中晚期妊娠三种引产方案临床疗效与宫内妊娠物残留治疗方法的探讨
发布时间：2018-08-16 08:56
【摘要】：研究背景全世界中期妊娠引产占所有人工终止妊娠的10%～15%[1],但其并发症占所有引产患者的2/3[2]。2015年,我国有985万例人工终止妊娠[3]。尽管中晚期妊娠引产的并发症远高于早期妊娠流产[4,5],但我国中期妊娠引产仍占人工终止妊娠的5%[6]。世界足月妊娠分娩宫内妊娠物残留的发生率大约为1%,在流产或引产时发生率明显增加[7]。国内外报道中期妊娠引产宫内妊娠物残留的发生率在2.3%～21.3%不等[8-12]。清宫是我国目前常用的治疗宫内妊娠物残留的方法。然而清宫会引起一系列的近远期并发症如盆腔炎、子宫穿孔、宫颈裂伤、宫腔粘连、不孕等[13-16]。而事实上妊娠终止后子宫复旧的过程,同样可以让蜕膜等妊娠物自行排出,因此,引产后不加选择地实施清宫术是否适当,目前需要解决的问题。第一部分中晚期妊娠三种引产方案的临床疗效分析[目的]比较中晚期妊娠三种引产方法的临床疗效。[方法]回顾性分析2014年1月至2015年12月到我科行中晚期妊娠引产的337例孕产妇的临床资料,根据引产方法将研究对象分成三组:乳酸依沙吖啶配伍米非司酮组(简称利凡诺组)224例,米索前列醇配伍米非司酮组(简称米索组)82例,水囊配伍米非司酮组(简称水囊组)31例。[结果](1)利凡诺组引产排胎时间小于米索组((38.6±12.9)VS(51.5±17.1)小时,P0.001)与水囊组((49.6±19.3)小时,P=0.012);米索组与水囊组比较差异无统计学意义(P=0.949)。(2)总引产成功率为92.6%。利凡诺组引产成功率高于米索组和水囊组(96.9%VS 82.9%和87.1%,χ2=18.499,P0.001);米索组和水囊组比较差异无统计学意义(P0.05)。(3)利凡诺组宫内残留妊娠物均径长于米索组((38.6±23.5)mm VS(28.9±16.1)mm,P0.001);水囊组(29.3±20.7)mm与利凡诺组和米索组比较差异无统计学意义(P0.05)。三组宫内妊娠物残留率比较差异无统计学意义(χ2=1.722,P=0.423)。米索组清宫率高于利凡诺组和水囊组(47.6%VS 32.6%和32.3%,P0.05),利凡诺组和水囊组比较差异无统计学意义(P0.05)。(4)三组血红蛋白变化水平、阴道流血时间和月经复潮时间比较差异无统计学意义(P0.05)。[结论]三种引产方案均能有效终止妊娠。虽然利凡诺组引产排胎时间较短,宫内残留妊娠物体积较大,但三种引产方案宫内妊娠物残留率和预后比较无差异,且米索组清宫率高于另外两组,因此尚不能认为三种引产方案何者优。第二部分中晚期妊娠引产后清宫率及清宫的相关危险因素分析[目的]探讨中晚期妊娠引产后清宫率,分析引产后清宫的危险因素。[方法]研究对象同第一部分。根据引产后清宫与否将研究对象分为清宫组(122例)和未清宫组(215例)。[结果](1)本研究清宫率为36.2%。(2)清宫组孕龄小于未清宫组((20.3±5.3)VS(23.4±6.5)周,t=4.679,P0.001)。清宫组引产排胎时间长于未清宫组((44.3±17.7)VS(36.2±12.7)小时,t=2.128,P0.001)。两组宫内残留妊娠物均径比较差异无统计学意义(t=0.556,P=0.579)。(3)孕龄是清宫的保护因素(优势比=0.920,95%可信区间0.885-0.956,P0.001),引产排胎时间是清宫的危险因素(优势比=1.013,95%可信区间1.001-1.026,P=0.036)。在控制了混杂因素后,孕龄仍是清宫的保护因素(优势比=0.932,95%可信区间0.888-0.979,P=0.005),引产排胎时间不再是清宫的危险因素(优势比=1.006,95%可信区间0.991-1.020,P=0.444),而宫内残留妊娠物均径成为了清宫的危险因素(优势比=1.012,95%可信区间1.000-1.024,P=0.044)。[结论]引产后清宫与孕龄、引产排胎时间及宫内残留妊娠物均径密切相关,孕龄越小、引产排胎时间越长及宫内残留妊娠物均径越大,清宫的风险越高。第三部分 清宫与期待治疗宫内妊娠物残留预后及其相关并发症的危险因素研究[目的]比较两种方法治疗宫内妊娠物残留的预后、再次妊娠结局及并发症,分析治疗后并发症发生的相关危险因素。[方法]回顾性分析2014年1月至2015年12月在我科行中晚期妊娠引产并因宫内妊娠物残留而接受期待观察或清宫治疗的270例孕产妇的临床资料。[结果](1)清宫组血红蛋白变化水平中位数大于期待治疗组(5 VS 2 g/L,Z=-2.960,P=0.003)。清宫组阴道流血时间中位数小于期待观察组(14 VS 17天,Z=2.824,P=0.005)。清宫组阴道流血时间超过42天者发生率高于期待观察组(6.1%VS 1.3%,P=0.040)。两组月经复潮时间比较差异无统计学意义(r=0.570,P=0.569)。两组月经复潮时间超过60天者发生率比较差异无统计学意义(χ2=0.076,P=0.783)。(2)清宫组第二周β-hCG对数值大于期待观察组(χ2=10.588,P=0.009)。两组第一周和第三周β-hCG对数值比较差异无统计学意义(P0.05)。两组β-hCG值转阴时间比较差异无统计学意义(t=2.088,=0.057)。(3)清宫是引产后并发症发生的危险因素(优势比=10.60,95%可信区间2.36-47.66,P =0.002)。控制混杂因素后,清宫仍然是引产后并发症发生的危险因素(优势比=18.26,95%可信区间 3.57-93.42,P0.001)。(4)两组计划妊娠者再次妊娠自然受孕率、再次妊娠后活产率和流产率比较差异均无统计学意义(P0.05)。[结论]与期待观察相比,清宫并不能减少阴道流血时间,对血β-hCG下降速度、月经复潮时间及再次妊娠结局无明显影响,反而会增加血红蛋白下降水平,且会增加感染、盆腔痛、异常子宫出血等并发症的发生风险。
[Abstract]:Background Mid-term pregnancy induced abortion accounts for 10% to 15% of all induced abortions in the world, but its complications account for 2/3 of all induced abortions. In 2015, there were 9.85 million induced abortions in China [3]. 5%[6]. The incidence of intrauterine pregnancy residue in full-term pregnancy is about 1% in the world. The incidence of intrauterine pregnancy residue in abortion or induced labor is significantly increased [7]. It can cause a series of short-term and long-term complications such as pelvic inflammation, uterine perforation, cervical laceration, intrauterine adhesion, infertility, etc. [13-16]. In fact, the process of uterine involution after termination of pregnancy can also allow decidua and other pregnant materials to be discharged by themselves. [Methods] The clinical data of 337 pregnant and lying-in women who were admitted to our department from January 2014 to December 2015 were retrospectively analyzed. The subjects were divided into three groups according to the induced labor method: ethacridine lactate. Results (1) The induced abortion time of Rivanol group was shorter than that of Misoprostol group ((38.6+12.9) VS (51.5+17.1) hours, P 0.001) and water bag group ((49.6+19.3) hours, P = 0.012). There was no significant difference between misoprostol group and water sac group (P = 0.949). (2) The total success rate of induced labor was 92.6%. The success rate of induced labor in rivanol group was higher than that in misoprostol group and water sac group (96.9% VS 82.9% and 87.1%, 2 = 18.499, P 0.001); there was no significant difference between misoprostol group and water sac group (P 0.05). (3) The diameter of intrauterine pregnancy residue in rivanol group was longer than that in metre group. There was no significant difference in the residual rate of intrauterine pregnancy among the three groups (2 = 1.722, P = 0.423). The clearance rate of misoprostol group was higher than that of rivanol group and water bag group (47.6% VS 32.6% and 32.3%, P 0.05). There was no significant difference between the normal group and the water bag group (P 0.05). (4) There was no significant difference in the hemoglobin level among the three groups, the time of vaginal bleeding and menstruation (P 0.05). [Conclusion] All the three abortion schemes can effectively terminate pregnancy. There was no difference in the residue rate and prognosis of intrauterine pregnancy among the three abortion schemes, and the clearance rate of misoprostol group was higher than that of the other two groups. The second part was about the clearance rate of mid-late pregnancy after induction of labor and the analysis of related risk factors. [Methods] The study subjects were the same as the first part. The subjects were divided into clear uterus group (122 cases) and unclear uterus group (215 cases). [Results] (1) The rate of clear uterus in this study was 36.2%. (2) The gestational age of clear uterus group was less than that of unclear uterus group ((20.3 + 5.3) VS (23.4 + 6.5) weeks, t = 4.679, P 0.001). There was no significant difference in the diameter of intrauterine residual pregnancies between the two groups (t = 0.556, P = 0.579). (3) Pregnancy age was the protective factor of uterine clearance (odds ratio = 0.920, 95% confidence interval 0.885-0.956, P 0.001), and the time of induced abortion and abortion were the risk factors of uterine clearance (odds ratio = 1.013, 95% confidence). After controlling for confounding factors, gestational age was still a protective factor for uterine clearance (odds ratio = 0.932, 95% CI 0.888-0.979, P = 0.005). The time of induced abortion and abortion was no longer a risk factor for uterine clearance (odds ratio = 1.006, 95% CI 0.991-1.020, P = 0.444). The diameter of intrauterine residual pregnancy was a risk factor for uterine clearance. [Conclusion] After induction of labor, uterine clearance is closely related to gestational age, time of induction and abortion and the diameter of intrauterine residual pregnancy. The younger the gestational age, the longer the time of induction and abortion and the bigger the diameter of intrauterine residual pregnancy, the higher the risk of uterine clearance. [Objective] To compare the prognosis of intrauterine pregnancy remnants treated with two methods, the outcome of second pregnancy and complications, and analyze the risk factors of complications after treatment. [Results] (1) The median hemoglobin level in the clearance group was higher than that in the expectant treatment group (5 VS 2 g/L, Z = - 2.960, P = 0.003). The median vaginal bleeding time in the clearance group was less than that in the expectant observation group (14 VS 17 days, Z = 2.824, P = 0.005). There was no significant difference in the time of menstruation between the two groups (r = 0.570, P = 0.569). There was no significant difference in the incidence of menstruation over 60 days between the two groups (2 = 0.076, P = 0.783). (2) The logarithm of beta-hCG in the second week of the uterine