宫腔镜联合球囊治疗宫颈妊娠的探讨

<正>宫颈妊娠是妇产科罕见的危急重症,发生率约1∶18 000[1],常因漏诊、误诊、误治造成难以控制的大出血,并因大出血切除子宫,如处理不当甚至危及患者生命。如何处理好育龄妇女的宫颈妊娠,是近年来妇产科医生关注的焦点。为探讨治疗宫颈妊娠的有效措施,2007年10月至2011年10月我院尝试应用宫腔镜联合球囊治疗宫颈妊娠13例,取得了一定的临床疗效,现报道如下。     

凝血酶用于宫颈妊娠出血3例分析

异位妊娠是妇产科常见病，而其中宫颈妊娠则较为罕见，近年来发病有上升趋势。由于宫颈仅含少许平滑肌，余为无收缩功能的纤维结缔组织，当发生自然流产或行刮宫术时，容易出现致命性大出血。因此，如何采用保守治疗方法处理宫颈妊娠出血，保留患者的子宫及生育功能，乃是目前妇产科临床上亟待解决的难题之一。我院自2000～     

宫颈环扎术的术后妊娠期管理

宫颈环扎术作为预防宫颈机能不全所致早产的治疗手段之一,已广泛用于临床,对于其术后患者是否需在围手术期使用抗生素和保胎药物、终止妊娠的时机和方式及遗留缝线的处理等问题值得临床医生关注和讨论。本文复习国内外文献及江南大学附属医院妇产科的临床经验就宫颈环扎术后妊娠期管理的一些重要问题进行初步探讨。     

实时组织弹性成像在妊娠期宫颈评价中的应用

目的:研究超声实时组织弹性成像技术在妊娠期宫颈成熟度评价中的应用。方法:选取2013年2月—10月在天津市中心妇产科医院进行超声检查的妊娠妇女145例,根据孕周分为3组。所有妊娠妇女在常规产科超声检查后自愿行经阴道超声进行宫颈评价,在二维超声成像基础上测量宫颈长度,之后进行实时组织弹性成像,获得早、中、晚期妊娠时宫颈感兴趣区弹性应变率。结果:各妊娠组间宫颈长度以及宫颈感兴趣区弹性应变率差异均有统计学意义(P0.05),且早、中期妊娠组宫颈长度大于晚期妊娠组,宫颈感兴趣区弹性应变率小于晚期妊娠组,差异有统计学意义(P0.05),而早期与中期妊娠组间差异无统计学意义(P0.05)。宫颈长度与弹性应变率间呈负相关(r=-0.95,P=0.032)。结论:超声实时组织弹性成像技术在妊娠期宫颈成熟度评价中发挥了重要的作用,为临床提供了宫颈成熟度检查的客观指标,并为预测早产开辟了一条新的检查途径。     

彩色多普勒超声对宫颈妊娠的诊断价值

目的:分析宫颈妊娠的超声声像图特征及彩色多普勒血流显像情况,探讨彩色多普勒超声对宫颈妊娠的诊断价值。方法:对43例可疑宫颈妊娠的患者应用彩色多普勒超声进行检查,将彩色多普勒超声诊断结果与病理诊断结果对照分析。结果:43例患者的彩色多普勒超声诊断宫颈妊娠有39例与病理诊断结果相符,诊断准确率为90.7%;4例病理诊断为不全流产。结论:彩色多普勒超声对宫颈妊娠的患者有极其重要的诊断价值,是目前早期诊断宫颈妊娠的首选检查方法。     

高强度超声聚焦对剖宫产瘢痕部位妊娠的治疗效果

目的比较高强度超声聚焦配合清宫术与子宫动脉栓塞介入配合清宫术对于剖宫产瘢痕部位妊娠(cesarean scar pregnancies,CSP)的治疗效果。 方法采用回顾性分析方法,纳入2014年1月至2019年1月在广州医科大学附属第三医院妇产科收治的CSP患者60例,分为观察组(高强度超声聚焦配合清宫术患者)30例与对照组(子宫动脉栓塞配合清宫术患者)30例,对比两组患者的治疗效果相关临床指标。采用t检验、χ²检验对数据进行统计分析。 结果观察组住院时间(6.87±2.64)d,低于对照组(10±4.79)d, Z＝2.21,P<0.05;观察组住院费用(15 524.47±8035.73)元,少于对照组(25 390.80±12 914.10)元,t＝2.51,P<0.05;观察组月经恢复时间为(35.93±4.00)d,少于对照组(40.90±6.63)d,t＝2.50,P<0.05;观察组术后疼痛发生率6.6%,低于对照组40%, χ²＝8.91,P<0.05。两组患者在术中阴道出血量、术后阴道出血持续时间、术后血HCG下降时间、胃肠道反应、术后发热及盆腔感染方面差异均无统计学意义(P>0.05)。 结论高强度超声聚焦配合清宫术能降低CSP患者住院时间短,住院费用低,术后恢复月经时间更短,术后疼痛的发生率更低。     

