자궁적출술 전후 정신.신체적 변화

곽영희(YH Kwak),조재성(JS Cho),한형장(HJ Han),박찬규(CK Park),민성길(SK Min) 대한산부인과학회 1987 Obstetrics & Gynecology Science Vol.30 No.9

1986년 2월 1일부터 1986년 10월 31일까지 연세대학교 의과대학 부속 세브란스병원에서 부인과적 적응력에 따라 자궁적출술을 시행한 환자 92명과 동기간중 외래로 자궁암 검진차 내원한 환자 중 신체검사상 정상으로 판단된 96명을 대상으로 정상인과 자궁적출술 시행환자 그리고 자궁적출술 시행환자에서 수술 전후에 있어 우울과 불안정도, 신체적 증상 그리고 이에 관련된 요인 등에 대하여 연구하여 다음과 같은 결과를 얻었다. 1. 자궁적출술군에서 수술전 자궁에 대한 이해정도는 자궁이 없어지면 기운이 없어진다-43명, 신체적인 이상이 올 것이다-40명, 부부생활에 나쁜 변화가 올 것이다-23명, 여성다움을 잃을 것이다-21명, 아기를 낳을 수 없다-17명, 기운이 난다-13명, 내자신이 쓸모없는 사람이 될 것이다-9명, 남편의 애정에 놓은 영향을 줄 것이다-7명, 부부생활에 좋은 변화가 올 것이다-6명, 노이로제같은 병이 생길 것이다-6명 등의 순으로 응답하였다. 또한 자궁이 없어지면 아기를 낳을 수 없다. 남편의 애정에 놓은 영향을 줄 것이다. 부부생활에 좋은 혹은 나쁜 변화가 온다. 여성다움을 잃을 것이다 등은 연령이 적을수록 통계적으로 유의하게 많은 응답을 보였다. 2. 정상인과 수술전 자궁적출술 환자를 비교시 SDS의 평균은 정상인 39.98, 수술전 자궁적출술환자 42.60으로 유의한 차이를 보였다. STAI S-A의 평균은 정상인 38.18, 수술전 자궁적출술환자 46.82로 유의한 차이를 보였다. STAI T-A의 평균은 정상인 39.81, 수술전 자궁적출술 환자 40.90으로 유의한 차이가 없었다. 3. 자궁적출술 환자에서 수술전후를 비교시 SDS의 평균은 수술전 42.60, 수술후 47.02로 유의한 증가를 나타냈다. STAI S-A의 평균은 수술전 46.82, 수술 후 37.68로 유의한 감소를 나타냈다. 4. 자궁적출술 환자에서 각 변인별 우울과 불안정도를 비교한 결과 연령, 교육정도, 종교, 경제수준, 성장지, 직업유무, 결혼상태, 가족력, 분만횟수, 난소보존 유무 그리고 빈혈유무 등에서 모두 유의한 상관관계가 없었다. There have been many clinical reports on the various symptoms that might emerge after hysterectomy. But the recent studies using prospective method and standardized scales tended to show the following results; A patient who showed definite clinical symptoms after hysterectomy might have already been present with psychological morbidity and the level of psychological morbidity was much higher than general population both before and after hysterectomy. The materials consisted of 92 patients who rceived hysterectomy at the department of Obstetrics and Gynecology, Yonsei University College of Medicine from Feb. 1st to Oct. 31th, 1986 and 96 patients from general population who visited the out patient clinic of the department of Obstetrics and Gynecology, Yonsei University College of Medicine for routin Papanicolau smear and confirmed healthy person by physical examination. The severity of depression and anxiety and somatic symptoms were compared for the following 2 pairs of groups; first between the hysterectomized patients and the general population and second in each hysterectomized patient before and after hysterectomy. The factors related to severity of depression and anxiety were also analysed. The results obtained were as follows: 1. Preoperative understanding of how hysterectomy would affect the future physical and psychological well-beings were as follows: 43 patients answered that there would be loss of strength; 40 patients, physical changes; 23 patients, poor sexual life; 21 patients, defeminization; 21 patients, loss of child bearing capability; 17 patients, bad effect to husbands affection; 13 patients, increased strength; 9 patients, feeling of worthlessness; 7 patients, increased affection from the husband; 6 patients, enhanced sexual life and 6 patients, neurotic disorder. And younger age froup showed significantly many answers in loss of childbearing capability, good effect to husbands affection, enhanced or poor sexual life and loss of feminity.

