宫颈锥切术后妊娠结局临床分析

目的探讨宫颈锥切术对妊娠结局的影响。方法锥切组为2007年9月1日至2011年8月31日期间在北京海淀区妇幼保健院住院分娩的共82例妊娠前曾因宫颈上皮内瘤样病变行宫颈锥切术(手术方式包括冷刀锥切术和环形电刀锥切术)的患者,随机选择同期480例未行宫颈锥切术的患者为对照组,比较两组患者的分娩方式、妊娠并发症等。结果 (1)锥切组剖宫产率59.76%(49/82),产钳助产率15.85%(13/82),明显高于对照组,自然分娩率24.39%(20/82),明显低于对照组,差异有统计学意义(P﹤0.01);如果去除剖宫产指征为社会因素的患者,锥切组剖宫产率31.71%(26/82),对照组剖宫产率29.58%(142/480),两组比较差异无统计学意义(P﹥0.05)。(2)锥切组早产发生率19.51%(16/82),胎儿窘迫发生率18.29%(15/82),明显高于对照组,差异有统计学意义(P﹤0.01);胎膜早破发生率23.17%(19/82),与对照组比较,差异有统计学意义(P﹤0.05)。软产道裂伤0例,低出生体重儿8.54%(7/82),与对照组比较,差异无统计学意义(P﹥0.05)。(3)宫颈锥切术与妊娠间隔时间≤1年早产的发生率8.6%(3/35),间隔时间﹥1年早产的发生率27.7%(13/47),后者高于前者,差异有统计学意义(P﹤0.05)。结论宫颈锥切术将会影响继之的妊娠结局,增加早产、胎膜早破等的发生率。如果去除社会因素,并没有增加剖宫产率。     

宫颈锥切术对宫颈上皮内瘤变患者妊娠及其结局的影响

目的探讨宫颈锥切术对宫颈上皮内瘤变（CIN）患者妊娠及其结局的影响。方法对北京协和医院妇产科1999年至2005年间收治的111例因CIN实施宫颈锥切术的患者进行电话随访,术前无原发不孕、年龄≤40岁、未生育过、有生育要求的35例患者纳入本研究。对35例患者的妊娠时间、妊娠周数、妊娠结局和终止妊娠方式进行回顾性分析。结果（1）35例患者,年龄23～40岁,平均31岁。35例患者中有25例获得26次妊娠,妊娠率为74％（26／35）,与该25例患者宫颈锥切术前的妊娠率（69％）比较,差异无统计学意义（P〉0．05）。（2）25例妊娠患者中,1例异位妊娠,4例自然流产。其中已分娩的13例患者中,1例早产行剖宫产术,早产率为8％（1／13）;胎膜早破2例,胎膜早破发生率为15％（2／13）;无低出生体重儿发生;10例行剖宫产术,剖宫产率为77％（10／13）。（3）已分娩的13例患者中,宫颈锥切高度平均为2．0cm（1．0～3．0cm）,锥切宽度平均为2．5cm（1．5～3．0cm）。结论宫颈锥切术对CIN患者的妊娠及其结局无明显影响,也不增加早产和低出生体重儿发生率。     

宫颈锥切术对生育能力及妊娠结局影响的研究进展

宫颈鳞状上皮内病变（squamous intraepithelial lesion,SIL）与宫颈癌的发生密切相关,近年来发病率逐渐升高且呈年轻化趋势,宫颈锥切术作为宫颈高级别鳞状上皮内病变（HSIL）患者的首选治疗方法被广泛应用。对于锥切术后有生育要求的患者,宫颈锥切术是否对妊娠产生影响目前尚不明确,现有的多数研究认为,宫颈锥切术不会显著影响生育能力,但可能增加早产、流产、胎膜早破和围生期死亡等不良妊娠结局的发生率,不会明显影响产程进展或增加剖宫产率;宫颈环形电刀锥切术（loop electrosurgical excisional procedure,LEEP）术后妊娠结局优于宫颈冷刀锥切术（cold-knife conization,CKC）,锥切术后应至少避孕6个月;锥切的深度和体积增加可增加不良妊娠结局的发生率;锥切术后患者不是必须行预防性宫颈环扎术。对于有生育要求的锥切术患者,应注意术后随诊,根据术中及术后恢复情况,个体化指导受孕,妊娠期严密监测宫颈长度及阴道感染情况,积极鼓励无阴道分娩禁忌患者行阴道试产。     

