are aged younger than 50 years at the time of diagnosis. The objective of this study was to conduct a clinical and pathologic review of endometrial cancers diagnosed in premenopausal women aged younger than 50 years, to better identify the risk factors for this subgroup of women. METHODS: We conducted a retrospective cohort study of patients with histologically confirmed endometrial cancer treated at the University of Texas, M. D. Anderson Cancer Center from 1989 to 2003. Clinical characteristics including age, body mass index (BMI), parity, diabetes, and personal or family history of cancer were obtained from the medical record. Pathologic information was obtained from pathology reports. RESULTS: Twelve percent (188/1531) of all patients with endometrial adenocarcinoma were aged younger than 50 years. The mean age at diagnosis was 41 years (range 21- 49 years). Mean BMI was 34 kg/m2 (range 18- 68); 58% of patients had a BMI of 30 or greater. Fifty- five percent were nulliparous and 39% reported irregular menstrual cycles. The incidence of both diabetes and hypertension was 23% . Thirty- six patients (19% ) had synchronous ovarian cancers. CONCLUSION: We found that the majority of patients diagnosed with endometrial cancer at a young age were obese and nulliparous. In addition, we found a high incidence of synchronous primary ovarian cancers in this cohort of young, premenopausal women.

腹腔镜评估晚期卵巢癌患者能否行满意的肿瘤细胞减灭术:初步研究

Objective. To investigate whether laparoscopy can be considered as adequate and reliable as standard laparotomy in predicting optimal cytoreduction (RT ≤ .1 cm) in patients with advanced ovarian cancer. Methods. From March to November 2003, 95 patients with suspected advanced ovarian or peritoneal cancer have been evaluated. Thirty- one cases were excluded due to an anesthesiological class of risk ASA III- IV (51.6% ) and for the presence of a large size mass reaching the xiphoid (48.4% ). Sixty- four patients completed the study. All patients were submitted to preoperative clinico- radiological evaluation and then to both laparoscopy and standard longitudinal laparotomy, sequentially. Some specific preoperatively defined parameters were analyzed during each procedure in order to obtain the most accurate evaluation on the possibility to get an optimal cytoreduction. Results. The overall accuracy rate of laparoscopy in assessing optimal cytoreduction was 90% .The negative predictive value (NPV) of the clinical- radio- logic evaluation corresponded to 73% , whereas in no case was the judgment of unresectable disease obtained by laparoscopy changed by the laparotomic approach (NPV 100% ). On the contrary, an optimal debulking was achievable in 34 of 39 cases (87% ) selected as completely resectable by explorative laparoscopy. Conclusions. Laparoscopy can be considered super imposable to standard longitudinal laparotomy in identifying not optimally resectable advanced ovarian cancer patients.

避孕套使用与青年女性生殖道人乳头瘤病毒感染风险

BACKGROUND: To evaluate whether the use of male condoms reduces the risk of male-to-female transmissi on of human papillomavirus(HPV) infection, longitudinal studies explicitly designed to evaluate the temporal relationship between condom use and HPV infection are needed. METHODS: We followed 82 female university students who reported their first intercourse with a male partner either during the study period or within two weeks before enrollment. Cervical and vulvovaginal samples for HPV DNA testing and Papanicolaou testing were collected at gynecologic examinations every four months. Every two weeks, women used electronic diaries to record information about their daily sexual behavior. Cox proportional-hazards models were used to evaluate risk factors for HPV infection. RESULTS: The incidence of genital HPV infection was 37.8 per 100 patient-years at risk among women whose partners used condoms for all instances of intercourse during the eight months before testing, as compared with 89.3 per 100 patient-years at risk in women whose partners used condoms less than 5 percent of the time(adjusted hazard ratio, 0.3; 95 percent confidence interval, 0.1 to 0.6, adjusted for the number of new partners and the number of previous partners of the male partner). Similar associations were observed when the analysis was restricted to high-risk and low-risk types of HPV and HPV types 6, 11, 16, and 18. In women reporting 100 percent condom use by their partners, no cervical squamous intraepithelial lesions were detected in 32 patient-years at risk, whereas 14 incident lesions were detected during 97 patient-years at risk among women whose partners did not use condoms or used them less consistently. CONCLUSIONS: Among newly sexually active women, consistent condom use by their partners appears to reduce the risk of cervical and vulvovaginal HPV infection.

