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子宫动脉栓塞术对剖宫产瘢痕妊娠患者的效果

来源:天津医科大学 作者:宫晓锦
发布于:2020-02-10 共7477字
  中文摘要
  
  目的: 观察子宫动脉栓塞术对剖宫产瘢痕妊娠患者月经、再次妊娠及妊娠结局、卵巢储备功能的影响。
  
  方法:
  
  1. 选取 2010 年 1 月-2017 年 6 月在天津医院(天和医院)确诊为剖宫产瘢痕妊娠并入院治疗的患者 200 例,其中行子宫动脉栓塞术+清宫术的患者 110 例,为观察组;直接行清宫术的患者 90 例,为对照组。查阅病历,记录两组患者妊娠前月经周期、月经期及经量情况;术后以电话或门诊复诊的方式随访至患者月经来潮 3 个周期,记录患者术后月经恢复的时间、术后月经周期、月经期、月经量的变化情况;记录两组中有再次妊娠意愿的患者,于术后 1-3 年随访其是否妊娠及妊娠结局的情况进行分析。通过月经及再次妊娠结局的情况来评估子宫动脉栓塞术对患者卵巢功能的影响。

子宫动脉栓塞术对剖宫产瘢痕妊娠患者的效果
  
  2. 选取 2017 年 6 月-2018 年 6 月在天津医院确诊为剖宫产瘢痕妊娠并入院进行子宫动脉栓塞术+清宫术治疗的患者 20 例作为研究组;同期在天津医院确诊为剖宫产瘢痕妊娠并入院进行清宫术治疗且与研究组年龄、孕周、孕次、产次、剖宫产次数等指标相匹配的患者 20 例作为对照组,进行前瞻性研究。入院后抽取患者静脉血检测卵泡刺激素(Follicle-stimulating hormone,FSH)、雌二醇(Estrogenic,E2)、抗苗勒氏管激素(Anti-mullerian hormone,AMH)水平、阴道超声测量卵巢窦卵泡计数(Antral follicle count,AFC)、卵巢体积(Ovarianvolume,OV);术后随访患者月经恢复时间,分别于术后第 1、3、6 月经周期的第 1-4 天之间抽取静脉血检测 FSH、E2、AMH 水平、阴道超声测量 AFC、卵巢体积并进行分析。通过卵巢激素分泌水平及卵巢形态学改变来评估子宫动脉栓塞术对患者卵巢储备功能的影响。
  
  结果:
  
  1. 观察组中 94.5%的患者在 1-2 个月后恢复正常月经,2.8%的患者在术后3 个月恢复,1.8%的患者在术后 4-6 个月恢复,0.9%的患者发生闭经现象,为子宫性闭经;对照组中 98.8%的患者在术后 1-2 个月恢复正常月经,0.2%的患者在术后 3 个月恢复月经,未出现闭经患者。
  
  2. 观察组与对照组妊娠前的月经周期、月经期差异无统计学意义(P>0.05),两组之间术后的月经周期、月经期差异无统计学意义(P>0.05)。观察组中月经量增多的患者 10 例(9.1%)、无变化的患者 77 例(70.0%)、减少的患者 22 例(20.0%)、闭经的患者 1 例(0.9%);对照组中月经量增多的患者 8 例(8.9%)、无变化的患者 65 例(72.2%)、减少的患者 17 例(18.9%)、无患者闭经。两组患者月经量改变的差异无统计学意义(P>0.05)。
  
  3. 在观察组与对照组中有再次妊娠意愿的患者中,子宫动脉栓塞+清宫术组 52 例,自然妊娠 33 例(63.5%),其中自然流产 4 例(7.7%)、早产 12 例(23.1%)、足月活产 17 例(32.7%);清宫术组 44 例,自然妊娠 28 例(63.6%),其中自然流产 3 例(6.8%)、早产 11 例(25.0%)、足月活产 14 例(31.8%)。
  
