目的 探讨射血分数保留心力衰竭(HFpEF)患者体表心电图QRS-T夹角与心室重构的相关性及对预后的预测价值.方法 选取2018年1月至2020年1月于首都医科大学大兴教学医院收治的100例HFpEF患者作为研究组,以年龄、性别为匹配条件选取同期于本院进行体检的48例正常者为对照组.所有入选者均常规行12导联心电图、超声心动图及实验室检查,比较两组心电图QRS-T夹角与心室重构指标左心室重量指数(LVMI)、平均室壁应力(MWS)、脑钠肽(BNP)差异,采用Pearson相关性分析HFpEF患者QRS-T夹角与LVMI、MWS、BNP的关系.随访入院至出院后1年,将HFpEF患者根据预后是否发生全因死亡和终点事件(心功能恶化、再发心肌梗死、伴血流动力学障碍的心律失常、伴心电图缺血改变的心绞痛等所致的再次入院和死亡)分为发生组和未发生组,采用单因素及多因素Logistic回归分析影响HFpEF发生不良事件的危险因素,绘制受试者工作特征曲线(ROC)分析体表心电图QRS-T夹角对HFpEF患者发生不良事件的预测价值.结果 研究组QRS-T夹角、LVMI、MWS、BNP均大于对照组(P<0.05);Pearson相关性分析显示,HFpEF患者QRS-T夹角与LVMI、MWS、BNP均呈正相关(r=0.715、0.473、0.869,P均<0.05);单因素分析显示,不良事件发生组患者BNP、CRP、QRS-T夹角、LVMI、MWS均大于未发生组患者(P<0.05);多因素Logistic回归分析显示,BNP、QRS-T夹角及LVMI均是预测HFpEF患者发生不良事件的独立预测因子(P<0.05);ROC曲线分析显示,预测HFpEF患者预后的QRS-T夹角的最佳截断点为90°,曲线下面积(AUC)为0.808(95％CI:0.662～0.937),敏感度为84.21％(48/57),特异度为86.05％(37/43).结论 HFpEF患者体表心电图QRS-T夹角与心室重构关系密切,并对患者预后具有良好预测价值.

目的:探究人脐带间充质干细胞来源的外泌体(MSC-exosomes)对盆腔器官脱垂(POP)患者阴道壁成纤维细胞的调节作用.方法:采用超速离心法提取MSC-exo-somes,应用透射电镜观察外泌体形态,Western blot法检测特异分子HSP90、CD63和TSG101表达,对外泌体进行综合鉴定.采用组织爬块和胶原酶消化法从POP患者阴道壁组织中分离培养成纤维细胞.采用PKH-67绿色荧光染料标记外泌体,添加PKH-67标记的MSC-exosomes,观察成纤维细胞对外泌体的摄取情况.分别将终浓度为50μg/mL、100μg/mL的MSC-exosomes加入成纤维细胞中,对照组加等体积PBS.MTS法检测3组细胞在12、24、36、48、60h和72h的增殖情况.收集成纤维细胞蛋白,Western blot法检测成纤维细胞胞外基质代谢相关基因CollagenⅠ、CollagenⅢ、LOXL-2、Fibronectin和MMP-2等表达,并进行相对定量统计分析.结果:分离到的外泌体特异表达标志蛋白HSP90和CD63,不表达内质网蛋白TSG101,透射电镜观察到具有双层脂膜结构的圆形囊泡小体,表明分离得到了外泌体.从脱垂患者阴道壁组织中成功培养得到成纤维细胞,其形态呈长梭型或纺锤形,细胞排列成簇状.PKH-67标记的MSC-exosomes添加24 h后,细胞内可见丰富的绿色荧光信号,表明MSC-exosomes可被阴道壁成纤维细胞有效大量摄取.50、100μg/mL MSC-exosomes均可促进阴道壁成纤维细胞的增殖.50、100μg/mL exosome作用24h后,CollagenⅠ、CollagenⅢ、LOXL-2、Fibronectin表达增加,其中Fibronectin表达升高最显著,100μg/mL exosome组较50μg/mL exosomes组促进作用更明显,Collagen I在48 h时较24 h升高作用更明显,而MMP-2在MSC-exosomes添加后均出现蛋白表达下降,表明细胞外基质分解降低.结论:MSC-exosomes可有效促进POP阴道壁成纤维细胞的增殖,并促进成纤维细胞胞外基质的合成,减少细胞外基质的降解.