임신성고혈압 환자 태반에서의 Adhesion Molecules의 표현과 자궁동맥 도플러초음파 소견과의 상관관계에 관한 연구

박용원,조재성,김태윤,최형민,김경수,임영구 대한산부인과학회 1997 Obstetrics & Gynecology Science Vol.40 No.6

Introduction: The pathophysiology of PIH remains unclear. Recently, placental abnormalities are stressed as a possible cause of PIH. Abnormal shallow invasion of trophoblasts, confined to decidua, without involving myometrium is believed to result in reduced uteroplacental perfusion, endothelial injury, and activation of coagulation cascade system. Integrin, one of the adhesive membrane proteins, is expected to be related to the regulation of trophoblasts invasion. Purpose: The purpose of this study is to investigate the expression of adhesion molecules in placenta and the correlation between uterine artery Doppler findings and integrin expressions in the placentas of PIH patients. Subjects: Thirty-six cases of severe PIH patients were enrolled in the study with 10 number of normal control pregnant women. The integrin subunit expressions with immunohistochemical staining were observed in floating villi, maternal-side cytotropholbasts, and fetal-side cytotrophoblasts. Uterine artery Doppler study was also performed, and the S/D ratio was evaluated. Abnormal Doppler findings was defined as S/D ratio≥2.6. Results: Cytoplasmic staining of villi and placental bed cytotrophoblast for the integrin α1 subunit in PIH specimen was weaker than those in normal controls. The expression of integrin β1 subunit was negative for both controls and PIH group. The positive cytoplasmic stain was observed among PIH placenta in contrast to normal control in which the expression of integrin β4 subunit was not detected. The expression of αvβ 3 in trophoblast with PIH was positive staining, but not in control group. Uterine artery Doppler velocimetry was performed in 25 cases with PIH. Trace(+/-) or - staining of integrin α1 subunit were observed in 60.0% of abnormal S/D(≥2.6) group, 20.0% of normal S/D ratio group patients, respectively. Trace or + staining of integrin β4 subunit were observed in 50.0% of abnormal S/D group and 6.7% of normal S/D group and this is in statistically significant. Trace or + staining of integrin αvβ3 subunit were observed 70.0% of abnormal S/D group and 26.7% of normal S/D group, and this statistically significant. Conclusion: In PIH the abnormality in the invasion of cytotrophoblats results in abnormal integrin subunit expression, but it is also correlated to the abnormal uterine artery Doppler velocimetry which shows a S/D ratio of greater than 2.6. Thus, the uterine artery Doppler velocimetry reflects abnormal placentation.

산전 초음파검사로 진단된 태아 선천성기형에 대한 연구

박용원,조재성,김태윤,김석영,최형민,김경수,임영구 대한산부인과학회 1997 Obstetrics & Gynecology Science Vol.40 No.6

The incidence of congenital anomalies is reported to be 2~3% of live born births. In the past, infection was one of the major cause of perinatal morbidity and mortality, but owing to the development of antibiotics and intensive care, congenital anomalies are becoming a major cause of perinatal morbidity and mortality. Prenatal diagnosis of congenital anomalies is becoming more important because appropriate perinatal care may minimize the effect of congenital anomalies. We studied the incidence of congenital anomalies diagnosed by antenatal ultrasound examinations retrospectively. The study group was 13,652 pregnant women who were taken antenatal obstetric ultrasound examinations between Jan. 1, 1991 and Dec. 31, 1995. There were 694 cases of congenital anomalies diagnosed by antenatal ultrasonography examinations. The incidence of congenital anomalies was 5.1%. The most common congenital anomalies by organ system was central nervous system(32.7%), and the next were urogenital (14.7%), heart(11.7%), face and neck(8.4%), multiple anomalies(8.4%), G-I(6.8%), abdominal wall defect(4.5%), skeletal(3.5%), thorax(3.2%) in order. The most common congenital anomalies was choroid plexus cyst(8.8%), and the next were hydrocephalus(7.9%), hydronephrosis (6.5%), cystic hygroma(4.2%), anencephaly(3.9%), cleft lip and/or palate(2.9%), hydrops fetalis(2.4%), small intestinal obstruction(2.3%), multicystic kidney(2.2%), diaphragmatic hernia(2.2%), omphalocele(2.0%), gastroschisis(2.0%), holoprosencephaly(1.9%), ovarian cyst(1.6%), esophageal atresia(1.4%), microcephaly(1.4%), amniotic band syndrome (1.3%), meningocele or meningomyelocele(1.3%) in decreasing order. Ultrasonography may be a useful prenatal diagnostic method of detecting congenial anomalies.