  两组之间妊娠率、自然流产率、早产率、足月活产率差异均无明显统计学意义(P>0.05)。
  
  4. 研究组与对照组之间术前 FSH、E2、AMH、AFC、卵巢体积水平差异无统计学意义(P>0.05)。两组之间术后第 1 月经周期 AMH 差异具有统计学意义(P<0.05),术后第 3、6 月经周期差异无统计学意义(P>0.05);两组之间术后第 1、3、6 月经周期 FSH、E2 差异无统计学意义(P>0.05)。研究组术后第3、6月经周期AMH较术后第1月经周期升高,差异有统计学意义(P<0.05),术后第 3、6 月经周期之间差异无统计学意义(P>0.05)。
  
  5. 研究组与对照组之间术后第 1、3、6 月经周期 AFC、卵巢体积相比差异无统计学意义(P>0.05)。
  
  结论:
  
  1. 子宫动脉栓塞术对患者月经及再次妊娠率无明显影响,本研究中未观察到子宫动脉栓塞术增加患者再次妊娠的不良结局。
  
  2. 子宫动脉栓塞术后短期内影响患者卵巢储备功能,但随着时间延长出现恢复的趋势。因本研究中无研究组人群非妊娠状态下 FSH、E2、AMH、AFC、卵巢体积的测量值,且年龄小于 40 岁,子宫动脉栓塞术后卵巢储备功能是否能恢复至孕前水平,以及对高龄患者的卵巢储备功能是否存在影响,需在后续研究中应进一步观察。在反应卵巢储备功能的指标中 AMH 更为敏感。
  
  3. 因本研究为单中心研究,样本较小,研究时间较短,所得结论有一定的局限性,还需大样本多中心的研究。
  
  关键词:  子宫动脉栓塞术 剖宫产瘢痕妊娠 卵巢功能 抗苗勒氏管激素 窦卵泡计数。
  
  Abstract
  
  Objective:To observe the effect of uterine artery embolization on menstruation,repregnancy, pregnancy outcome and ovarian reserve function in patients with cesarean scar pregnancy.
  
  Methods:
  
  1. From January 2010 to June 2017, 200 cases of patients diagnosed with cesarean scar pregnancy in Tianjin hospital (Tianhe hospital) and admitted for treatment were selected, including 110 cases of patients who underwent uterine artery embolization +dilatation and curettage, as the observation group. A total of 90 patients who underwent dilatation and curettage were included in the control group.Medical records were reviewed and the menstrual cycle, menstrual period and menstrual volume before pregnancy were recorded in the two groups. Patients were followed up by telephone or outpatient consultation for 3 periods after the operation,and the time of postoperative menstrual recovery, postoperative menstrual cycle,menstrual period and menstrual volume were recorded. Patients in the two groups with the intention of repregnancy were selected and their pregnancy status and pregnancy outcome were followed up 1-3 years after the operation for analysis. The effect of uterine artery embolization on ovarian function was assessed by the outcomes of menstruation and repregnancy.
  
  2. Twenty patients diagnosed with cesarean scar pregnancy in Tianjin hospital from June 2017 to June 2018 and admitted for uterine artery embolization + dilatation and curettage were selected as the research group. During the same period, 20 patients who were diagnosed as cesarean scar pregnancy in Tianjin hospital and were admitted to the hospital for dilatation and curettage and were matched with age, gestational age, number of pregnancy, birth and cesarean section in the research group were selected as the control group for prospective study. Extraction after admission in patients with venous blood test FSH, E2, AMH levels, vaginal ultrasound measurement of AFC, OV;postoperative follow-up of patients with menstrual recovery time, intravenous blood tests were performed between the first and fourth days of the menstrual cycle on FSH, E2, AMH levels, vaginal ultrasound, AFC, and ovarian volume at the first, third, and sixth day of the postoperative menstrual cycle, respectively. To evaluate the effect of uterine artery embolization on ovarian reserve function by ovarian hormone secretion level and ovarian morphological changes.
  