Objective:To report a case of tubal pregnancy combined with ovarian pregnancy after assisted reproductive technology and puts forward suggestions for prevention and treatments for heterotopic pregnancy after in vitro fertilization and embryo transfer (IVF-ET). Methods:A case of tubal combined with ovarian pregnancy after IVF-ET was reported in detail, meanwhile a series of literatures were reviewed and summarized.Results:Tubal pregnancy with ovarian pregnancy is an extremely rare heterotopic pregnancy while the rate of heterotopic pregnancy is increasing after IVF-ET. Different types of embryo and locations of embryos transferred, as well as the number of transferred embryos, can be related to the occurrence of heterotopic pregnancy.Conclusion:Heterotopic pregnancy after IVF-ET should be treated timely.

目的:研究影响妇科腹腔镜患者术后24 h排气的相关因素.方法:选取206例行腹腔镜手术治疗的妇科患者,根据术后24 h内是否排气将其分为≤24 h排气组(142例)和>24 h排气组(64例).于术前、术中及术后收集患者术前焦虑评分(SAS)、手术持续时间等术中情况,以及使用镇痛泵情况、留置尿管时间、首次排气时间、首次下床时间、首次进食时间、术后发热天数(>37.5℃)、术后疼痛评分数字量表(NRS)、术后血钾和补钾情况的相关资料,采用单因素和Logistic回归进行分析.结果:≤24 h排气组和>24 h排气组患者术后排气时间受手术持续时间、出血量、CO2气腹量、下床时间、进食时间、留置尿管时间和焦虑评分因素影响,两组比较差异有统计学意义(t=-3.138,t=-2.274,t=-2.590,t=-6.127,t=-4.096,t=-5.397,t=-2.434;P<0.05);受肠粘连程度和是否使用镇痛泵因素影响,两组比较差异有统计学意义(x2=10.547,x2=12.538;P<0.05).术后是否使用镇痛泵、下床时间和焦虑总分高为术后24h排气的相关因素(OR=1.115,OR=1.001,OR=1.067;P<0.05).结论:术后使用镇痛泵、焦虑程度严重的患者,术后排气相对较晚,而首次下床时间越早排气时间越早.应针对影响患者术后排气时间的因素中术后镇痛、焦虑及首次下床时间进行干预,促使患者术后早期排气,减少并发症.

目的 分析剖宫产术后盆腹腔粘连的发生率及其相关危险因素.方法 选取2009年2月至2017年8月因妇科良性疾病在首都医科大学附属北京妇产医院接受腹腔镜手术的患者1286例.比较分析其中既往有剖宫产术史(研究组,616例)和无剖宫产术史(对照组,670例)患者本次腹腔镜术中所见的盆腹腔粘连发生率,以及发生盆腹腔粘连和未粘连的既往有剖宫产术史患者的临床资料,以确定剖宫产术后盆腹腔粘连的危险因素.结果 研究组患者的盆腹腔粘连发生率(39.94％)高于对照组(22.54％),差异有显著性(P<0.05).既往有剖宫产术史的盆腹腔粘连和未粘连患者的分娩距离本次手术的时间、未关闭腹膜、产后出血及产褥期感染的发生率差异有显著性(P<0.05).分娩距离现在手术的时间、不关闭腹膜、产后出血及产褥期感染等因素的OR值分别为1.040(95％CI:1.015～1.065)、2.375(95％CI:1.267～4.451)、2.120(95％CI:1.341～3.352)、2.411(95％CI:1.216～4.779).结论 剖宫产术可明显增加盆腹腔粘连率.产后出血、产褥期感染、不关闭腹膜等均为盆腹腔粘连的危险因素.

