488例复发性流产女性子宫解剖因素分析

发布时间：2018-05-28 07:26

本文选题：复发性流产 + 子宫解剖因素　；参考：《山东大学》2017年硕士论文

【摘要】：背景和目的复发性流产(recurrent spontaneous abortion,RSA)的定义目前在国际上存在诸多争议,现行较为常用的定义之一是:接连发生两次及以上的流产,与不同性伴侣发生的流产不计数在内,且胎儿丢失(体重≤500g)发生于妊娠20周之前,其中流产必须是经过超声学或组织学证实的宫内妊娠(intrauterine pregnancy),生化妊娠(biochemical pregnancy)和输卵管妊娠流产(fallopian pregnancy abortion)不列入计算。由于RSA的诊断标准在不同国家和地区存在.较大差异,也给其流行病学调查工作带来了困难;目前国际上较为公认的结果是:在全体妇女中,RSA的发生比率大致为5%,其中存在三次及以上流产史患者的比率在1%左右。关于RSA的定义,各国不尽相同。美国生殖医学学会(American Society for Reproductive Medicine)的标准是2次或2次以上妊娠失败;2016年我国中华医学会妇产科分会产科学组(Department of Obstetrics and gynecology of Chinese Medical Association)通过讨论决定将RSA的诊断标准定为发生三次及以上的流产,其中流产是指在妊娠28周之前的胎儿丢失。近年来,国内外众多学者对连续发生两次流产的人群进行宫腔镜检查后即可查见多种类型的宫腔异常;同时结合国内外关于RSA的定义及流行病学研究情况,本研究设定的RSA的筛查标准为:与同一个性伴侣连续发生的两次及以上妊娠20周以内的自然流产。RSA的病因复杂多样,除遗传、免疫、感染及内分泌等因素外,子宫作为提供胚胎和胎儿生存发育环境的场所,子宫的结构与功能正常与否对于妊娠的结局意义尤为重大。据流行病学资料统计,子宫因素占复发性流产因素中的比例为16.4%,并随不良孕产发病率地增加,子宫因素所占比例也逐渐增加。本研究所采用的方法为回顾性病例对照分析,设定存在RSA的女性为病例组,共488例。统计其经宫腔镜检查后明确诊断的子宫解剖异常的类型与数量;设定同时期对照组,统计分析两组患者的宫腔异常情况,观察是否存在统计学差异,探索研究子宫解剖结构异常与复发性流产的关系。研究方法本项研究随机选择488例于2011年1月至2015年6月期间至山东大学附属生殖医院就诊的RSA患者,将其设定为病例组。病例组纳入标准:连续发生2次或2次以上的流产,以上流产必须与同一性伴侣发生,且胎儿丢失(体重≤500g)发生于妊娠20周之前,生化妊娠和输卵管妊娠流产均不计入本研究范围,只有经过超声学或组织学证实的宫内妊娠才被认定为流产。通过查询电子病历系统及相关纸质文档,调阅病例组患者的详细病史及各相关辅助检查结果(包括经过宫腔镜检查所明确诊断的宫腔情况)。本研究将病例组分为两组,分类标准为患者病史中所述流产次数,发生2次流产的患者被设定为A组;而若病史中所记述的流产次数为3次或3次以上,则被设定为B组。同时选取同期于我院因男性因素或输卵管因素就诊的无复发性流产病史(包括自然流产、胚胎停育及生化妊娠)的508例低风险人群,将其设定为对照组。统计收集对照组人群的病史、宫腔镜检查结果及其他相关检查结果。对照组排除标准:夫妻双方明确的染色体异常;全身代谢异常相关疾病,包括糖尿病、甲状腺功能异常、多囊卵巢综合征(polycystic ovary syndrome,PC0S)等;抗磷脂抗体综合征(antiphospholipid syndrome,APS)、系统性红斑狼疮(systemic lupus erythematosus,SLE)等自身免疫性疾病。病例组及对照组患者的病史及各项辅助检查结果被收集整理后列表整理,包括夫妻双方染色体结果、甲状腺功能、自身抗体、TORCH(Toxoplasma,others,Rubella.Virus,Cytomegalo.Virus,Herpes.Virus)、女性激素六项等。本研究中所有行宫腔镜检查术的患者均在排除相关禁忌症后于月经干净后3-7天内进行;宫腔镜检查术过程中记录先天性宫腔异常(congenital anomalies),包括完全性纵隔子宫/部分性纵隔子宫(uterine septum/subseptate uterus)、弓状子宫(arcuate uterus)、单角子宫(uterus unicornis)等;获得性宫腔异常(acquired anomalies),包括宫腔粘连(intrauterine adhesions)、子宫内膜息肉(endometrial polyp)、黏膜下子宫肌瘤(submucous myoma)等。检查中所取得的相关病理标本均进行常规病理检查,如有必要,部分患者择期住院行矫正手术治疗。在本研究中,病例组及对照组中均存在某一患者同时合并多种宫腔异常的情况(详见附表注释),由于各项宫腔异常的发生之间并无明显关联及相互作用,结合本研究的目的及统计学原理,在尊重事实及临床实际工作的基础上采用如下方法计数:以上同时存在多种异常的病例每一异常类型均计数一次。本研究所有统计分析均采用SPSS 20.0统计学软件完成,在理论频数足够的情况下,采用卡方分析,若较少时则行校正卡方或Fisher确切概率法。设定P0.05为差异有统计学意义。分析病例组、对照组之间及病例组中A、B两组之间宫腔异常发生率是否存在统计学差异。研究结果1.在488例复发性流产患者中,经宫腔镜检查未发现明显宫腔异常的有371例,占病例组总人数的76.02%;先天性异常38例,占7.87%;获得性异常98例,占20.08%。在508例对照组人群中,有406例未见明显宫腔异常,占对照组总人数的79.92%;先天性异常17例,占3.35%;获得性异常96例,占18.90%。以对照组宫腔镜检查结果为例:对照组中有2名患者同时存在子宫内膜息肉及子宫纵隔,3名合并子宫内膜增生及子宫内膜息肉,1名合并子宫内膜息肉及单角子宫,1名合并子宫内膜息肉及粘膜下肌瘤,1名合并宫腔粘连及弓形子宫,1名合并子宫内膜炎及单角子宫,1名合并双子宫及子宫内膜息肉,1名合并子宫内膜息肉及子宫内膜炎。如前所述,如某患者同时存在两种及以上宫腔异常,则每种宫腔异常均计数一次,由于使用该计数方法,所有宫腔异常的例数之和大于病例组总人数,各项异常比例相加亦大于百分之百,但不会影响进行相关统计学检验;为防止引起误解,特此说明。两组之间先天性异常发生地比率被认定有统计学差异(P=0.005)。在各类获得性宫腔异常中,病例组与对照组发生率最高的依次是宫腔粘连和子宫内膜息肉,且两组之间两种异常均存在统计学差异(P0.001)。2.根据病史中流产次数将病例组分为A、B两组,其中A组(2次流产)患者中宫腔镜检查未见异常患者228例,占A组总人数的78.62%;先天性异常21例,占7.24%;获得性异常52例,占17.93%;B组(3次或3次以上)患者中经过宫腔镜检查未发现明显宫腔异常的病例有143例,占B组总人数的72.22%;先天性异常17例,占8.59%;获得性异常46例,占23.23%。A、B两组中也存在类似对照组中一名患者合并两种及以上宫腔异常的情况,相关结果说明同前。在A、B两组中,正常宫腔、先天性宫腔异常及获得性宫腔异常例数均未见统计学差异。研究结论1、先天性子宫解剖结构异常(包括完全性纵隔子宫/部分性纵隔子宫等)与RSA之间存在明显的统计学相关性;获得性宫腔异常中,发生率最高的是宫腔粘连,该种类型的宫腔异常与复发性流产存在明显的统计学关联。2、宫腔镜检查在诊断宫腔异常方面具有独特优势,且能进行相应矫正手术。连续2次流产后,再次计划妊娠前,有必要进行宫腔镜检查以发现异常,减少流产的发生,提高妊娠成功率。