高强度聚焦超声治疗包块型剖宫产瘢痕妊娠19例临床分析

目的:探讨高强度聚焦超声(HIFU)对包块型剖宫产瘢痕妊娠(CSP)治疗的临床价值。方法:收集2015年1月到2015年9月在重庆医科大学附属第一医院诊断为包块型CSP的患者19例。19例患者均行1次HIFU治疗,术后行清宫术或门诊随访。以超声造影检查比较治疗前后包块血流灌注变化,比较治疗前后血β-HCG变化、清宫术中出血量、月经复潮等情况。结果:19例患者HIFU术后即刻超声造影提示妊娠包块内血流灌注明显减少。17例患者于HIFU术后1~4天行清宫术,10例患者一次清宫术完全清除妊娠物,术中出血10~100ml[平均(36.36±34.71)ml],6例行第二次清宫术,术中出血40~400ml[平均(120.0±156.68)ml],1例HIFU+清宫术失败,转行介入栓塞术+清宫术;2例患者HIFU术后给予观察处理,1例术后4月妊娠物完全消失,1例患者行宫腹腔镜下病灶切除术。所有患者均在1月后月经来潮,血β-HCG阴性,其中1例患者术后3月诊断宫内妊娠。结论:HIFU联合宫腔镜下清宫术治疗包块型CSP是一种安全、有效、可供选择的新型治疗方式。     

宫颈妊娠、峡部妊娠的超声诊断价值

目的：探讨峡部妊娠、宫颈妊娠的超声表现和诊断价值；方法：回顾性分析11例经手术及病理证实峡部妊娠、宫颈妊娠的超声表现；结果：11例中，6例子宫峡部妊娠、2例宫颈妊娠、2例难免流产，超声诊断病灶部位与临床结果基本一致；结论：峡部妊娠、宫颈妊娠的表现有其特殊部位的特点，对临床早期明确诊断及治疗有重要价值。     

宫颈病变锥切术后妊娠8例分析

近年来，宫颈病变的发病越来越年轻化，宫颈锥切术也较多地用于宫颈病变的治疗，使得年轻患者的生育功能得以保留。临床上，值得引起重视的是宫颈锥切术后妊娠期和分娩期的管理问题，如果处理不当，可造成不良妊娠结局。中国医科大学附属盛京医院妇产科报道了8例因宫颈病变行锥切术后妊娠及其结局，虽然病例数不多，但临床观察资料较完整，能够初步说明宫颈锥切术后妊娠，容易并发阴道炎症、宫颈机能不全、流产和早产等。因此，应高度重视宫颈锥切术后妊娠的管理，注意阴道炎的防治，适时行宫颈环扎术，避免不必要的流产和早产，可改善妊娠结局。对于早期宫颈癌（Ia期），尤其是Ia1期的年轻患者，也可行锥切术治疗，但术后可以妊娠的时间，以及分娩后随访等问题，尚有待进一步研究。[编者按]     

药物联合宫腔镜治疗子宫颈妊娠二例报告

宫颈妊娠发生率为妊娠数的1/18 000～1/2 500[1].宫颈妊娠的发生率虽只占异位妊娠的约1％,但处理不当可发生大出血,导致子宫切除而丧失生育功能,甚至危及患者生命,因此,选择恰当的治疗措施很重要.大连医科大学附属第二医院妇产科2005至2010年共收治异位妊娠患者499例,其中宫颈妊娠6例.在6例宫颈妊娠中2例采用口服米非司酮后行超声引导下宫颈妊娠囊穿刺注射甲氨蝶呤(MTX),再辅以宫腔镜下宫颈妊娠囊电切术,取得了满意的疗效,现报道如下.     

Medical therapy (methotrexate and mifepristone) alone or in combination with another type of therapy for the management of cervical or interstitial ectopic pregnancy

Objective

To describe cases of cervical or interstitial ectopic pregnancy managed conservatively with combined medical treatment (methotrexate and mifepristone) alone or in association with other minimally invasive strategies.