임신중독증 산모 혈청의 인슐린 유사 성장인자 결합 단백질-1

박용원,조재성,최형민,이연혜,유용균 대한산부인과학회 1998 Obstetrics & Gynecology Science Vol.41 No.5

인슐린 유사 성장인자(IGF)는 태아 성장을 조절하는데 중요한 역할을 한다고 알려져 있고, 인슐린 유사 성장인자 결합단백질(IGF-BP-1)이 인슐린 유사 성장인자의 기능을 조절하고 인슐린 유사 성장인자 결합단백질 자체도 태아의 성장과 발달에 중요한 역할을 한다고 생각된다. 본 연구에서 정상 산모와 임신중독증 산모, 그리고 임신중독증이 있으면서 저체중아를 분만한 산모 혈청의 인슐린 유사 성장인자 결합단백질을 측정하여 다음과 같은 결과를 얻었다. 1. 임신중독증을 가진 산모에서 출생한 신생아와 대조군에서 출생한 신생아의 체중은 각각 2321.5± 647.8, 3187.5±338.5 g으로 의의 있는 차이가 있었으 며 산모 혈청내 IGF-BP-1은 각각 183.5±46.3 ng/ml, 148.9±44.3 ng/ml로 임신중독증을 가진 산모에서 의 의있게 높았다(p value<0.001). 2. 임신중독증을 가진 산모 중 자궁내 태아 발육 지연이 있었던 산모혈청의 IGF-BP-1은 1991.1±44.8 ng/ml로 자궁내 태아 발육 지연이 없었던 산모 혈청 내의 IGF-BP-1 167.1±42.2 ng/ml보다 높았다(p value <0.001). 이상의 결과로 임신중독증과 태아의 체중에 따라 산모 혈청의 인슐린 유사 성장인자 결합단백질은 차 이가 있었으며 임상적으로 이용하기 위해서는 좀더 많은 연구가 필요할 것으로 사료된다. IGF-BP-1 is known to have a important role in fetal growth and development by modulation of the actions of IGF, but also has its independent actions and in vitro IGF- BP-1 inhibits cytotrophoblastic invasion into decidualized stromal multilayers. The goals of this study are to investigate the IGF-BP-1 in maternal serum of women with pregnancy induced hypertension and without and evaluate the relationship between IGF-BP-1 of maternal serum and intrauterine growth restriction. IGF-BP-1 levels in maternal serum with pregnacy induced hypertension were 183.5±46.3 ng/ml compared with 148.9±44.3 ng/ml in controls (p<0.01). IGF-BP-1 levels in maternal serum with pregnancy induced hypertension and intrauterine growth restriction were 199.1±44.8 ng/ml compared with 167.1±42.2 ng/ml in maternal serum with pregnancy induced hypertension but without intrauterine growth restriction. In conclusion, elevated maternal serum IGF-BP-1 levels may contribute to restricted placental and therefore fetal growth.