[Abstract]:The definition of background and objective recurrent spontaneous abortion (RSA) is currently controversial in the world. One of the most commonly used definitions is that two and more abortions occur in succession, the abortion is not counted with the same sex partner, and the loss of fetus (weight < 500g) occurs before 20 weeks of pregnancy. Abortion must be intrauterine pregnancy (intrauterine pregnancy) confirmed by ultrasound or histology, biochemical pregnancy (biochemical pregnancy) and fallopian pregnancy abortion (fallopian pregnancy abortion) are not included in the calculation. Since the diagnostic criteria for RSA exist in different countries and regions. Major differences are also given to its epidemiological survey. It is difficult to do so; the internationally recognized result is that among all women, the incidence of RSA is approximately 5%, of which three and more abortion patients have a ratio of about 1%. The definition of RSA is not the same. The standard of the American Institute of reproductive medicine (American Society for Reproductive Medicine) is 2 or 2 times. In 2016, Department of Obstetrics and Gynecology of Chinese Medical Association, China's Chinese Medical Association of Chinese Medical Association, decided to determine the diagnostic criteria of RSA as three or more abortions, of which abortion was lost before 28 weeks of pregnancy. In recent years, many domestic and foreign countries A variety of uterine cavity abnormalities can be found after hysteroscopy for two consecutive abortions. At the same time, combined with the domestic and international definition of RSA and epidemiological studies, the screening criteria for RSA in this study are: spontaneous abortion within 20 weeks of pregnancy and more than 20 weeks of pregnancy with the same sexual partner. The cause of A is complex and varied. Besides heredity, immunity, infection and endocrinology, the uterus is the place to provide the survival and development environment of embryo and fetus. The structure and function of the uterus are of particular significance to the outcome of pregnancy. According to the epidemiological data, the proportion of uterine factors in recurrent abortion is 16.4%. The incidence of bad pregnancy increased and the proportion of uterine factors increased gradually. The method used in this study was a retrospective case control analysis, a case group of women with RSA was set as a case group. A total of 488 cases were diagnosed by hysteroscopy, and the types and numbers of abnormal uterine anatomic abnormalities diagnosed by hysteroscopy were statistically analyzed, and the same period control group was set, the statistical analysis was two. The abnormal uterine cavity situation in the group of patients, observed whether there is statistical difference, explore the relationship between abnormal uterine anatomy and recurrent abortion. This study randomly selected 488 cases of RSA patients who visited the affiliated reproductive Hospital of Shandong University from January 2011 to June 2015, and set it as a case group. Standard: 2 or more than 2 times of abortion, the above abortion must occur with the same sexual partner, and the fetal loss (weight < 500g) occurs before 20 weeks of pregnancy, biochemical pregnancy and tubal pregnancy abortion are not included in the scope of this study, only through ultrasound or histology confirmed intrauterine pregnancy can be identified as abortion. Through inquiries through inquiry. The electronic