宫颈冷刀锥切术对生育能力及妊娠结局的影响

目的:探讨宫颈冷刀锥切术对患者生育能力的影响及是否产生不良妊娠结局。方法:收集1998年10月至2008年9月收治的因宫颈上皮内瘤变(CIN)或宫颈原位癌于我院实施宫颈冷刀锥切术且有生育要求的患者96例作为观察组,随机抽取同期孕前门诊的100例无宫颈锥切术史的妇女作为对照组。对两组对象的生育能力、妊娠结局及围生儿情况进行分析。结果:①观察组术后妊娠率(89.6%)与对照组(91.0%)相比,差异无统计学意义(P>0.05)。②观察组剖宫产率(34.7%)高于对照组(20.5%)(P<0.05),两组流产率、阴道试产成功率、产钳助产率、平均产程及各项剖宫产指征比较差异均无统计学意义(P>0.05)。③观察组严重早产发生率(8.0%)和早产胎膜早破发生率(10.7%)高于对照组(1.2%和2.4%)(P<0.05),而观察组新生儿出生体重低于对照组(P<0.05);观察组早产及小于胎龄儿发生率与对照组比较差异无统计学意义(P>0.05);④宫颈锥切术距术后初次妊娠时间间隔<6月组、6～12月组及≥12月组的不良妊娠结局比较,3组差异均无统计学意义(P>0.05);⑤将锥切高度<10mm、10～20mm及≥20mm分成3组,流产率、早产率、早产胎膜早破及小于胎龄儿发生率随宫颈锥切的高度递增,但差异无统计学意义(P>0.05)。结论:宫颈锥切术后对患者妊娠能力无明显影响,但可增加不良围生结局发生率;宫颈锥切术距术后妊娠的时间间隔和锥切高度与不良围生结局无明显关系。     

宫颈锥切术对未来妊娠结局的影响

目前宫颈锥切术是否增加未来不良妊娠结局的风险,尚存争议。宫颈锥切术对患者的生育能力无显著影响,但可能增加未来早产、低出生体重、胎膜早破及围产期死亡的风险。宫颈锥切术的术式、切除范围和手术至妊娠的时间是影响不良妊娠结局的重要因素。宫颈锥切术可引起宫颈狭窄及宫颈机能不全,应用超声监测宫颈长度有助于预测早产。目前尚无证据表明,宫颈锥切术增加剖宫产率。     

妊娠期行宫颈环形电切除术的安全性及对妊娠结局的影响

随着宫颈病变的年轻化以及宫颈环形电切除术的广泛开展,妊娠期行宫颈环形电切除术的安全性及对妊娠结局的影响成为医患双方共同关注的焦点。妊娠期宫颈病变有较小的恶化趋势,妊娠期可予随访,定期行细胞学及阴道镜检查,于产后6周复查,根据病理结果按宫颈病变妇科治疗原则处理。宫颈癌前病变及原位癌的稳定状态与分娩方式无关,分娩方式的选择取决于产科指征,无特殊指征的患者仍提倡阴道分娩。宫颈环形电切除术对妊娠结局的影响尚有争议,须进一步大样本研究证实。     