Study design

We describe four cervical and two interstitial ectopic pregnancies at our hospital between 2006 and 2010. All received combined treatment with methotrexate and mifepristone. A search of MEDLINE is also described.

Results

The literature search identified only four previous cases of cervical ectopic pregnancies and no cases of interstitial ectopic pregnancy managed with combined therapy. In our study, all patients were successfully treated and had no adverse reactions with intramuscular methotrexate 50 mg/m² and oral mifepristone 600 mg, either alone or in association with minimally invasive treatment (uterine artery embolization and evacuation dilation and curettage). All patients remained asymptomatic with β-HCG levels that decreased and became negative within 14–49 days: the median hospital stay was 5.5 days. We also describe the first patient with a cervical ectopic pregnancy treated with methotrexate and mifepristone, followed by vaginal misoprostol 800 mcg for cervical evacuation.

Conclusion

Methotrexate–mifepristone, either alone or in combination with other minimally invasive strategies, could be considered an option for the treatment of both cervical and interstitial ectopic pregnancy. An individualized approach should be used in each patient, however, given the wide variety of possible clinical situations and the potential seriousness of ectopic pregnancy.     

Conservative treatment of cervical ectopic pregnancy with transvaginal ultrasound-guided aspiration and single-dose methotrexate

OBJECTIVE: To present a case of cervical ectopic pregnancy successfully treated with ultrasound-guided aspiration and single-dose methotrexate administered systemically. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 27-year-old nulliparous woman with a cervical ectopic pregnancy. INTERVENTION(S): Transvaginal ultrasound-guided aspiration of the cervical ectopic pregnancy followed by single-dose methotrexate administered systemically. MAIN OUTCOME MEASURE(S): Recovery of the patient, successful conservative treatment of the cervical ectopic pregnancy, with preservation of the uterus. RESULT(S): The cervical ectopic pregnancy was successfully aborted, and the reproductive capability of the patient was preserved. CONCLUSION(S): Transvaginal ultrasound-guided aspiration in combination with single-dose methotrexate administered systemically can be safely used to treat cervical ectopic pregnancies.     

经阴道超声对异位妊娠的诊断价值

目的:探讨经阴道超声对异位妊娠的诊断价值。方法:回顾分析127例经手术、病理证实的异位妊娠的声像图特征。结果:经阴道超声检查漏诊2例,误诊2例,异位妊娠超声检出率及定位正确率为96．8%。结论:经阴道超声对异位妊娠的诊断有较大的临床应用价值。     

Cervical ectopic pregnancy: surgical or medical treatment?

Cervical pregnancies are one of the rarest forms of ectopic gestations. The incidence of cervical ectopic pregnancies ranges between 1 in 1,000 to 95,000 gestations (Parente et al., Obstet Gynecol 62:79–82, 1983). Prior surgical trauma, including dilatation and curettage of the cervix, has been identified as one of the leading risk factors (Pisarska et al., Lancet 351:1115–1120, 1998; Yankowitz et al., Obstet Gynecol Surv 45:405–414, 1990). Cervical ectopic pregnancies are especially feared due to their associated life-threatening hemorrhage. Therefore, massive blood transfusions and emergency hysterectomy have often been required previously. Nevertheless, general guidelines for clinical management are lacking. In case reports medical and surgical treatment modalities are described. Overall, conservative management of an asymptomatic cervical ectopic pregnancy using methotrexate or potassium chloride seems to be superior to surgical intervention. The treatment of choice in patients suffering from symptomatic cervical ectopic pregnancy is still under discussion. In the case reported here, a combination of surgical and medical treatment conserving the patient’s childbearing capacity was successfully implemented. However, severe hemorrhage occurred and consecutive blood transfusions were urgently necessary. Emergency hysterectomy could be avoided.     