자궁태반 기능부전증의 예측에 있어 Doppler 초음파검사의 유용성

박용원,조재성,김태윤,최형민,김경수,임영구 대한산부인과학회 1997 Obstetrics & Gynecology Science Vol.40 No.5

This study was designed to investigate a possible role for Doppler velocimetry as a predictor of uteroplacental insufficiency with fetal heart rate(FHR) tracing. From January 1994 to through May 1996, we studied 419 high risk pregnant women who underwent Doppler velocimetry within 1 week of intrapartum cardiotocogram or contraction stress test (CST) after 30 gestational weeks. The presence of a diastolic notch in uterine artery, elevated systolic/diastolic(S/D) ratios in umbilical artery(more than 3.0), or in uterine artery (more than 2.6) were considered abnormal. All of the 419 subjects were performed intrapartum cardiotocogram or CST within 1 week after Doppler veocimetry. Seventeen cases were associated with persistent late deceleration or positive CST. The sensitivity, specificity, positive predictive value, negative predictive value, and relative risk of umbilical artery S/D ratio for predicting abnormal FHR tracing were 23.5%(4/17), 89.3%(359/402), 8.5%(4/ 47), 96.5%(359/372), and 0.97. those of uterine artery S/D ratio and diastolic notch were 29.4%(5/17), 92.5%(372/402), 14.3%(5/35), 96.9%(372/384), 1.35 and 35.3%(6/17), 90.3% (363/402), 13.3%(6/45), 97.6%(363/374), 3.88 respectively. The presence of uterine artery diastolic notch in Doppler velocimetry seems to be a better predictor for abnormal FHR tracing after 30 weeks gestation than are S/D ratios in umbilical or uterine arteries. In conclusion, we can suggest that the presence of diastolic notch in uterine artery Doppler velocimetry might be useful to predict the uteroplacental insufficiency after 30 gestational weeks.

산전 초음파에 의해 진단된 외엽성폐격리증 1 예

박용원,조재성,최형민,신동환,이연혜,유용균,최은경,이현희 대한산부인과학회 1997 Obstetrics & Gynecology Science Vol.40 No.9

Pulmonary sequestration is a congenital anomaly of lung in which a portion of lung par-enchyma has no communication with the tracheobronchial tree and receives its blood supply via systemic artery. Sequestration represents a developmental anomaly of tracheobronchial branching with persistence and localized development of a separated branch fragment and retention of its embr- yonic systemic vascular supply. In the review of the literature, this disease is so rare that only 540 cases were reported worldwide. The anomaly is divided into 2 types;intralobar and extr- alobar. The ratio of intralobar type and extralobar type is about 3.5 : 1 and intralobar type is more common than the latter in all age groups. The intralobar type is contiguous with normal lung parenchyma and within the same visceral pleural envelope ; in contrast, the extralobar type is enclosed within its own pleural membrane, usually close to a normal lung but separated and discovered most commonly in the left hemithorax with rare cases in the abdominal cavity. Traditionally, this disease has been presented as an incidental lung mass in routine chest X-ray in the postnatal period and with confirmation by aortic angiography, but recently, pul- monary sequestration is diagnosed in the antenatal period along with the development of ant- enatal ultrasonography. Ultrasonography shows the pulmonary sequestration as a hyperecho- genic mass near the diaphragm with posterior echo-free shadow. We have experienced one case of pulmonary sequestration which was found by antenatal ultrasonography and confirmed by operation and histopathologic report in the neonatal period, and we present the case with a brief review of the literatures.