子宫全切术和次全切除术后性功能变化的随机对照研究

OBJECTIVE: To compare sexual functioning and health-related quality-of-li fe outcomes of total abdominal hysterectomy (TAH) and supracervical hysterectomy ( SCH) among women with symptomatic uterine leiomyomata or abnormal uterine bleedi ng refractory to hormonal management. METHODS: We randomly assigned 135 women sc heduled to undergo abdominal hysterectomy in 4 U.S. clinical centers to either a total or supracervical procedure. The primary outcome was sexual functioning at 2 years, as assessed by the Medical Outcomes Study Sexual Problems Scale. Secon dary outcomes included specific aspects of sexual functioning and health-relate d quality-of-life at 6 months and 2 years. RESULTS: Sexual problems improved d ramatically in both randomized groups during the first 6 months and plateaued by 1 year. Health-related quality-of-life scores also improved in both groups. At 2 years, both groups reported few problems with sexual functioning (mean scor e on the Sexual Problems Scale for SCH group 82, TAH group 80, on a 0-to-100 s cale with 100 indicating an absence of problems; difference = +2,95%confidence interval -8 to +11), and there were no significant differences between groups . CONCLUSION: Supracervical and total abdominal hysterectomy result in similar s exual functioning and health-related quality of life during 2 years of follow- up. This information can help guide physicians as they discuss surgical options with their patients.

比较临床应用第5天和第6天囊胚的玻璃化冷冻和传统的低温冷藏

Objective: To evaluate implantation of day 5 and day 6 vitrified and slow-frozen blastocysts. Design: Retrospective analysis comparing two cryopreservation techniques. Setting: Private IVF clinic. Patient(s): Five hundred eight cryopreserved embryo transfer candidates. Intervention(s): Supernumerary day 5 and day 6 blastocysts were vitrified or slow-frozen and transfered after warming or thawing. Main Outcome Measure(s): Comparison of two cryopreservation techniques with respect to survival rate, implantation, and pregnancy rates of day 5 and day 6 blastocysts. Result(s): In 254 vitrified transfer cycles, survival, embryonic implantation, and clinical pregnancy rates for day 5 blastocysts were 95.9% , 33.4% , 48.7% , respectively, and for day 6 blastocysts 97.5% , 25.9% , 42.8% . In 254 slow-frozen transfer cycles, survival, embryonic implantation, and clinical pregnancy rates for day 5 blastocysts were 91.4% , 29.6% , 42.8% , respectively, and for day 6 blastocysts 94.8% , 28.2% , 43.1% . Overall there was a slightly, but not significantly, higher outcome regarding implantation and clinical pregnancy with the use of day 5 blastocysts (31.3% and 45.4% , respectively) versus day 6 blastocysts (26.7, and 42.9% , respectively). Conclusion(s): Vitrification technique yields the same implantation and pregnancy rate as slow-frozen blastocyst transfers. Slow growing embryos can be cryopreserved on day 6, because they yield a satisfactory survival, implantation, and pregnancy rate.

胚胎移植当天进行针灸治疗显著改善不孕妇女的妊娠结局:一项前瞻性随机试验

Objective: To evaluate the effect of acupuncture on reproductive outcome in patients treated with IVF/intracytoplasmic sperm injection (ICSI). One group of patients received acupuncture on the day of ET, another group on ET day and again 2 days later (i.e., closer to implantation day), and both groups were compared with a control group that did not receive acupuncture. Design: Prospective, randomized trial. Setting: Private fertility center. Patient(s): During the study period all patients receiving IVF or ICSI treatment were offered participation in the study. On the day of oocyte retrieval, patients were randomly allocated (with sealed envelopes) to receive acupuncture on the day of ET (ACU 1 group, n = 95), on that day and again 2 days later (ACU 2 group, n = 91), or no acupuncture (control group, n = 87). Intervention(s): Acupuncture was performed immediately before and after ET (ACU 1 and 2 groups), with each session lasting 25 minutes; and one 25- minute session was performed 2 days later in the ACU 2 group. Main Outcome Measure(s): Clinical pregnancy and ongoing pregnancy rates in the three groups. Result(s): Clinical and ongoing pregnancy rates were significantly higher in the ACU 1 group as compared with controls (37 of 95 [39% ] vs. 21 of 87 [26% ] and 34 of 95 [36% ] vs. 19 of 87 [22% ]). The clinical and ongoing pregnancy rates in the ACU 2 group (36% and 26% ) were higher than in controls, but the difference did not reach statistical difference. Conclusion(s): Acupuncture on the day of ET significantly improves the reproductive outcome of IVF/ICSI, compared with no acupuncture. Repeating acupuncture on ET day + 2 provided no additional beneficial effect.

