延长放置宫腔球囊支架预防中重度宫腔粘连术后复粘的临床初探
|
摘要
目的探讨延长放置COOK球囊支架预防宫腔粘连(IUA)术后复发的有效性及安全性。方法 38例中、重度宫腔粘连患者行宫腔镜下宫腔粘连分离术,术后宫腔内放置COOK球囊支架预防宫腔粘连复发,术后1月左右行宫腔镜二探手术、同时取出COOK球囊支架,随访效果。结果 38例患者随访7~25个月,平均17.5个月。二探术中约90%的患者(AFS评分系统97.4%,ESGE评级系统89.5%)宫腔粘连程度减轻,81.6%(31/38)的中、重度宫腔粘连患者仅需单次手术即可达到满意的宫腔形态重塑效果,超过70%的患者(AFS评分系统73.7%,ESGE评级系统78.9%)达无粘连/轻度粘连。7.6%(3/38)的患者发生可控的感染,不影响二探效果。在33例原有月经减少或闭经的患者中经量改善的总有效率为81.8%(27/33)。25例患者尝试妊娠,总的妊娠率44.0%(11/25),其中18例自然试孕,平均试孕8个月(2~15个月),自然妊娠率27.8%(5/18)。由于随诊时间较短,活产率仅为8.0%(2/25)。结论宫腔粘连分离术后延长放置宫腔球囊支架可有效巩固和维持手术对宫腔重建的效果,出现的个例感染并发症均不严重而可控,绝大多数患者在距离前次手术一个月左右的二探术中无需重复治疗,月经改善和术后妊娠率均比较可观。
Objective:To assess the efficacy and safety of prolonged placement of a heart-shaped intrauterine balloon in the prevention of adhesion reformation after hysteroscopic adhesiolysis in patients with moderate to severe Asherman's syndrome.Methods:In 38 patients with moderate to severe adhesions,hysteroscopic adhesiolysis was performed.A heart-shaped intrauterine balloon was placed inflated in the uterus after surgery and was deflated the next day.Patients were prescribed 1 month of estrogen as well as progestin therapy.A second-look hysteroscopy was carried out in all patients after the first withdrawal vaginal bleeding,at the same time the balloon uterine stent was removed.The uterine cavity was evaluated,and adhesions were further lysed.Main outcomes measured were pregnancy rate and live birth rate.Results:Thirty-eight patients were followed-up with a mean time of 17.5 months(range 7-25 months).81.8%(27/33)of the patients had an improvement in menstrual blood volume and about 90% of the patients had lower IUA scores postoperatively.The need for repeated treatment was in 7/38(18.4%)patients.Genital tract infection developed in 3/38(7.6%)patients,which abated promptly after the removal of the balloon uterine stent and antibiotics treatment.Overall pregnancy rate after treatment was 11/25(44.0%),while spontaneous pregnancy rate was 5/18(27.8%)and live birth rate was 2/25(8.0%).Conclusions:Prolonged placement of a balloon uterine stent in the prevention of adhesion reformation after hysteroscopic adhesiolysis of moderate to severe Asherman's syndrome appeared to be effective and safe for the reconstruction of a functional uterine cavity,with a pregnancy rate of 44.0% and infection rate of 7.6%
Objective:To assess the efficacy and safety of prolonged placement of a heart-shaped intrauterine balloon in the prevention of adhesion reformation after hysteroscopic adhesiolysis in patients with moderate to severe Asherman's syndrome.Methods:In 38 patients with moderate to severe adhesions,hysteroscopic adhesiolysis was performed.A heart-shaped intrauterine balloon was placed inflated in the uterus after surgery and was deflated the next day.Patients were prescribed 1 month of estrogen as well as progestin therapy.A second-look hysteroscopy was carried out in all patients after the first withdrawal vaginal bleeding,at the same time the balloon uterine stent was removed.The uterine cavity was evaluated,and adhesions were further lysed.Main outcomes measured were pregnancy rate and live birth rate.Results:Thirty-eight patients were followed-up with a mean time of 17.5 months(range 7-25 months).81.8%(27/33)of the patients had an improvement in menstrual blood volume and about 90% of the patients had lower IUA scores postoperatively.The need for repeated treatment was in 7/38(18.4%)patients.Genital tract infection developed in 3/38(7.6%)patients,which abated promptly after the removal of the balloon uterine stent and antibiotics treatment.Overall pregnancy rate after treatment was 11/25(44.0%),while spontaneous pregnancy rate was 5/18(27.8%)and live birth rate was 2/25(8.0%).Conclusions:Prolonged placement of a balloon uterine stent in the prevention of adhesion reformation after hysteroscopic adhesiolysis of moderate to severe Asherman's syndrome appeared to be effective and safe for the reconstruction of a functional uterine cavity,with a pregnancy rate of 44.0% and infection rate of 7.6%
引文
[1] AAGL Elevating Gynecologic Surgery.AAGL Practice Report:Practice Guidelines on Intrauterine Adhesions Developed in Collaboration With the European Society of Gynaecological Endoscopy(ESGE)[J].J Minim Invasive Gynecol,2017,24:695-705.
[2] Salazar CA,Isaacson KB.Office operative hysteroscopy:an update[J].J Minim Invasive Gynecol,2018,25:199-208.
[3] Yang JH,Chen CD,Chen SU,et al.The influence of the location and extent of intrauterine adhesions on recurrence after hysteroscopic adhesiolysis[J].BJOG,2016,123:618-623.