선천성 심장질환의 진단에서 태아 심초음파검사의 진단적 유용성

박용원,조재성,최형민,이연혜,유용균 대한산부인과학회 1998 Obstetrics & Gynecology Science Vol.41 No.7

1991년 1월부터 1996년 12월까지 연세대학교 의과대학부속 세브란스병원 산부인과에 내원한 임산부 중 4-CV와 SAV, LAV를 모두 관찰하였고, 본원에서 분만한 5,598명의 산모를 대상으로 태아 심초음파의 진단적 정확도를 조사하여 다음과 같은 결과를 얻었다. 연구 대상 5,598명 중 선천성 심장기형은 54예로 1,000명당 9.6명의 빈도를 보였고, 산전 태아 심초음파의 진단적 정확도는 4-CV만을 사용한 경우에는 54명의 선천성 심장기형을 가진 태아 중 28예를 진단하여 민감도 는 51.9%, 양성 예측도는 100%였으며 4-CV와 LAV를 함께 사용한 경우에는 54명 중 35예를 진단하여 민감도는 64.8%, 양성 예측도는 94.6%였다. 선천성 심장기형의 진단에는 기존의 선별검사로서 이 용되던 4-CV가 진단적 한계가 있어, 등 여러 단면을 이용하게 된다. 그러나 4-CV, LAV, SAV 등의 모든 단면을 검사하는 것은 검사자의 숙련도, 기계의 해상력, 소요시 간 등의 문제점이 있다. 이상의 결과에서 4-CV, LAV, 그리고 SAV를 모두 사 용한 경우와 4-CV에 LAV만을 추가한 경우의 진단적 정확도는 유사하며, 따라서 비교적 용이하게 시행할 수 있 는 LAV를 기존의 4-CV에 추가하여 선천성 심장기형을 가진 태아의 산전 진단을 위한 선별검사시 사용하면, 좀 더 많은 선천성 심장기형을 가진 태아를 산전에 진단할 수 있을 것으로 사료된다. It is important to recognize congenital heart disease (CHD) prenatally, because CHD is the most common congenital major anomaly in neonates that contributes to significant perinatal morbidity and mortality. Previous studies have demonstrated the usefulness of the four-chamber view (4-CV) for the prenatal detection of cardiac anomalies. Our purpose was to determine whether the addition of long axis view (LAV) and short axis view (SAV) would detect more congenital cardiac anomalies. This study included 5,598 pregnant women who were obtained all 4-CV, LAV and SAV, and delivered in Severance hospital from Jan 1991 through Dec 1996. The diagnostic accuracy of each view was evaluated. Information of outcome was obtained from physical examinations, postnatal echocardiography and/or autopsies. The 4-CV detected 28 (51.9%) of the 54 fetuses with abnormal heart. Adding the LAV increased the sensitivity to 64.8% and adding the SAV increased the sensitivity to 57.4%. Adding the LAV and SAV increased the sensitivity to 64.8% and was same as adding only LAV. In conclusion, adding the only LAV to the standard 4-CV will result in the more prenatal detection of cardiac anomalies.

신장이식을 받은 여성에서의 성공적인 임신 및 분만에 관한 보고

송찬호,박용원,조재성,연혜정,김유선,박기일 대한산부인과학회 1993 Obstetrics & Gynecology Science Vol.36 No.8

신장이식후의 임신은 산모와 태아에 여러 위험성을 안고있는 고위험인신군으로 high risk obstetric unit 에서 임신전 평가를 거쳐야 한다. 만성 신장질환 환자는 혈액투석중이나 신장이식후 수개월내에 임신이 될 수 있으므로 적어도 1년간 피임을 해야하며 barrier method(콘돔)가 가장 적합하다고 생각된다. 또한 감염의 위험이 많으므로 바이러스나 요로 감염을 적극적으로 감시하여야 하며, 정기적인 자궁경부의 세포진검사를 시행하여야 한다. 임신중에는 신장기능과 임신성고혈압의 발생, 빈혈 및 감염의 진단과 치료에 주의하되 산전방문은 임신 28주까지는 2주마다, 그후에는 1주마다 시행하며 이때 각 시기에 필요한 검사를 실시한다. 현재 사용중인 면역억제제는 태아와 산모 모두에게 비교적 안전하게 사용할 수 있으나 임신중의 약물대사, 이식신장의 예후 및 후손에 미치는 장기-단기적인 영향을 감시하고 위해 주의깊은 추적관찰이 필요하다고 하겠다. 저자들은 연세의료원에서 신장이식을 시행했던 가임여성중 5명에서 성공적인 분만예를 경험하였기에 문헌고찰과 함께 이를 보고하는 바이다. Transplant recipients who are pregnant are often faced with several kinds of medical problems, such as toxemia and infection, which may contribute to produce a high incidence of preterm labor. As yet many questions regarding the likelihood of successful pregnancy and birth in women after renal allograft and unanswered. In this report, we present our experience of 5 cases of successful pregnancy and birth after renal transplant under strict perinatal care protocol with short review of world literature to establish the proper guideline. There were neither serious complications during gestation in mothers nor problems in infants. But still unknown is the feature of these infants and their progency because of their intrauterine exposure to immunosuppressive drugs. In conclusion, renal allograft with chronic immunosuppression is not per sean obstacle for successful pregnancy and birth, if graft function is excellent and stable.