  Results:
  
  1. In the observation group, 94.5% of the patients recovered to normal menstruation after 1-2 months, and 2.8% of the patients recovered to normal menstruation after 3 months,1.8% of the patients recovered 4-6 months aftersurgery, and 0.9% developed amenorrhea, which was uterine amenorrhea;In the control group, 98.8% of the patients returned to normal menstruation 1-2 months after surgery, and 0.2% of the patients returned to menstruation 3 months after surgery without amenorrhea.
  
  2. There was no statistically significant difference between the observation group and the control group in menstrual cycle and menstrual period before pregnancy and after surgery (P > 0.05).In the observation group, there were 10patients (9.1%) with increased menstrual volume, 77 patients (70.0%) with no change,22 patients (20.0%) with decrease, and 1 patient (0.9%) with amenorrhea. In the control group, 8 patients (8.9%) had increased menstrual volume, 65 patients (72.2%) had no change, 17 patients (18.9%) had decreased menstrual volume, and none had amenorrhea.
  
  3. Among the patients in the observation group and the control group who wanted to have a second pregnancy, there were 52 patients in the uterine artery embolization + dilatation and curettage group, and 33 patients in the naturalpregnancy group (63.5%), including 4 cases of spontaneous abortion (7.7%), 12 cases of premature delivery (23.1%), and 17 cases of full-term live birth (32.7%).Among the 44 patients in the dilatation and curettage group, 28 patients(63.6%) had natural pregnancy, including 3 patients (6.8%) had spontaneous abortion, 11 patients (25.0%) had premature delivery, and 14 (31.8%) had full-term live birth. There was no significant difference in pregnancy rate, spontaneous abortion rate, preterm birth rate and full-term live birth rate between the two groups (P > 0.05).
  
  4. There were no statistically significant differences in preoperative FSH, E2, AMH, AFC and ovarian volume levels between the study group and the control group (P > 0.05).There was statistically significant difference in AMH between the two groups at the first postoperative menstrual cycle (P < 0.05), but no statistically significant difference at the third and sixth postoperative menstrual cycles (P > 0.05).There was no significant difference in FSH and E2 between the two groups at the 1st, 3rd and 6th menstrual cycles after surgery (P > 0.05).In the study group, the postoperative AMH in the 3rd and 6th menstrual cycles was higher than that in the 1st menstrual cycle (P < 0.05), while there was no statistically significant difference between the 3rd and 6th menstrual cycles (P > 0.05).
  
  5. There was no significant difference in AFC and ovarian volume between the study group and the control group on the 1st, 3rd and 6th menstrual cycles after surgery (P > 0.05).
  
  Conclusions:
  
  1. Uterine artery embolization had no significant effect on menstruation and the rate of second pregnancy. In this study, we did not observe increased adverse outcomes of uterine artery embolization in patients with second pregnancy.
  
  2. Uterine artery embolization affects ovarian reserve function in the short term,but it tends to recover with time. Because of this study has no FSH, E2, AMH, AFC,ovarian volume measurements with the unpregnant subjects younger than 40, whether ovarian reserve function can be restored to the normal level before pregnancy after uterine artery embolization and whether there is any effect on ovarian reserve function in elderly patients need to be further observed in the follow-up study. AMH is more sensitive in indicators reflecting ovarian reserve function.
  
  3. Because this study is a single-center study, with a small sample size and a short research time, the conclusions obtained have some limitations, and a multi-center study with a large sample is required.
  
