子宫动脉栓塞术对子宫瘢痕妊娠患者治疗价值的新探讨
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摘要
目的:探讨子宫动脉栓塞术(UAE)对子宫瘢痕妊娠患者的治疗价值,进一步证实I型子宫瘢痕妊娠可直接行彩超引导下清宫术。方法:随机选取2015年1月至2017年5月保定市第二中心医院收治的子宫瘢痕妊娠患者58例,依据随机自愿原则将这些患者分为子宫动脉栓塞术组(31例)和直接行清宫术组(27例),对两组患者的年龄、孕囊直径、距离子宫前壁肌层厚度、术前血HCG值、术后血HCG值降至正常时间、术中出血量、住院时间、术后月经量的改变、术后卵巢功能进行统计分析。结果:术后月经量占正常经量的比例分为4级:1级为术后月经量占正常经量1/4,以此类推。采用秩和检验:直接行清宫术组平均秩次38. 50,秩次之和1039. 50; UAE组平均秩次21. 66,秩次之和671. 50,两组比较差异具有统计学意义(P<0. 05),说明行子宫动脉栓塞术后再行彩超引导下清宫组术后月经量较前明显减少,其中宫腔镜检查发现4例重度宫腔粘连。两组患者的年龄、孕囊大小、子宫切口瘢痕处前壁肌层厚度、术中出血量、住院时间、两组患者的术前β-h CG水平、转阴时间差异无统计学意义(P> 0. 05)。两组患者术后的血清E2、LH、FSH水平之间的差异无统计学意义(all P> 0. 05)。结论:UAE导致术后月经量严重减少,甚至宫腔粘连,影响患者生育功能。进一步证实I型子宫瘢痕妊娠(根据剖宫产术后子宫瘢痕妊娠诊治专家共识(2016))患者可不行子宫动脉栓塞术。虽然UAE在子宫疤痕妊娠的治疗中能显著降低大出血的风险,是安全有效的治疗方法,根据分型标准,正确分型,根据患者年龄及生育要求,慎重选择终止妊娠方式。
Objective: To investigate the value of uterine artery embolization for uterine scar pregnancy.Methods: 58 patients with uterine scar pregnancy in our hospital from January 2013 to May 2017 were randomly selected and divided into uterine artery embolization group( n = 31) and uterine curettage group( n = 27). The patients' age,gestational sac diameter,thickness of the anterior wall of the uterus,time of postoperative HCG level returning to normal level,intraoperative blood loss,hospital stay,change in menstrual blood volume and postoperative ovarian function of the two groups were statistically analyzed. Results: The ratio of postoperative menstrual volume and normal menstrual volume was divided into 4 grades: grade 1 for postoperative menstrual volume accounting for1/4 of normal menstrual volume,and so on. The rank-sum test was used: the average rank of uterine curettage group was 38. 50,and the sum of ranks was 1039. 50; the average rank of uterine artery embolization group was21. 66,and the sum of ranks was 671. 50. The differences between the two groups were statistically significant( P <0. 05). The patients' age,gestational sac diameter,thickness of the anterior wall of the uterus,intraoperative blood loss,hospital stay,preoperativeβ-h CG level and time of negative conversion of the two groups had no significant difference( P > 0. 05). The differences in serum E2,LH and FSH levels between the two groups after operation were not statistically significant( all P > 0. 05). Conclusions: UAE can significantly reduce the risk of massive bleeding in the treatment of uterine scar pregnancy,safe and effective. But the postoperative menstrual volume is seriously reduced,and even intrauterine adhesion may occur,which affects the fertility function of patients. Thus,patients with type I uterine scar pregnancy may be not suitable for uterine artery embolization and termination methods of pregnancy should be carefully chosen according to the classification standard,correct classification,patients' ages and fertility requirements.