임신 제 2 분기에서의 자궁동맥 도플러 초음파 소견상 이완기 함요의 임상적 의의

김재욱,박용원,조재성,최형민,김경수,권혜경 대한산부인과학회 1998 Obstetrics & Gynecology Science Vol.41 No.3

Introduction: The early diastolic notch of the uterine artery Doppler waveform analysis is thought to be the result of high resistance in blood flow. It is known to be associated with intrauterine growth restriction, pregnancy induced hypertension, and poor perinatal outcomes. But the clinical significance of early diastolic notch in the second trimester is not well known. Purpose: To evaluate the clinical significance of early diastolic notch of uterine artery Doppler waveform in the second trimester and to evaluate a possible role for notch index [NI] of uterine artery Doppler waveform in the second trimester to predict the persistence of early diastolic notch in the third trimester. Materials & Methods: Total 1708 pregnant women who had taken antenatal ultrasonographic examinations and uterine artery Doppler waveform analysis in the second and third trimester were groupped by the presence of early diastolic notch in the second and third trimester: group I [1553 cases] with no notch, group II [80 cases] with notch in the second trimester only, group III[36 cases] with notch in the third trimester only, and group IV [39 cases] with notch in both second and third trimester. The depth of early diastolic notch was assessed by NI, that was calculated as minimal velocity in early diastole divided by maximal velocity in diastole. Criteria of poor perinatal outcomes were as follows: cesarean section due to fetal distress, 5 minute Apgar score below 6, intrauterine growth restriction, neonatal intensive care unit admission, and perinatal death. The uterine artery Doppler waveform were measured at crossing area between uterine artery and iliac artery. Results: Ratio of poor perinatal outcomes of group Ⅰ, Ⅱ, Ⅲ, and Ⅳ were 10.6%, 15.0%, 47.2%, and 41.0%, respectively, and were significantly different between the groups [p<0.05]. In the second trimester, the NI of cases with notch in the second trimester only [group Ⅱ, 0.84±0.16] showed significant difference from those of whom with notch in both second and third trimester [group IV, 0.80±0.19] [p<0.05]. Conclusion: If there is an early diastolic notch of uterine artery velocity waveform in the second trimester, to evaluate the depth of early diastolic notch by NI could be useful in predicting whether early diastolic notch persists or not in the third trimester.

고위험임산부에서 저용량 Aspirin의 투여 결정을 위한 도플러초음파의 임상적 효용성

송찬호,박용원,조재성,김태윤,김행수,김경수 대한산부인과학회 1997 Obstetrics & Gynecology Science Vol.40 No.1

We investigated the capacity of low dose aspirin in reducing the incidence of pregnancy induced hypertension and affecting the pregnancy outcomes in women at high risk for this disorder. And we also studied the efficacy of Doppler ultrasound as an effective means of selecting a patient population of good candidate to administer low dose aspirin. Seventy women with chronic hypertension or a history of severe preeclampsia in their previous pregnancy were randomly assigned to treated group receiving low dose aspirin(60 mg/d, n=32) or control group(n=38). Daily administration of low dose aspirin could not prevent the development of pregnancy induced hypertension in the treated group(21.9% vs. 28.3%, p$gt;0.05). And there was no differences between the treated and control groups in the rates of emergency cesarean section for fetal distress(6.3% vs. 10.3%, p$gt;0.05), neonatal intensive care unit admission(9.4% vs. 15.8%, p$gt;0.05), fetal growth retardation(15.6% vs. 13.2%, p$gt;0.05), and perinatal death(3.1% vs. 7.9%, p$gt;0.05). In the group showing abnormal Doppler flow velocity waveform, aspirin seemed to improve the mean gestational age(35.7±2.8 vs. 34.4±3.1 weeks), birth weight(2271.9±730.8 vs. 1887.0±619.0 gm) and the pregnancy outcomes(31.3% vs. 60.6%), however, these results were not statistically significant(p$gt;0.05). This study suggests that low dose aspirin therapy is not effective in reducing the incidence of pregnancy induced hypertension. However, combination of Doppler ultrasound study with low doe aspirin therapy may improve pregnancy outcomes in women with high risk pregnancy.