  Keywords:    Uterine arterial embolization Sesarean scar pregnancy Ovarian function Anti-mullerian hormone Antral follicle count。
  
  前言
  
  研究现状、成果。

  
  剖宫产瘢痕妊娠(Cesarean scar pregnancy,CSP)指受精卵在既往剖宫产瘢痕处着床的妊娠状态,属于异位妊娠的一种,特指妊娠在 12 周以内(≤12 周)的阶段,大于 12 周的 CSP 被诊断为“中期妊娠,剖宫产瘢痕妊娠,胎盘植入”。
  
  [1]因为我国既往剖宫产率较高,在“二孩”时代来临之际,剖宫产瘢痕妊娠的发生也越来越多。CSP 早期可无明显症状,或如正常妊娠出现疲乏、嗜睡、恶心、呕吐或阴道少量出血、轻度腹痛或腹坠等,但部分患者会以大量阴道出血为首先症状而就诊,更有甚者会伴有绒毛植入、子宫破裂、甚至需要切除子宫、危及患者生命,因此 CSP 应早期诊断,尽早清除妊娠组织物。因临床工作者对该病越来越重视,且超声、核磁等影像学检查技术与设备等不断进步,CSP 能够早期诊断并得到了更加有效及适当的治疗。
  
  根据临床症状、分型、是否存在绒毛植入、远期有无生育要求等临床特点的不同,治疗剖宫产瘢痕妊娠的方法具有多样性,包括局部或全身药物治疗、子宫动脉栓塞术(Uterine artery embolization,UAE)、清宫术、宫腹腔镜手术、经腹、经阴道病灶切除并子宫修补术和子宫切除术等,目前尚无统一的治疗标准,往往需多种方法的联合应用。子宫动脉栓塞术是一种介入治疗技术,利用数字减影血管造影(Digital substraction angiography,DSA)造影,经动脉穿刺插管,超选至子宫动脉并注入栓塞剂、化疗药物等进行疾病的治疗。在剖宫产瘢痕妊娠的治疗中,UAE 通过阻断双侧子宫动脉的血供,术中栓塞剂促进局部血栓形成,来达到快速止血的作用,特别适用于伴有阴道大出血症状、子宫前壁瘢痕处肌层菲薄甚至局部外凸、病灶周围血供丰富的 CSP 患者,不仅能够抢救患者生命、保留患者的生育功能,而且还为后续治疗争取时间及减少治疗中出血风险。
  
  子宫动脉栓塞术应用范围广泛,除了应用在剖宫产瘢痕妊娠之外,子宫肌瘤也是子宫动脉栓塞术的适应症之一,随着临床应用的增多,UAE 术后卵巢功能下降、生育能力受到影响、流产率增加、甚至卵巢早衰等不良反应的报道增加;但同时也有研究称 UAE 手术对卵巢功能并无明显影响。目前国外文献报道的关于对卵巢功能的影响多是应用于子宫肌瘤治疗,而国内现有的 CSP 患者UAE 术后的研究中,对是否影响卵巢功能也存在一定争议,且在评估卵巢功能时,应用 FSH、E2 较多,其他评估卵巢功能的指标包括抑制素 B(INHB)、抗苗勒氏管激素(AMH)、窦卵泡计数(AFC)、卵巢体积、最大平面平均直径等[2]则更多地应用在辅助生殖技术,较少用于 UAE 术后卵巢功能的评估。有研究指出,FSH、E2 仅反映卵巢内分泌功能,不能反映储备功能[3,4]。本课题通过回顾性及前瞻性研究方法,研究子宫动脉栓塞术对剖宫产瘢痕妊娠患者卵巢功能的影响。
  
  研究目的、方法。
  
  本研究通过对子宫动脉栓塞术后患者月经恢复情况、月经模式改变、再次妊娠结局及卵巢储备功能情况分析,研究子宫动脉栓塞术对剖宫产瘢痕妊娠患者卵巢功能的影响,更好地指导 CSP 患者,尤其对有再次生育要求的患者,选择适当的治疗方案及适当的监测卵巢功能的指标。
  
  研究方法分为回顾性及前瞻性研究两部分。
  
  1. 选取 2010 年 1 月-2017 年 6 月在天津医院(天和医院)确诊为剖宫产瘢痕妊娠并入院治疗的患者 200 例,其中行子宫动脉栓塞术+清宫术的患者 110 例,为观察组;直接行清宫术的患者 90 例,为对照组。查阅病历,记录两组患者妊娠前月经周期、月经期及经量情况;术后以电话或门诊复诊的方式随访至患者月经来潮 3 个周期,记录患者术后月经恢复的时间、术后月经周期、月经期、月经量的变化情况;记录两组中有再次妊娠意愿的患者,于术后 1-3 年随访其是否妊娠及妊娠结局的情况进行分析。通过月经及再次妊娠结局的情况来评估子宫动脉栓塞术对患者卵巢功能的影响。
  