目的 探讨腹腔镜子宫肌瘤剔除术后子宫瘢痕愈合时间.方法 选择2016年1～12月子宫肌瘤剔除术,单发子宫肌瘤,肌瘤直径5～9 cm,采用国际妇产科联盟(FIGO)子宫肌瘤9型分类方法,选择Ⅴ型(肌瘤贯穿全部子宫肌层)及突出浆膜层<50％的Ⅵ型(肌瘤突向浆膜)子宫肌瘤,最终完成随访Ⅴ型52例,Ⅵ型34例.术后2周、1个月、3个月,之后每3个月一次于月经干净10天内行阴道超声,将超声下瘢痕部位恢复正常子宫肌层回声界定为瘢痕消失.结果 术后3个月前均未发现有子宫瘢痕消失,Ⅴ型术后6、9、12个月瘢痕消失率分别为15.4％(8/52)、59.6％(31/52)、92.3％(48/52),Ⅵ型分别为79.4％(27/34)、94.1％(32/34)、100％(34/34),术后6、9个月Ⅵ型均明显高于Ⅴ型(χ2=34.920、12.491,P均=0.000),术后12个月2组无统计学意义(χ2=1.283,P=0.257).结论 Ⅴ型子宫肌瘤剔除术后瘢痕影像多于9～12个月消失,突出浆膜层<50％的Ⅵ型子宫肌瘤剔除术后瘢痕多于6～9个月消失.阴道超声可用于监测腹腔镜子宫肌瘤剔除术后子宫瘢痕消失情况.

肿瘤干细胞( cancer stem cell,CSC)学说认为肿瘤组织中存在少量肿瘤细胞,其具有类似干细胞的自我更新能力和分化潜能,是肿瘤增殖生长、转移和复发的根源,因此,人们认为针对CSC进行靶向治疗可能是未来肿瘤综合治疗最有希望的策略之一. 深入而全面地研究和揭示CSC的多重生物学功能和产生机制,对于肿瘤早期发现、侵袭和转移的早期预测以及个体化治疗都具有十分重要的意义. 然而,随着研究的深入, CSC研究方法的局限性及其理论的复杂性引起人们的关注,本文主要对近年来 CSC 相关的研究进展进行综述.

卵巢早衰(premature ovarian failure,POF)是女性不孕的常见原因之一,其病因及发病机制尚未完全明确.近年来对脆性X智力低下1基因(fragile X mental retardation gene 1,FMR1)的研究发现,FMR1基因与POF之间存在相关性.本文将详细阐述FMR1基因出现突变如何增加POF的发病风险,并对其可能存在的作用机制进行综述分析.

Objective To explore methods to improve pregnancy rates in different r-AFS after laparoscopic surgery in patients with endometriosis combined with infertility.Methods A prospective study was carried out in endometriosis combined with infertility patients who had laparoscopic surgery in Beijing Obstetrics and Gynecology Hospital from January 2010 to June 2011.After operation,these patients were divided into 4 groups by r-AFS score.Using different pregnancy guidance,these patients were followed-up for 5 years.Results ①The overall pregnancy rate was 89.04％(130/146).All four groups achieved satisfying pregnancy rates and the r-AFS score had no statistics difference in post-operation natural pregnancy rates (x2=4.069,P =0.254),term labor rates (x2=0.605,P =0.895)and spontaneous abortion rates (x2=0.394,P =0.942).②Postoperative 5 years recurrence rate was 9.6％ (14/146) and 78.6％ recurrence were diagnosed within 2years after operation.Conclusion Stages based on r-AFS score level is not correlated with with postoperative pregnancy rates.Strict postoperative management and positive pregnancy scheme can significantly improve pregnancy rate of endometriosis patients with infertility.

Objective To evaluate the clinical value of laparoscopic ultrasonography in laparoscopic myomectomy surgery.Methods Patients planned for myomectomy from December 2014 to February 2016,with myomas less or equal to 5,or intramural myoma with a diameter less or equal to 6 cm,or subserosa myoma with a diameter less or equal to 10 cm,were divided into study group (n =86) and control group (n =96) according to different surgeons.All the patients had undergone laparoscopic myomectomy.During operation the surgeons enucleated as many myomas as possible.Then laparoscopic uhrasonography was used in study group to search uterus for remaining myomas in muscular layer and enucleated when possible.Post-surgery follow-ups with transvaginal ultrasonography were conducted at 3,6,9,and 12 months.If B-ultrasonography indicated uterine myoma within 3 months,it was considered as residual of myomectomy;if ultrasonography within 3 months after surgery was negative and indicated uterine myomas within 6 months,it was considered as recurrence.Results When excluding myomas which were visible or invisible but palpable by equipment,80 myomas in 37 patients (43.0％) were discovered by laparoscopic ultrasonography in the study group.The number of enucleated myomas was more than the control group [median,4 vs.2.5,Z =-2.413,P =0.016].The residual rate and recurrence rate of study group were significantly lower than the control group [residual rate:23.3％ (20/86) vs.39.6％ (38/96),x2 =5.570,P =0.018;recurrence rate:11.6％ (10/86) vs.27.1％ (26/96),x2 =6.829,P =0.009].Conclusion Laparoscopic ultrasonography in laparoscopic myomectomy can safely and effectively reduce the residual rate and recurrence rate of myomas after surgery.

