重度宫腔粘连术后球囊联合放环预防再粘连的疗效观察

发布时间：2018-03-15 17:32

  本文选题：宫腔镜　切入点：重度宫腔粘连　出处：《郑州大学》2012年硕士论文　论文类型：学位论文

【摘要】：宫腔粘连(intrauterine adhesions, IUA)是指子宫内膜在受到创伤后出现子宫内膜纤维化并形成粘连带,导致宫腔部分或全部闭锁。临床表现为月经异常(可为经量减少或继发性闭经等),周期性下腹痛,继发不孕及异常妊娠(包括复发性流产,胎死宫内及胎盘异常)等。按宫腔镜检查所见宫腔粘连的面积及程度可分为轻度,中度及重度粘连,轻、中度宫腔粘连预后多较好,重度宫腔粘连预后最差。目前多采用宫腔镜下宫腔粘连分离术,也是宫腔粘连的标准治疗方法。但是重度宫腔粘连分离术后妊娠率低、再粘连率高,给患者及临床医生带来很大的困扰,而如何预防再粘连、提高术后妊娠率也一直是人们研究的热点和难点。本研究比较了重度宫腔粘连宫腔镜分离术后先放置球囊3天后改为宫内节育器的患者与单纯放置宫内节育器患者的月经改善率、术后妊娠率及再粘连率,以寻求一种更好的预防宫腔粘连术后复发的方法。 材料与方法 1研究对象 选择于2009年6月至2010年12月之间在郑州大学第三附属医院妇科内镜中心行宫腔镜下重度宫腔粘连分离术的120例患者为研究对象,年龄(31.4±4.6)岁(22-43岁),病程2个月-4年。 所有患者术前检查重要脏器均无严重合并症,内分泌检查正常。而对于有妊娠要求的患者还应符合以下要求：1)排卵正常(应用B超监测)2)配偶的精液常规检查正常。3)不合并导致不孕的其他疾病。诊断按March分类标准：轻度粘连：粘连范围小于宫腔的1/4,仅有菲薄或膜性粘连,输卵管的开口及宫底上段有很轻微的病变或无病变；中度粘连：粘连累及1/4至3/4的宫腔,仅有粘连,而无宫壁之间的粘着,输卵管的开口及宫腔上段仅有部分闭锁；重度粘连：粘连范围超过宫腔的3/4,宫壁之间相互粘着或有致密肥厚的粘连带形成,输卵管的开口及宫底上段闭锁。 2手术方法及术后处理 所有患者均行宫腔镜下宫腔粘连电切术,手术在经腹B超监护下进行。术后宫腔注射玻璃酸钠,放置充水球囊或宫内节育器,雌孕激素人工周期治疗2个周期。 3分组及术后随访情况 按照术后预防再粘连方法的不同将患者分为放环组及水囊+放环组：放环组61例,手术后向宫腔内注射玻璃酸钠针25mmg并放置金属圆环1枚；水囊+放环组59例,手术后向宫腔内注射玻璃酸钠25mg同时放置Foley氏导尿管,B超监护下根据宫腔大小向导尿管球囊内灌注生理盐水3～5ml,3天后取出Foley氏导尿管并于宫腔内放置金属圆环1枚。 术后2个疗程人工周期结束后行宫腔镜检查了解患者宫腔形态并取出宫内节育器,之后第3、6个月及以后每6个月随访一次,了解患者月经量及妊娠情况。随访时间6个月至24个月,中位随访时间16个月。 4统计学处理 应用SPSS18.0软件对数据进行统计学处理,连续型变量采用t检验,率的比较采用χ2检验,检验水准α=0.05。 结果 球囊+放环组术后再粘连率16.9%,低于放环组32.8%(P0.05)。球囊+放环组与放环组月经改善率分别为96.6%,85.2%,前者高于后者,差异有统计学意义(P0.05)。对于有妊娠要求的患者,球囊+放环组与放环组术后妊娠率分别为：38.5%,33.9%,差异无统计学意义(P0.05)。 结论 重度宫腔粘连宫腔镜电切分离术后充水球囊联合放环能更有效预防宫腔再粘连,更好的改善月经,但不能提高术后妊娠率。
[Abstract]:Intrauterine adhesions (intrauterine adhesions IUA) refers to the endometrium in trauma after endometrial fibrosis and the formation of adhesions, leading to intrauterine atresia. All or part of the clinical manifestations of abnormal menstruation (as by the amount of reduction or secondary amenorrhea etc.), periodic abdominal pain, infertility and abnormal pregnancy (including recurrent spontaneous abortion, fetal death and abnormal placenta). By hysteroscopy see the area and the degree of intrauterine adhesions can be divided into mild, moderate and severe adhesion, light, moderate intrauterine adhesions and the prognosis is much better, severe intrauterine adhesions after pretreatment is the worst. The current use of hysteroscopic intrauterine adhesions. Is the standard treatment for intrauterine adhesions. But severe intrauterine adhesions after low pregnancy rate and high recurrent rate, bring great distress to the patients and clinicians, and how to prevent re adhesion, improve the postoperative pregnancy rate has also been a person The hot and difficult research. This study compares severe hysteroscopic after exclusion of 3 days to first balloon placement of IUD patients with simple IUD in patients with menstrual improvement rate, postoperative pregnancy rate and recurrent rate, to seek a better prevention of intrauterine adhesions the postoperative recurrence.
Materials and methods
1 research objects
From June 2009 to December 2010, 120 patients with severe intrauterine adhesion separation under hysteroscopy were enrolled in the gynecology center of the Third Affiliated Hospital of Zhengzhou University. The age of the patients was (31.4 + 4.6) years (22-43 years), and the duration of the disease was 2 months -4 years.
All the patients had no serious complications of important organs, endocrine examination was normal. But for pregnancy patients should meet the following requirements: 1) normal ovulation (B-ultrasound monitoring) 2) the spouse of the normal semen.3) not associated with other diseases causing infertility diagnosis. According to March classification: mild adhesion: adhesion of the uterine cavity range is less than 1/4, only a thin or membranous adhesions, tubal opening and upper fundus have very slight lesions or no lesions; moderate adhesions: intrauterine adhesions involving 1/4 and 3/4 only adhesion, and no adhesion between the uterine wall, tubal opening and palace only the upper part of cavity atresia; severe adhesion of uterine cavity adhesion: range of more than 3/4, the formation of adhesions between the uterus wall with dense adhesion or hypertrophy, tubal opening and fundus upper atresia.
2 methods of operation and postoperative treatment
All patients underwent hysteroscopic intrauterine adhesion electrocision in abdominal surgery under B-ultrasound monitoring. Postoperative intrauterine injection of sodium hyaluronate, water filled balloon or placed IUD, estrogen and progesterone artificial cycle for 2 cycles.
3 groups and postoperative follow-up
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