  2. 选取 2017 年 6 月-2018 年 6 月在天津医院确诊为剖宫产瘢痕妊娠并入院进行子宫动脉栓塞术+清宫术治疗的患者 20 例作为研究组;同期在天津医院确诊为剖宫产瘢痕妊娠并入院进行清宫术治疗且与研究组年龄、孕周、人流术次数、剖宫产次数等指标相匹配的患者 20 例作为对照组,进行前瞻性研究。入院后抽取患者静脉血检测卵泡刺激素(Follicle-stimulating hormone, FSH)、雌二醇(Estrodiol,E2)、抗苗勒氏管激素(Anti-mullerian hormone, AMH)水平、阴道超声测量卵巢窦卵泡计数(Antral follicle count, AFC)、卵巢体积(Ovarianvolume, OV);术后随访患者月经恢复时间,分别于术后第 1、3、6 月经周期的第 1-4 天之间抽取静脉血检 FSH、E2、AMH 水平、阴道超声测量 AFC、卵巢体积并进行分析。通过卵巢激素分泌水平及卵巢形态学改变来评估子宫动脉栓塞术对患者卵巢储备功能的影响。
  
  【由于本篇文章为硕士论文,如需全文请点击底部下载全文链接】
 
  
  一、子宫动脉栓塞术对 CSP 患者月经、再次妊娠结局的影响
  
  1.1 对象和方法 .

  1.1.1 研究对象
  1.1.2 治疗方法
  1.1.3 研究方法
  1.1.4 统计学方法
  
  1.2 结果 .
  1.2.1 患者月经恢复情况及月经模式的情况.
  1.2.2 患者再次妊娠率及妊娠结局的情况.
  
  1.3 讨论
  1.3.1 子宫动脉栓塞术对 CSP 患者月经的影响
  1.3.2 子宫动脉栓塞术对 CSP 患者再次妊娠及妊娠结局的影响
  
  1.4 小结 .
  
  二、子宫动脉栓塞术对 CSP 患者卵巢储备功能的影响.
  
  2.1 对象和方法 .

  2.1.1 研究对象
  2.1.2 治疗方法
  2.1.3 研究方法
  2.1.4 统计学方法
  
  2.2 结果 .
  2.2.1 患者卵巢激素分泌的情况.
  2.2.2 患者卵巢形态学指标的情况.
  
  2.3 讨论
  2.3.1 子宫动脉栓塞术对 CSP 患者卵巢激素分泌水平的影响
  2.3.2 子宫动脉栓塞术对 CSP 患者卵巢形态学的影响
  
  2.4 小结 .

  结论。

  1. 子宫动脉栓塞术对患者月经及再次妊娠率无明显影响,本研究中未观察到子宫动脉栓塞术增加患者再次妊娠的不良结局。

  2. 子宫动脉栓塞术后短期内影响患者卵巢储备功能,但随着时间延长出现恢复的趋势。因本研究无研究组人群非妊娠状态下 FSH、E2、AMH、AFC、卵巢体积的测量值,且研究组患者年龄小于 40 岁,子宫动脉栓塞术后卵巢功储备能是否能恢复至孕前水平,以及对高龄患者的卵巢储备功能是否存在影响,需在后续研究中应进一步观察。在反应卵巢储备功能的指标中 AMH 更为敏感。

  3. 因本研究为单中心研究,样本较小,研究时间较短,所得结论有一定的局限性,还需大样本多中心的研究。

  参考文献.

作者单位:天津医科大学
原文出处:宫晓锦. 子宫动脉栓塞术对卵巢功能的影响[D].天津医科大学,2019.
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