Objective To evaluate the clinical value of laparoscopic ultrasonography in laparoscopic myomectomy surgery. Methods Totally 78 patients underwent laparoscopic myomectomy in our hospital from March 2016 to December 2016 were chosen. In all cases, visible fibroids were enucleated during laparoscopic myomectomy. Then we used laparoscopic ultrasonography to scan, positioning for residual fibroids and guide operator to enucleate them. Results Before the application of laparoscopic ultrasonography, the total number of enucleated fibroids compared with the total number of fibroids founded by preoperative transvaginal ultrasonography, there was no significant difference. The total number of enucleated fibroids in different locations of uterus (anterior wall, posterior wall, fundus, cervix) and in different locations of myometrium (intramural, submucosal, subserosal) was mostly less than the total number of fibroids founded by preoperative transvaginal ultrasonography, there was significant difference in intramural and submucosal fibroids. After the application of laparoscopic ultrasonography, the total number of enucleated fibroids compared with the total number of fibroids founded by preoperative transvaginal ultrasonography, there was significant statistical difference. The total number of enucleated fibroids in different locations of uterus and in different locations of myometrium was more than the total number of fibroids founded by preoperative transvaginal ultrasonography, there was significant statistical difference in anterior wall and intramural fibroids. The median diameter of minimum fibroids found by preoperative transvaginal ultrasonography was 1.5 cm, which by laparoscopic ultrasonography was 1.2 cm, there was significant statistical difference. Conclusion Laparoscopic ultrasonography in laparoscopic myomectomy can increase the fibroids detection rate and reduce the residual rate and recurrence rate of postoperative fibroids.

Endometriosis(EM) is a chronic disease affecting a portion of women in reproductive age.Most common pain symptoms of EM,which need long-term treatment,include dysmenorrhea,dyspareunia,and chronic pelvic pain.Only a few drugs have been introduced into clinical practice.The first line treatment for EM associated pain is still oral contraceptives.Progestins represent an acceptable ahemative.Other agents such as gonadotropin-releasing hormone (GnRH) analogues,GnRH antagonist,aromatase inhibitors,selective progesterone receptor modulator,danazol,nonsteroidal anti-inflammatory drugs seem to be promising,but significant side effects,high price should be taken into account.Therefore,the choice of the medication should be based on needs of patients,cost and drug tolerance.

Objective:To analyze the effect of biofeedback combined with electrical stimulation on the treatment of female pelvic floor dysfunction (PFD).Methods:1000 cases of PFD in our hospital from January 2011 to March 2016 were selected and divided into experimental group and control group according to the random number table method,500 cases in each group.The experimental group was treated with biofeedback and electrical stimulation,and the control group was treated with functional electrical stimulation.Compared with the two groups before and after the treatment of pelvic floor muscle muscle strength classification,the improvement of pelvic floor function and the improvement of patients before and after treatment.Results:After treatment,two groups of pelvic floor muscle strength grading showed a significant upward trend (Z=52.587,37.581;P＜0.001),and the improvement effect of the observation group was better than the control group (Z=27.588,P＜0.001);After treatment,the muscle strength of the pelvic floor in the experimental group was higher than that in the control group,the difference was statistically significant (x2=-68.323,P＜0.05);After treatment,the maximum systolic blood pressure and the increase of the continuous systolic blood pressure in the experimental group were significantly higher than that of the bladder neck,compared with the control group,the differences were statistically significant (P＜0.05),and after treatment,the two groups were improved by urination,the experimental group was better than the control group (P＜0.05).Conclusion:Biofeedback combined with electrical stimulation on female PFD has good effect,can improve the patient's pelvic floor maximum systolic pressure,continuous systolic pressure,reduce bladder neck mobility,improve the patient's urination function.