输卵管间质部妊娠高危因素及诊治进展

输卵管间质部妊娠在异位妊娠中所占比例较小,但一旦破裂,可出现致命性大出血。其发病高危因素有输卵管病变、盆腔炎性疾病、盆腔炎性疾病病史、异位妊娠史、输卵管手术史等。输卵管间质部妊娠的术前诊断主要依靠超声检查或MRI,宫腔镜和腹腔镜是诊断输卵管间质部妊娠的最直接和最可靠的方法。除少数病例适合药物治疗外,腹腔镜手术是输卵管间质部妊娠治疗的主要方法,常用的有宫角切除及缝合术(宫角楔形切除术)和宫角切开及缝合术两种术式。     

Non-tubal Ectopic Pregnancies: Overview and Treatment via Local Injection

Ectopic pregnancies account for 1.5% to 2% of all pregnancy in the United States. Of these, approximately 10% implant in nontubal locations, including the abdominal cavity, cervix, ovary, interstitial portion of the fallopian tube, broad ligament, the uterine cornua, or within a cesarean section scar. Because these pregnancies tend to present later than typical tubal pregnancies, they have been associated with greater maternal morbidity and mortality. Advances in ultrasound technology have allowed for earlier diagnosis of nontubal ectopic pregnancies, which in turn has led to the development of novel minimally invasive techniques to manage them. One of these methods involves the local injection of 1 of several agents directly into the ectopic pregnancy. In this article we provide a guide to this technique of local injection, including an overview of the potential agents that can be used, and review the diagnostic and specific ultrasound criteria, other possible treatment options, and overall outcomes for nontubal ectopic pregnancies.     

Manejo de la gestación ectópica cervical. Tratamiento médico con pauta multidosis de metotrexato intramuscular; a propósito de un caso

Cervical pregnancy is a rare form of extra-uterine pregnancy, and is associated with high rate of morbidity and mortality. It is estimated that 1 of 9000 ectopic pregnancies are implanted at the level of the cervix (less than 1% of extra-uterine pregnancies). Recent advances in diagnostic imaging and high resolution ultrasound have made its early diagnosis possible, and consequently, improve the conservative medical and surgical treatment. Among them, the multiple-dose treatment scheme with systemic methotrexate can be an effective and safe option. This has a success rate of 92.7%, with a considerable reduction in the number of major complications, as well as preserving fertility. The case is presented of a patient diagnosed with cervical ectopic pregnancy, treated with a scheme of multiple doses of intramuscular methotrexate combined with folinic acid, with an excellent response and complete resolution.     

超声诊断宫外孕105例分析

目的 探讨超声检查诊断宫外孕的价值。方法 回顾分析105例宫外孕超声检查情况。结果 105例宫外孕中，流产型9例，占8．6％；破裂型45例，占42．9％；未破裂型21例，占20．O％；陈旧型30例，占28．6％。结论 B超对宫外孕诊断的准确率高，检查迅速且无痛苦、无创伤，可作为妇产科急症首选的检查方法。     

Cervical pregnancy: a case report of hysteroscopic resection and balloon compression combined with systematic methotrexate treatment

ObjectiveCervical pregnancy is a rare type of ectopic pregnancy. When the pregnancy is terminated, it will sometimes lead to persistent bleeding. In some cases, hysterectomy is inevitable and the patient loses fertility. Therefore, early diagnosis and targeted management with systemic or local injection of methotrexate is the first-line treatment. Multiple interventions of cervical pregnancy were used to prevent massive hemorrhage, including dilatation and curettage, laparoscopic resection, hysteroscopic resection combined with uterine artery embolization, or uterine artery clip.Case reportWe report a case of cervical pregnancy with a high beta-hCG level accompanied by a visible fetal heartbeat that was successfully treated with hysteroscopic cervical tissue resection and balloon compression combined with systemic administration of methotrexate.ConclusionEfficacy and safety with preserved fertility were important issues in the management of cervical pregnancy. We provide a safe, simple and effective treatment of cervical pregnancy.     

Plasma hCG and ultrasound in suspected ectopic pregnancy

The value of plasma hCG determinations (based on the recognition of β-subunit of hCG) and ultrasound was examined in 48 cases of suspected ectopic pregnancy. In 11 patients with the final diagnosis of ectopic pregnancy (23%), the plasma hCG was clearly subnormal (0.37–3.96 IU/ml), with only one exception, where a normally developed fetus was operated from the fallopian tube (hCG 21.1 IU/ml in the 8th wk). The plasma hCG levels allowed differentiation of the non-pregnant cases from the normal intrauterine pregnancies and the ectopic cases, but not at all between the different forms of intrauterine early pregnancy failures and ectopic pregnancies. By ultrasound, however, it was possible to reliably diagnose intrauterine pregnancies from the 7th wk of amenorrhea onwards, and to classify them into the normal and pathological subgroups. The direct demonstration of ectopic pregnancy by ultrasound is problematic, but the exclusion of intrauterine pregnancy by this method, combined with the simultaneous plasma hCG determination by sensitive and rapid method, can be recommended for primary examinations in suspected ectopic pregnancy.