[4] Robinson JK,Colimon LM,Isaacson KB.Postoperative adhesiolysis therapy for intrauterine adhesions(Asherman’s syndrome)[J].Fertil Steril,2008,90:409-414.
[5] Yang JH,Chen MJ,Chen CD,et al.Optimal waiting period for subsequent fertility treatment after various hysteroscopic surgeries[J].Fertil Steril 2013,99:2092-2096.
[6] Hamou J,Salat-Baroux J,Siegler AM.Diagnosis and treatment of intrauterine adhesions by microhysteroscopy[J].Fertil Steril,1983,39:321-326.
[7] Howes EL,Harwey SC.The strength of the healing wound in relation to the holding strength of the chromic catgut suture[J].N Engl J Med,1929,200:1285-1291.
[8]中华医学会妇产科学分会.宫腔粘连临床诊疗中国专家共识[J].中华妇产科杂志,2015,50:881-887.
[9] Bosteels J,Weyers S,D’Hooghe TM,et al.Anti-adhesion therapy following operative hysteroscopy for treatment of female subfertility.Cochrane Database Syst Rev,2017,(11):CD011110.
[10] Lin YH,Jang TN,Hwang JL,et al.Bacterial colonization with balloon uterine stent placement in the uterus for 30days:a randomized controlled clinical trial[J].Fertil Steril,2015,103:513-518.
[11]朱蕾蕾,冯淑英,张莘,等.长时间放置cook球囊支架预防宫腔粘连术后复发的临床应用[J].中国现代药物应用,2016,6:82-83.
[12] Khan Z,Goldberg JM. Hysteroscopic management of Asherman’s syndrome[J].J Minim Invasive Gynecol,2018,25:218-228.
[13]汤一群,段华,汪沙,等.中重度宫腔粘连术后妊娠率及其影响因素分析[J].中国计划生育和妇产科,2017,9:37-41.
[14] Zhao J,Chen Q,Cai D,et al.Dominant factors affecting reproductive outcomes of fertility-desiring young women with intrauterine adhesions[J].Arch Gynecol Obstet,2017,295:923-927.
[15]吴敬妮,张松英.比较不同宫腔粘连分类系统提示妊娠预后的价值[D].浙江大学硕士学位论文,2015.
[16] March CM,Israel R,March AD,et al.Hysteroscopic management of intrauterine adhesions[J].Am J Obstet Gynecol,1978,130:653-657.
[17] The American Fertility Society classifications of adnexal adhesions,distal tubal occlusion,tubal occlusion secondary to tubal ligation,tubal pregnancies,Müllerian anomalies and intrauterine adhesions[J].Fertil Steril,1988,49:944-955.
[2] Salazar CA,Isaacson KB.Office operative hysteroscopy:an update[J].J Minim Invasive Gynecol,2018,25:199-208.
[3] Yang JH,Chen CD,Chen SU,et al.The influence of the location and extent of intrauterine adhesions on recurrence after hysteroscopic adhesiolysis[J].BJOG,2016,123:618-623.
[4] Robinson JK,Colimon LM,Isaacson KB.Postoperative adhesiolysis therapy for intrauterine adhesions(Asherman’s syndrome)[J].Fertil Steril,2008,90:409-414.
[5] Yang JH,Chen MJ,Chen CD,et al.Optimal waiting period for subsequent fertility treatment after various hysteroscopic surgeries[J].Fertil Steril 2013,99:2092-2096.
[6] Hamou J,Salat-Baroux J,Siegler AM.Diagnosis and treatment of intrauterine adhesions by microhysteroscopy[J].Fertil Steril,1983,39:321-326.
[7] Howes EL,Harwey SC.The strength of the healing wound in relation to the holding strength of the chromic catgut suture[J].N Engl J Med,1929,200:1285-1291.
[8]中华医学会妇产科学分会.宫腔粘连临床诊疗中国专家共识[J].中华妇产科杂志,2015,50:881-887.
[9] Bosteels J,Weyers S,D’Hooghe TM,et al.Anti-adhesion therapy following operative hysteroscopy for treatment of female subfertility.Cochrane Database Syst Rev,2017,(11):CD011110.
[10] Lin YH,Jang TN,Hwang JL,et al.Bacterial colonization with balloon uterine stent placement in the uterus for 30days:a randomized controlled clinical trial[J].Fertil Steril,2015,103:513-518.
[11]朱蕾蕾,冯淑英,张莘,等.长时间放置cook球囊支架预防宫腔粘连术后复发的临床应用[J].中国现代药物应用,2016,6:82-83.
[12] Khan Z,Goldberg JM. Hysteroscopic management of Asherman’s syndrome[J].J Minim Invasive Gynecol,2018,25:218-228.
[13]汤一群,段华,汪沙,等.中重度宫腔粘连术后妊娠率及其影响因素分析[J].中国计划生育和妇产科,2017,9:37-41.
[14] Zhao J,Chen Q,Cai D,et al.Dominant factors affecting reproductive outcomes of fertility-desiring young women with intrauterine adhesions[J].Arch Gynecol Obstet,2017,295:923-927.
[15]吴敬妮,张松英.比较不同宫腔粘连分类系统提示妊娠预后的价值[D].浙江大学硕士学位论文,2015.
[16] March CM,Israel R,March AD,et al.Hysteroscopic management of intrauterine adhesions[J].Am J Obstet Gynecol,1978,130:653-657.
[17] The American Fertility Society classifications of adnexal adhesions,distal tubal occlusion,tubal occlusion secondary to tubal ligation,tubal pregnancies,Müllerian anomalies and intrauterine adhesions[J].Fertil Steril,1988,49:944-955.