clearance group was higher than that in the expected observation group (2 = 10.569). There was no significant difference in the logarithmic value of beta-hCG between the two groups at the first week and the third week (P 0.05). There was no significant difference in the negative time of beta-hCG between the two groups (t = 2.088, = 0.057). (3) Clearance of uterus was a risk factor for postpartum complications (odds ratio = 10.60, 95% confidence interval 2.36-47.66, P = 0.002). The uterus was still a risk factor for complications after induction of labor (odds ratio = 18.26, 95% CI 3.57-93.42, P 0.001). (4) There was no significant difference in the natural conception rate, live birth rate and abortion rate of the planned pregnancies between the two groups (P 0.05). [Conclusion] Clearance of uterus did not reduce vaginal bleeding compared with expected observation. Meanwhile, there was no significant effect on the decrease rate of blood beta-hCG, the time of menstruation and the outcome of second pregnancy. On the contrary, it increased the level of hemoglobin decrease, and increased the risk of complications such as infection, pelvic pain and abnormal uterine bleeding.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R719.3
本文编号：2185509
[Abstract]:Background Mid-term pregnancy induced abortion accounts for 10% to 15% of all induced abortions in the world, but its complications account for 2/3 of all induced abortions. In 2015, there were 9.85 million induced abortions in China [3]. 5%[6]. The incidence of intrauterine pregnancy residue in full-term pregnancy is about 1% in the world. The incidence of intrauterine pregnancy residue in abortion or induced labor is significantly increased [7]. It can cause a series of short-term and long-term complications such as pelvic inflammation, uterine perforation, cervical laceration, intrauterine adhesion, infertility, etc. [13-16]. In fact, the process of uterine involution after termination of pregnancy can also allow decidua and other pregnant materials to be discharged by themselves. [Methods] The clinical data of 337 pregnant and lying-in women who were admitted to our department from January 2014 to December 2015 were retrospectively analyzed. The subjects were divided into three groups according to the induced labor method: ethacridine lactate. Results (1) The induced abortion time of Rivanol group was shorter than that of Misoprostol group ((38.6+12.9) VS (51.5+17.1) hours, P 0.001) and water bag group ((49.6+19.3) hours, P = 0.012). There was no significant difference between misoprostol group and water sac group (P = 0.949). (2) The total success rate of induced labor was 92.6%. The success rate of induced labor in rivanol group was higher than that in misoprostol group and water sac group (96.9% VS 82.9% and 87.1%, 2 = 18.499, P 0.001); there was no significant difference between misoprostol group and water sac group (P 0.05). (3) The diameter of intrauterine pregnancy residue in rivanol group was longer than that in metre group. There was no significant difference in the residual rate of intrauterine pregnancy among the three groups (2 = 1.722, P = 0.423). The clearance rate of misoprostol group was higher than that of rivanol group and water bag group (47.6% VS 32.6% and 32.3%, P 0.05). There was no significant difference between the normal group and the water bag group (P 0.05). (4) There was no significant difference in the hemoglobin level among the three groups, the time of vaginal bleeding and menstruation (P 0.05). [Conclusion] All the three abortion schemes can effectively terminate pregnancy. There was no difference in the residue rate and prognosis of intrauterine pregnancy among the three abortion schemes, and the clearance rate of misoprostol group was higher than that of