medical record system and related paper documents were used to read the detailed medical history of the case group and the results of the related auxiliary examination (including the uterine cavity clearly diagnosed by hysteroscopy). The case group was divided into two groups. The classification standard was the number of abortions in the patient's history, and the patients who had 2 abortions were set as group A; The number of miscarriages described in the medical history was 3 or more than 3 times, and it was set as group B. At the same time, 508 cases of low risk of recurrent abortion (including natural abortion, embryo arrest and biochemical pregnancy) in our hospital were selected as control group. History, hysteroscopy results and other related examination results. Control group exclusion criteria: chromosomal abnormalities of both husband and wife; systemic metabolic disorders related to diabetes, thyroid dysfunction, polycystic ovary syndrome (polycystic ovary syndrome, PC0S); anti phospholipid antibody syndrome (antiphospholipid syndrome, APS). The history of systemic lupus erythematosus (SLE) and other autoimmune diseases. The history of the case group and the control group were collected and collated, including the chromosomal results of both husband and wife, thyroid function, autoantibody, TORCH (Toxoplasma, others, Rubella.Virus, Cytomegalo.Virus, Herpes.Vir). Us), female hormone six. All patients undergoing hysteroscopy in this study were performed within 3-7 days after the exclusion of contraindications and after menstruation. During hysteroscopy, the congenital uterine cavity abnormalities (congenital anomalies), including the complete mediastinal uterus / partial mediastinal uterus (uterine septum/subseptate uterus), were recorded. Arcuate uterus (arcuate uterus), single horned uterus (uterus unicornis), acquired uterine cavity abnormalities (acquired anomalies), including intrauterine adhesion (intrauterine adhesions), endometrial polyps (endometrial polyp), submucosal hysteromyoma (submucous myoma), etc.. The pathological specimens obtained in the examination were all routine pathological examination, such as It is necessary for some patients to be hospitalized for corrective surgery. In this study, the case group and the control group have a case of a patient with a variety of uterine abnormalities (detailed in the annotation of the appendix). There is no obvious association and interaction between the occurrence of various uterine cavity abnormalities, and the purpose and statistical principle of this study are combined with the principle of statistics. On the basis of heavy facts and clinical practice, the following methods are counted as follows: all the abnormal cases are counted at the same time. All the statistical analysis of this study is completed by SPSS 20 statistics software. In the case of sufficient frequency of the theory, the chi square analysis is adopted, and the correction card or Fisher is performed if it is less. The exact probability method. The difference was statistically significant in setting the P0.05. Whether there was a statistical difference in the incidence of abnormal uterine cavity between A and B two groups between the control group and the case group. 1. in 488 cases of recurrent abortion, there were 371 cases of no obvious uterine cavity abnormalities by hysteroscopy, accounting for 76 of the total number of cases in the case group. 