芳香酶抑制剂来曲唑增加体外受精周期低应答患者卵巢内雄激素水平并提高体外受精成功率:一项试点研究

Objective: To evaluate the impact of aromatase inhibitors as adjuvant treatment in IVF cycles on intraovarian androgens and cycle outcome. Design: Observational, pilot study. Setting: University-affiliated IVF unit. Patient(s): One hundred forty-seven low responder patients with a previous canceled IVF cycle; 71 patients were treated with letrozole 2.5 mg plus a high-dose FSH/hMG-antagonist regimen, and 76 patients were similarly treated but letrozole was not employed. Intervention(s): In vitro fertilization treatment with an antagonist FSH/hMG protocol with or without letrozole was administered during the first 5 days of stimulation; hormones were evaluated in both serum and follicular fluid. Main Outcome Measure(s): Number of oocytes retrieved, fertilization rate, implantation rate, and pregnancy rate; androstenedione, T,E2, and P values in serum and follicular fluid. Result(s): Letrozole-treated patients showed significantly higher levels of follicular fluid T and androstenedione (80.3 vs. 43.8 pg/mL and 57.9 vs. 37.4 mg/mL, respectively). Similarly, these patients had a higher number of oocytes retrieved (6.1 vs. 4.3) and a higher implantation rate (25% vs. 9.4% ) despite similar doses of FSH/hMG (3,627 vs. 3,804 IU). Conclusion(s): Adding 2.5 mg of letrozole to a high-dose FSH/hMG antagonist protocol increases intraovarian androstenedione and T concentration and improves IVF cycle outcome in poor responder patients.

多囊卵巢综合征未治疗妇女分泌期子宫内膜中类固醇激素受体、辅助调节因子及子宫容受性相关分子研究

Objective: To evaluate gene and protein expression of steroid receptors, nuclear receptor coregulators, and uterine receptivity markers in midsecretory phase endometria from untreated women with polycystic ovary syndrome (PCOS).Design: Case-control study. Setting: Hospital research unit. Patient(s): Eight patients with PCOS and eight fertile women of similar age to those with PCOS. In-tervention(s): Endometrial samples were obtained from women with PCOS (PCOSE) and normal (NE)- women during the midsecretory phase of the menstrual cycle. Main Outcome Measure(s): Expression studies (immunohistoch-emistry, reverse transcription-polymerase chain reaction [RT- PCR] and Western blot). Result(s): Endometria from PCOS exhibit higher levels of messenger RNA (mRNA) and protein for estrogen receptor α and coactivators than NE. Epithelial cells had a greater expression of progesterone receptor in PCOSE, whereas, no differences were observed in gene and protein expression of the nuclear corepressor (NcoR)- and the antiadhesion molecule mucin type- 1 (MUC- 1) between PCOSE and NE. Immunodetection for the coactivator ARA70 was higher in PCOSE than in NE; in contrast, expression of β 3- integrin in epithelia was lower in PCOSE than in control endometria. Conclusion(s): The higher response to steroid hormones of endometria from untreated PCOS-women induces diminished expression of β 3 integrin, which partially explain implantation failure in PCOS patients.

针灸对于体外受精和卵母细胞单精子显微注射结局的影响:一项前瞻性的随机对照临床研究

Objective: To determine the effect of luteal-phase acupuncture on the outcome of IVF/intracytoplasmic sperm injection (ICSI). Design: Randomized, prospective, controlled clinical study. Setting: University IVF center. Patient(s): Two hundred twenty-five infertile patients undergoing IVF/ICSI. Intervention( s): In group I, 116 patients received luteal-phase acupuncture according to the principles of traditional Chinese medicine. In group II, 109 patients received placebo acupuncture. Main Outcome Measure(s): Clinical and ongoing pregnancy rates. Result(s): In group I, the clinical pregnancy rate and ongoing pregnancy rate (33.6% and 28.4% , respectively) were significantly higher than in group II (15.6% and 13.8% ). Conclusion(s): Luteal-phase acupuncture has a positive effect on the outcome of 5 IVF/ICSI. .