the other two groups. The second part was about the clearance rate of mid-late pregnancy after induction of labor and the analysis of related risk factors. [Methods] The study subjects were the same as the first part. The subjects were divided into clear uterus group (122 cases) and unclear uterus group (215 cases). [Results] (1) The rate of clear uterus in this study was 36.2%. (2) The gestational age of clear uterus group was less than that of unclear uterus group ((20.3 + 5.3) VS (23.4 + 6.5) weeks, t = 4.679, P 0.001). There was no significant difference in the diameter of intrauterine residual pregnancies between the two groups (t = 0.556, P = 0.579). (3) Pregnancy age was the protective factor of uterine clearance (odds ratio = 0.920, 95% confidence interval 0.885-0.956, P 0.001), and the time of induced abortion and abortion were the risk factors of uterine clearance (odds ratio = 1.013, 95% confidence). After controlling for confounding factors, gestational age was still a protective factor for uterine clearance (odds ratio = 0.932, 95% CI 0.888-0.979, P = 0.005). The time of induced abortion and abortion was no longer a risk factor for uterine clearance (odds ratio = 1.006, 95% CI 0.991-1.020, P = 0.444). The diameter of intrauterine residual pregnancy was a risk factor for uterine clearance. [Conclusion] After induction of labor, uterine clearance is closely related to gestational age, time of induction and abortion and the diameter of intrauterine residual pregnancy. The younger the gestational age, the longer the time of induction and abortion and the bigger the diameter of intrauterine residual pregnancy, the higher the risk of uterine clearance. [Objective] To compare the prognosis of intrauterine pregnancy remnants treated with two methods, the outcome of second pregnancy and complications, and analyze the risk factors of complications after treatment. [Results] (1) The median hemoglobin level in the clearance group was higher than that in the expectant treatment group (5 VS 2 g/L, Z = - 2.960, P = 0.003). The median vaginal bleeding time in the clearance group was less than that in the expectant observation group (14 VS 17 days, Z = 2.824, P = 0.005). There was no significant difference in the time of menstruation between the two groups (r = 0.570, P = 0.569). There was no significant difference in the incidence of menstruation over 60 days between the two groups (2 = 0.076, P = 0.783). (2) The logarithm of beta-hCG in the second week of the uterine clearance group was higher than that in the expected observation group (2 = 10.569). There was no significant difference in the logarithmic value of beta-hCG between the two groups at the first week and the third week (P 0.05). There was no significant difference in the negative time of beta-hCG between the two groups (t = 2.088, = 0.057). (3) Clearance of uterus was a risk factor for postpartum complications (odds ratio = 10.60, 95% confidence interval 2.36-47.66, P = 0.002). The uterus was still a risk factor for complications after induction of labor (odds ratio = 18.26, 95% CI 3.57-93.42, P 0.001). (4) There was no significant difference in the natural conception rate, live birth rate and abortion rate of the planned pregnancies between the two groups (P 0.05). [Conclusion] Clearance of uterus did not reduce vaginal bleeding compared with expected observation. Meanwhile, there was no significant effect on the decrease rate of blood beta-hCG, the time of menstruation and the outcome of second pregnancy. On the contrary, it increased the level of hemoglobin decrease, and increased the risk of complications such as infection, pelvic pain and abnormal uterine bleeding.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R719.3
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