孕前及孕期经阴道子宫峡部环扎术治疗宫颈机能不全的临床对照研究

发布时间：2018-05-22 15:03

  本文选题：孕前环扎 + 孕期环扎　； 参考：《浙江大学》2017年硕士论文

【摘要】：目的比较孕前及孕期经阴道子宫峡部环扎术治疗宫颈机能不全的临床疗效。方法此次临床对照研究纳入了 2017年2月之前在浙江大学医学院附属邵逸夫医院就诊的具有反复孕中期流产病史的宫颈机能不全患者,共62名患者。根据手术方式将其分为孕前环扎组及孕期环扎组。主要观察指标是37周妊娠率、34周妊娠率、活产率。次要观察指标包括手术时间、术中出血、手术并发症、28周妊娠率、分娩孕周、新生儿体重、新生儿并发症。结果①此次研究共82人符合初筛标准,其中孕前环扎组39人,孕期环扎组43人。孕前环扎组中有6人处于妊娠状态,3人失访,余30人已有妊娠结局。孕期环扎组中10人处于妊娠状态,1人失访,余32人已有妊娠结局。最终将有妊娠结局的62名患者纳入统计,包括孕前环扎组30人和孕期环扎组32人。②两组患者之间的年龄,体重指数,既往孕中期流产史,既往宫腔操作史,宫颈手术史,8号扩棒通过情况,妊娠方式,既往不孕史均未见明显差异(P0.05),孕前环扎组和孕期环扎组的术前闭合宫颈阴道段长度分别为29.16±2.76mm和33.18±4.76mm。孕前环扎组中自然妊娠患者的平均备孕时间为3.20月,孕期环扎组的平均手术孕周为孕15周。③根据磁共振检查及腹腔镜术中所见,经阴道子宫峡部环扎术的环扎线高度达子宫峡部水平。④孕前环扎手术时间明显长于孕期环扎(69.40±24.85vs51.41±12.06分;P=0.001)。孕前环扎和孕期环扎组的术中出血也有统计学差异(20.17±34.53 vs 43.75±33.96ml;P=0.009)。62例手术均顺利进行,仅孕期环扎组的1名患者出现了术后环扎部位渗血。余均未出现宫颈裂伤、胎膜早破、围手术期感染等并发症。孕前环扎及孕期环扎组的术中评估宫颈阴道段长度未见明显差异(12.60±5.26vs13.31±5.56mm;P0.05)。而孕期环扎的抗生素使用时间(3.66±1.13 vs 2.57±0.50 天;P0.001)和住院天数(9.84±5.43 vs 4.00±0.74天;P0.001)明显长于孕前环扎组。⑤妊娠结局方面,孕前环扎组的37周妊娠率为24/30(80.0%),34周妊娠率为29/30(96.7%),28周妊娠率为30/30(100.0%),活产率30/30(100%),平均分娩孕周为37.43±1.59周,平均新生儿体重为3163.33±516.03克;孕期环扎组37周妊娠率为31/32(96.9%),34周妊娠率为 32/32(100.0%),28 周妊娠率为 32/32(100%),活产率 32/32(100%),平均分娩孕周为38.09±1.09周,平均新生儿体重为3373.44±314.43克,两组在统计学上未显示明显差异(P0.05)。孕前环扎组中出现1例高胆红素血症,孕期环扎组出现2例胎粪吸入综合征和3例高胆红素血症,余未见脓毒血症、坏死性小肠炎、颅内出血等新生儿并发症。两组间的剖宫产率(86.7%vs 87.5%;P0.05)和新生儿 NICU 天数(1.57±4.26vs0.81±2.13 天;P0.05)未见明显差异。结论①改良经阴道子宫峡部环扎术,可以在不开腹、不打开Douglas窝的情况下达到子宫峡部的环扎高度。②经阴道子宫峡部环扎术因其疗效确切,操作简单,安全可靠等优势,有较大的临床应用前景。但孕前经阴道子宫峡部环扎术与孕期环扎相比,妊娠结局未见明显差异。③该研究的样本量有限,需要进行更多高质量的临床试验来指导宫颈环扎的临床应用。
[Abstract]:Objective to compare the clinical efficacy of transvaginal isthmus cerclage in the treatment of cervical incompetence before and during pregnancy. Methods the clinical control study was included in 62 patients with a history of repeated mid-term abortion in the Sir Run Run Shaw Hospital of the Zhejiang University medical college before February 2017. The main observation indexes were 37 weeks pregnancy rate, 34 week pregnancy rate and live rate. The secondary observation indexes included operation time, intraoperative bleeding, surgical complications, 28 weeks pregnancy rate, pregnancy week, newborn weight, neonatal complications. Results 1. The results of this study were in line with the initial screening criteria, prepregnancy before pregnancy. There were 39 in the ring group and 43 in the pregnancy group. 6 of them were in pregnancy, 3 were lost and 30 had pregnancy outcomes. 10 of them were in pregnancy, 1 were lost, and 32 had pregnancy outcomes. In the end, 62 patients with pregnancy outcomes included 30 pregnant cerclage group and 32 pregnant ring group. (2) the age, body mass index, the history of past mid-term abortion, the history of previous uterine cavity operation, the history of cervical surgery, the passage of No. 8, pregnancy and previous infertility had no significant difference (P0.05). The preoperative closed cervical and vaginal segment length was 29.16 + 2.76mm and 33.18 + 4.76mm. respectively. The