Objective To evaluate the predictive value of endometriosis fertility index (EFI) for reproductive perforrnance after laparoscopic surgery in endometriosis(EMs)-associated infertility.Methods From Jun 2012 to June 2014,consecutive EMs associated with infertility patients who underwent laparoscopic surgery were studied retrospectively.EFI was calculated by history factors,least function(LF) score and r-AFS endometriosis stage.The cumulative pregnancy rate 3 years after surgery was calculated by Kaplan-Meier survival analysis,and compared by Log Rank test.Results Within 3 years after surgery,the cumulative pregnancy rates among patients with EFI score 1-4,5,6,7,8,9 and 10 were 14.3％,50.0％,66.7％,69.2％,73.7％,75.0％ and 83.3％ respectively,the Log Rank test showed statistical significant difference among the above sub-groups (x2=18.83,P =0.004).The subjects were divided into 3 groups according to EFI score,the cumulative pregnancy rate within 3 years of EFI 1-4,EFI 5 and EFI 6-10 were 14.3％,50.5％ and 73.1％,respectively.The difference among these 3 groups was statistically significant (x2=18.106,P ＜ 0.001).In contrast,the cumulative pregnancy rate within 3 years ofr-AFS stage Ⅰ,Ⅱ,Ⅲ and Ⅳ were 79.1％,63.6％,58.5％ and 66.7％ respectively.No statistical significant difference among these stages was found (x2=4.075,P =0.253).Conclusion EFI has been demonstrated to have better predictive value than r-AFS for reproductive performance after laparoscopic surgery in endometriosis-associated infertility.EFI is valuable to guide management decision upon post-surgical pregnancy.

Endometriosis is a common disease which often leads to dysmenorrhea , infertility and other symptoms in women of childbearing age .Abnormal expression of microRNA ( miRNA ) plays an important role in the occurrence and development of endometriosis .miRNA may affect endometriosis through various pathophysiological processes ,but the precise role of miRNA has not yet been fully elucidated .Some miRNAs can promote endometriosis by regulating apoptosis and angiogenesis of endometriosis .miRNA is expected to become a potential therapeutic and diagnostic tool for endometriosis .

Objective To analyze the risk factors for previous cesarean scar defect.Methods Totally 128 patients who had received cesarean section were recruited in the study.Fifty-six of the cases came to visit a doctor because of previous cesarean scar defect between January 2013 and December 2015,while the other seventy-two cases had their scars healed under the vaginal ultrasound and with no symptoms related to previous cesarean scar defect.The medical records included general conditions (age,uterine position,gestational age,gravidity and parity history and neonatal weight) and perioperative conditions (pregnancy complications,puerperal infection,time of operation,and ways of incision suture) were collected.Risk factors for previous cesarean scar defect were analyzed.Results There were more cases of retroflexed uterus,delivery,cesarean sections,patients with gestational diabetes mellitus,cesarean sections during the second stage of labor,and more cases of single layer closure incision (P ＜ 0.05) in the group with previous cesarean scar defect.The risk factors for previous cesarean scar defect were the retroflexed uterus(OR =0.370,P ＜ 0.05),multiple cesarean sections(OR =0.147,P ＜ 0.01),cesarean sections during the second stage of labor (OR =0.543,P ＜ 0.05),and incisions with single layer closure(OR =1 1.126,P ＜ 0.05).Conclusions Rigorous control of indications,proper timing of cesarean sections,and improving surgical expertise are effective means of reducing the risk of previous cesarean scar defect.