Objective: To investigate the value of uterine artery embolization for uterine scar pregnancy.Methods: 58 patients with uterine scar pregnancy in our hospital from January 2013 to May 2017 were randomly selected and divided into uterine artery embolization group( n = 31) and uterine curettage group( n = 27). The patients' age,gestational sac diameter,thickness of the anterior wall of the uterus,time of postoperative HCG level returning to normal level,intraoperative blood loss,hospital stay,change in menstrual blood volume and postoperative ovarian function of the two groups were statistically analyzed. Results: The ratio of postoperative menstrual volume and normal menstrual volume was divided into 4 grades: grade 1 for postoperative menstrual volume accounting for1/4 of normal menstrual volume,and so on. The rank-sum test was used: the average rank of uterine curettage group was 38. 50,and the sum of ranks was 1039. 50; the average rank of uterine artery embolization group was21. 66,and the sum of ranks was 671. 50. The differences between the two groups were statistically significant( P <0. 05). The patients' age,gestational sac diameter,thickness of the anterior wall of the uterus,intraoperative blood loss,hospital stay,preoperativeβ-h CG level and time of negative conversion of the two groups had no significant difference( P > 0. 05). The differences in serum E2,LH and FSH levels between the two groups after operation were not statistically significant( all P > 0. 05). Conclusions: UAE can significantly reduce the risk of massive bleeding in the treatment of uterine scar pregnancy,safe and effective. But the postoperative menstrual volume is seriously reduced,and even intrauterine adhesion may occur,which affects the fertility function of patients. Thus,patients with type I uterine scar pregnancy may be not suitable for uterine artery embolization and termination methods of pregnancy should be carefully chosen according to the classification standard,correct classification,patients' ages and fertility requirements.
引文
[1]汪永平,岳红萍,邱皓,等.子宫动脉化疗栓塞联合宫腔镜治疗高风险子宫瘢痕妊娠的价值.中国中西医结合影像学杂志,2016,14(5):576-578.
[2]李从青,张庆龙,卫兵,等.子宫动脉栓塞术在妇产科中的应用现状及进展.安徽医药,2013,17(11):1973-1975.
[3]何俊峰,闫国珍,穆永旭,等.彩色多普勒血流成像在检测子宫动脉栓塞术前后卵巢血流变化中的应用.中国医学影像学杂志,2012,20(2):138-140.
[4]段丽芬,徐虹,何萍,等.经阴道彩色多普勒超声在剖宫产术后子宫瘢痕妊娠诊治的应用.中国临床医学影像杂志,2014,25(4):260-262.
[5] Lumsden MA. Embolization versus myomectomy versus hysterectomy:Which is best,when? Hum Reprod,2001,17(2):253-25.
[6] Pelage JP,Le DO,Soyer P,et al. Fibroid-related menorrhagia:treatment with superselective embolization of the uterine arteries and midterm follow-up. Radiology,2000,215(2):428-431.
[7] Walker WJ,Pelage JP. Uterine artery embolisation for symptomatic fibroids:clinical results in 400 women with imaging follow up. Bjog,2002,109(11):1262-1272
[8] Tropeano G,Litwicka K,Di Stasi C,et al. Permanent amenorrhea associated with endometrial atrophy after uterine artery embolization for symptomatic uterine fibroids. Fertil Steril,2003,79(1):132-135.
[9] Mara M,Fucikova Z,Kuzel D,et al. Hysteroscopy after uterine fibroid embolization in women of fertile age. J Obstet Gynaecol Res,2007,33(3):316-324.
[10] Mara M,Horak P,Kubinova K,et al. Hysteroscopy after uterine fibroid embolization:evaluation of intrauterine findings in 127 patients.J Obstet Gynaecol Res,2012,38(5):823-831.
[11]马奔,曾北蓝,陈春林,等.子宫动脉栓塞术后闭经的影响因素分析.妇产与遗传(电子版),2012,2(1):24-27.
[12]宋冬梅,夏恩兰,Li T,et al.子宫动脉栓塞后宫腔粘连生殖预后分析——附26例报告.国际妇产科学杂志2014,41(5):513-517.
[13]中华医学会妇产科学分会计划生育学组.剖宫产术后子宫瘢痕妊娠诊治专家共识(2016).全科医学临床与教育. 2017. 15(1):5-9.
[14] Abuzeid OM,Hebert J,Ashraf M,et al. Pediatricfoley catheter placement after operative hysteroscopy does not cause ascending infection.J Minim Invasive Gynecol,2018,25(1):133-138.
[15] Setubal A,Alves J,Osório F,et al. Treatment foruterine isthmocele,a pouchlike defect at the site of a cesarean section scar. J Minim Invasive Gynecol,2018,25(1):38-46.