2%, 38 cases of congenital abnormalities, accounting for 7.87%, 98 cases of acquired abnormalities, accounting for 20.08%. in 508 cases of control group, 406 cases had no obvious uterine cavity abnormalities, accounting for 79.92% of the total number of the control group, 17 cases of congenital abnormalities, 3.35%, and 96 cases of acquired abnormalities, accounting for the results of hysteroscopy in the control group, for example, there were 2 patients in the control group at the same time. Endometrial polyps and uterine mediastinum, 3 with endometrial hyperplasia and endometrium polyps, 1 with endometrial polyps and single angle uterus, 1 with endometrial polyps and submucous myoma, 1 with intrauterine adhesions and arcuate uterus, 1 with endometritis and single angle uterus, 1 with double uterus and endometrium polyps, 1 with 1 endometrium polyps. Endometrial polyps and endometritis. As mentioned earlier, if there are two or more abnormalities of the uterine cavity in a certain patient, the abnormalities of each uterine cavity are counted once, because the number of cases of all uterine abnormalities is greater than the total number of cases, and the addition of each anomaly is more than one hundred percent, but does not affect the phase. In order to prevent misunderstandings, the rate of congenital anomaly between the two groups was found to be statistically different (P=0.005). In all kinds of acquired uterine abnormalities, the highest incidence of the case group and the control group was the intrauterine adhesions and the endometrium, and the two abnormalities between the two groups were statistically poor. P0.001.2. was divided into A and B two groups according to the number of miscarriages in the medical history. Among them, 228 cases of hysteroscopy were found in group A (2 abortions), accounting for 78.62% of the total number of A, 21 cases of congenital abnormalities, 7.24%, 52 of acquired abnormalities, and 17.93%, and in the B group (3 or more than 3 times), hysteroscopy did not find obvious palace in hysteroscopy. There were 143 cases of abnormal cavity, which accounted for 72.22% of the total number of B group, 17 cases of congenital abnormalities, 8.59%, 46 cases of acquired abnormalities, and 23.23%.A. There were also two or more cases of abnormal uterine cavity in the group B two, which were similar to those in the control group. In the group of A, B two, normal uterine cavity, congenital uterine cavity abnormality and acquired palace. There was no statistical difference in the number of abnormal cases. Conclusion 1, there is a significant statistical correlation between congenital uterine anatomic abnormalities (including complete mediastinal uterus / partial mediastinal uterus) and RSA; the highest incidence of acquired uterine cavity abnormalities is uterine cavity adhesion, the type of uterine cavity abnormality and recurrent abortion exist. Significant statistical correlation.2, hysteroscopy in the diagnosis of abnormal uterine cavity has a unique advantage, and can carry out corresponding corrective surgery. After 2 consecutive abortions, again before pregnancy, it is necessary to carry out hysteroscopy to find abnormality, reduce the occurrence of abortion, and improve the success rate of pregnancy.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R714.21

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