目的：探讨经阴道传统手术治疗盆腔脏器脱垂的疗效及其对术后生活质量的影响。方法选取经阴道传统手术(改良曼氏手术、阴道前后壁修补术、阴式全切+前后壁修补术、阴道封闭术等)治疗盆腔脏器脱垂的患者170例，进行术后随访，根据盆底功能影响问卷(PFIQ-7)、盆底不适调查表(PISQ)和尿失禁性生活问卷(PISQ)评分，评估传统手术对患者生活质量的影响。结果170例患者中，主观治愈率92.35%，客观治愈率70.59%。术后尿失禁症状消失的患者占54.2%，新发尿失禁的患者11例，占6.5%；术前PISQ评分为(32.43±4.89)分，术后为(34.71±6.79)分，差异有显著性(P<0.05)，术后性交痛新发生率为9.9%。结论经阴道传统手术有效地改善了尿失禁症状和性生活满意度，提高了患者的生活质量。

本研究的目的在于探讨血管内皮生长因子(VEGF)和血小板反应蛋白-1(TSP-1)在子宫内膜异位症患者的在位内膜、卵巢子宫内膜异位囊肿及正常子宫内膜中的表达及意义.采用qPCR法检测在北京妇产医院接受腹腔镜手术的62例内异症患者的异位内膜、在位内膜及23例不孕症患者正常子宫内膜中VEGF和TSP-1 mRNA的表达水平.结果表明卵巢子宫内膜异位囊肿间质细胞中的VEGF mRNA的表达水平与在位子宫内膜间质细胞相比明显降低(p=0.001),而TSP-1 mRNA的表达水平明显高于后者(p＜0.001).VEGF mRNA在卵巢子宫内膜异位囊肿组织中的表达水平明显低于在位子宫内膜组织(p＜0.001),而TSP-1 mRNA的表达水平明显高于后者(p＜0.001).VEGFmRNA在在位子宫内膜组织中的表达水平明显高于正常子宫内膜组织(p＜0.001).TSP-1 mRNA的表达与后者相比无统计学差异(p=0.221).血管形成相关基因VEGF和TSP-1在卵巢子宫内膜异位囊肿和在位子宫内膜组织、细胞中表达不同,其可能参与了子宫内膜异位症的发生和发展.

子宫内膜异位症(endometriosis，内异症)，是育龄期妇女的常见病，其病变广泛，形态多样，极具侵袭性，易复发，可造成患者身体、心理的损害，严重影响生命质量[1]。目前，内异症的发病机制不明，其中包括子宫内膜种植学说、体腔上皮化生学说、遗传免疫内分泌机制及郎景和院士提出的“在位内膜决定论”等[2-3]。血管形成在内异症的病理生理中起重要作用；类似于肿瘤的转移，异位内膜的种植需要血管的形成，进而侵入细胞外基质、形成内异症病灶[4]。血管形成因子--血管内皮生长因子(VEGF)和血管形成抑制因子--血小板反应蛋白1(TSP-1)通过调控血管形成在内异症病灶的发生、发展中起着重要作用[5]。

Objective To investigate the preoperative evaluation , the choice of operative procedures and measures for the prevention of postoperative recurrence of cervical atresia , so as to preserve fertility function maximatily .Methods Analysis and evaluation were conducted on clinical data of 8 cases of congenital cervical atresia admitted during the period of January 1992 to March 2014 in Beijing Obstetrics and Gynecology Hospital of Capital Medical University to explore the best treatment for congenital cervical atresia .Results The ages of the cases ranged from 11 to 24 years old.All cases suffered from congenital absence of vagina .Among them 2 cases had uterine malformation, 3 cases had adenomyosis and 4 ovarian endometrioma .Four cases had hysterectomy , and 3 of them had excision of ovarian endometrioma at the same time .These four cases underwent vaginal reconstructive procedures after they got married .Two cases was planned to perform utero-vaginal anastomosis .After vaginaplasty , the tissue between top of the vagina and the mass was found to be tough , so hysterectomy was performed after failure of attempting to open the clearance .One of them had excision of ovarian endometrioma at the same time.Both used amniotic membrane as lining material in the vaginal reconstructive procedures .Two cases successfully accepted utero-vaginal anastomosis , and measurement was adopted to prevent cervical re-adhesion.After procedure the menstruation was normal , and no hypogastralgia was found .Conclusion For patients with congenital cervical atresia , a preoperative assessment should be made including the clinical situation and prognosis , and then develop a treatment plan .Utero-vaginal anastomosis should be chosen cautiously , and to keep the uterine drainage unobstructed with a support in the cervix after operation is the key to the success of surgery .