[16] Fan D,Wu S,Ye S,et al. Umbilical cord mesenchyme stem cell local intramuscular injection for treatment of uterine niche:Protocol for a prospective,randomized,double-blinded,placebo-controlled clinical trial. Medicine(Baltimore),2017,96(44):e8480-e8480.
[17] Volochoviˇc J,Ramasauskaite D,Simkeviˇciūte R. Clinical aspects and antenatal diagnosis of invasive placenta:a review of ten-years'experience of a multi-profile hospital in Lithuania. Acta Med Litu,2017,24(3):176-187.
[18] Mosad A,Altraigey A. Scar pregnancy and spontaneous rupture uterus-a case report. Ginekol Pol,2017,88(12):698-699.
[2]李从青,张庆龙,卫兵,等.子宫动脉栓塞术在妇产科中的应用现状及进展.安徽医药,2013,17(11):1973-1975.
[3]何俊峰,闫国珍,穆永旭,等.彩色多普勒血流成像在检测子宫动脉栓塞术前后卵巢血流变化中的应用.中国医学影像学杂志,2012,20(2):138-140.
[4]段丽芬,徐虹,何萍,等.经阴道彩色多普勒超声在剖宫产术后子宫瘢痕妊娠诊治的应用.中国临床医学影像杂志,2014,25(4):260-262.
[5] Lumsden MA. Embolization versus myomectomy versus hysterectomy:Which is best,when? Hum Reprod,2001,17(2):253-25.
[6] Pelage JP,Le DO,Soyer P,et al. Fibroid-related menorrhagia:treatment with superselective embolization of the uterine arteries and midterm follow-up. Radiology,2000,215(2):428-431.
[7] Walker WJ,Pelage JP. Uterine artery embolisation for symptomatic fibroids:clinical results in 400 women with imaging follow up. Bjog,2002,109(11):1262-1272
[8] Tropeano G,Litwicka K,Di Stasi C,et al. Permanent amenorrhea associated with endometrial atrophy after uterine artery embolization for symptomatic uterine fibroids. Fertil Steril,2003,79(1):132-135.
[9] Mara M,Fucikova Z,Kuzel D,et al. Hysteroscopy after uterine fibroid embolization in women of fertile age. J Obstet Gynaecol Res,2007,33(3):316-324.
[10] Mara M,Horak P,Kubinova K,et al. Hysteroscopy after uterine fibroid embolization:evaluation of intrauterine findings in 127 patients.J Obstet Gynaecol Res,2012,38(5):823-831.
[11]马奔,曾北蓝,陈春林,等.子宫动脉栓塞术后闭经的影响因素分析.妇产与遗传(电子版),2012,2(1):24-27.
[12]宋冬梅,夏恩兰,Li T,et al.子宫动脉栓塞后宫腔粘连生殖预后分析——附26例报告.国际妇产科学杂志2014,41(5):513-517.
[13]中华医学会妇产科学分会计划生育学组.剖宫产术后子宫瘢痕妊娠诊治专家共识(2016).全科医学临床与教育. 2017. 15(1):5-9.
[14] Abuzeid OM,Hebert J,Ashraf M,et al. Pediatricfoley catheter placement after operative hysteroscopy does not cause ascending infection.J Minim Invasive Gynecol,2018,25(1):133-138.
[15] Setubal A,Alves J,Osório F,et al. Treatment foruterine isthmocele,a pouchlike defect at the site of a cesarean section scar. J Minim Invasive Gynecol,2018,25(1):38-46.
[16] Fan D,Wu S,Ye S,et al. Umbilical cord mesenchyme stem cell local intramuscular injection for treatment of uterine niche:Protocol for a prospective,randomized,double-blinded,placebo-controlled clinical trial. Medicine(Baltimore),2017,96(44):e8480-e8480.
[17] Volochoviˇc J,Ramasauskaite D,Simkeviˇciūte R. Clinical aspects and antenatal diagnosis of invasive placenta:a review of ten-years'experience of a multi-profile hospital in Lithuania. Acta Med Litu,2017,24(3):176-187.
[18] Mosad A,Altraigey A. Scar pregnancy and spontaneous rupture uterus-a case report. Ginekol Pol,2017,88(12):698-699.