average time of pregnancy for the patients with natural pregnancy was 3.20 months in the anterior cerclage group, and the average operative week for the cerclage group was 15 weeks. (3) the cerclage line of the transvaginal isthmus cerclage reached the level of the uterine isthmus according to the magnetic resonance examination and laparoscopy. (4) the time of pre pregnancy ring fixation was longer than that of pregnancy (69.40 + 24.85vs5). 1.41 + 12.06 points; P=0.001). There were also significant differences in intraoperative bleeding between prenatal cerclage and pregnancy ligation group (20.17 + 34.53 vs 43.75 + 33.96ml; P=0.009).62 cases were carried out smoothly. Only 1 patients in the group of pregnant cerclage group had postoperative ligation of blood. No complications of cervical laceration, premature rupture of membranes, perioperative infection and other complications. There was no significant difference in the length of cervical and vaginal segment (12.60 + 5.26vs13.31 + 5.56mm; P0.05) in the anterior cerclage group and pregnant cerclage group, and the use of antibiotics in pregnancy (3.66 + 1.13 vs 2.57 + 0.50 days, P0.001) and the days of hospitalization (9.84 + 5.43 vs 4 + 0.74 days; P0.001) were significantly longer than that in the pre pregnancy ligation group. The 37 week pregnancy rate in the ring group was 24/30 (80%), the 34 week pregnancy rate was 29/30 (96.7%), the 28 week pregnancy rate was 30/30 (100%), the survival rate was 30/30 (100%), the average birth rate was 37.43 + 1.59 weeks, the average newborn weight was 3163.33 + 516.03 grams. The pregnancy rate in the pregnancy cycle group was 31/32 (96.9%) and the pregnancy rate was 32/32. 32/32 (100%), the survival rate of 32/32 (100%), the average birth pregnancy week was 38.09 + 1.09 weeks, the average weight of the newborn was 3373.44 + 314.43 grams, the two groups did not show significant difference (P0.05). There were 1 hyperbilirubinemia in the pre pregnancy ring group, 2 cases of meconium aspiration syndrome and 3 hyperbilirubinemia in the pregnancy cerclage group, and no sepsis. The cesarean section rate (86.7%vs 87.5%; P0.05) and the number of NICU days in the newborn (1.57 + 4.26vs0.81 + 2.13 days; P0.05) were not significantly different between the two groups. Conclusion (1) the improved transvaginal uterine isthmus cerclage can reach the isthmus of the uterine isthmus without opening the abdomen and opening the Douglas nest. The transvaginal uterine isthmus cerclage has the advantages of definite curative effect, simple operation, safe and reliable and so on. But there is no significant difference in pregnancy outcome between prepregnancy vaginal isthmus cerclage and cerclage during pregnancy. 3. The sample size of this study is limited, and more high quality clinical trials are needed. To guide the clinical application of cervix cerclage.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R714.2
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本文编号：1922563