宫颈环形电切术治疗宫颈上皮内瘤变对妊娠结局影响的临床研究

目的:探讨宫颈环形电切术(LEEP)治疗宫颈上皮内瘤变(CIN)对妊娠结局的影响.方法:选取2006年8月至2011年2月因CIN在重庆市妇幼保健院宫颈专科接受LEEP治疗,并有生育计划的患者228例,同时选取同期有生育计划的健康妇女400例作为对照组,随访两组妇女妊娠情况.结果:①实验组228例患者共获得179次妊娠,受孕率78.51％,对照组共获得321次妊娠,受孕率80.25％,两组比较差异无统计学意义(P＞0.05).②实验组92例患者妊娠时限超过20周;对照组225例妊娠时限超过20周,两组孕妇在妊娠时间、早产率、新生儿体重、胎膜早破发生率、宫颈裂伤率等方面差异均无统计学意义(P＞0.05).③实验组剖宫产率为79.12％(72/91),明显高于对照组(54.67％,123/225),差异有统计学意义(P＜0.01).去除以社会因素为指征的剖宫产患者,两组剖宫产率比较差异无统计学意义(P＞0.05).④实验组中宫颈锥切深度与分娩孕周呈负相关(r=-0.438,P＜0.05).结论:LEEP治疗CIN是可行的,正确掌握手术适应证与手术切除深度与范围,对其后的妊娠结局无明显影响.     

LEEP术治疗宫颈上皮内瘤变对妊娠母儿相关结局影响的Meta分析

目的：探讨宫颈上皮内瘤变（cervical intraepithelial neoplasia,CIN）行宫颈环形电切术（loop electrosurgical excision procedure,LEEP）治疗对妊娠母儿相关结局的影响。方法：检索PubMed、Cochrane Library、CNKI、CBM、万方、维普等电子数据库发表的有关CIN行LEEP治疗对妊娠母儿结局影响的病例对照研究,采用Revman 5.3软件进行统计分析。结果：共纳入40篇病例对照研究,共9 002例病例,其中病例组4 196例、对照组4 806例。Meta分析结果显示,与对照组比较,CIN患者LEEP术后妊娠情况如下。（1）妊娠早、中期相关结局：流产（RR=1.34,９5%CI：1.14～1.57,P＜0.05）风险增加,而受孕率、引产率及异位妊娠率差异无统计学意义（均P＞0.05）;（2）妊娠晚期相关结局：① 孕产妇方面,早产（RR=1.60,95%CI：1.37～1.86,P＜0.05）、未足月胎膜早破（RR=2.72,95%CI：1.46～5.07,P＜0.05）风险明显增加,而胎膜早破、剖宫产、前置胎盘及产后出血的发生率差异无统计学意义（均P＞0.05）;② 围生儿方面,低出生体质量儿发生率（RR=1.35,95%CI：1.10～1.66,P＜0.05）增加,而胎儿窘迫、新生儿窒息及新生儿病死率差异无统计学意义（均P＞0.05）;③分娩方式及其并发症方面,LEEP术不增加急产、产钳与胎头吸引助产及宫颈裂伤的风险（均P＞0.05）。结论：LEEP术增加流产、早产、未足月胎膜早破及低出生体质量儿发生的风险。对于有生育要求的CIN患者,LEEP术前应充分告知妊娠不良结局的风险。     

子宫内膜切除术后妊娠结局的探讨

目的 探讨经宫颈子宫内膜切除术（TCRE）后妊娠的结局及其处理方法。方法 回顾分析我院TCRE后妊娠26例32例次的妊娠情况及其结局。结果 1例次自然流产,27例次人工流产,其中1例次宫腔粘连,狭窄,用宫腔电切镜切开后吸宫,1例次吸出完整胎囊后出血700ml,一般处理无效,行宫腔球囊压迫止血,另1例次右宫角妊娠,吸宫失败,行经腹子宫切除术,1例次宫颈妊娠,大出血;2例输卵管妊娠,1例足月妊娠,胎盘植入,剖宫产分娩一足月小样儿,同时切除子宫。结论 TCRE后仍有妊娠可能,但其困难流产,胎盘植入,胎儿生长受限,第三产程异常等并发症发生率升高,故应视为高危人群,加强监护。     

子宫颈上皮内瘤变患者行宫颈环切术对妊娠结局的影响

目的探讨对宫颈上皮内瘤变患者行宫颈环切术对妊娠结局的影响。方法回顾性分析1995年5月～2002年4月因宫颈上皮内瘤变行宫颈环切术27例患者的妊娠结局。结果占同期宫颈环切术手术的13．3％(27／203),患者年龄为23～40岁,中位年龄为30．3岁。27例中,10例因计划生育行人工流产术,1例异位妊娠,2例妊娠6～8周自然流产。14例足月分娩,其中阴道分娩9例。剖宫产5例。所有分娩孕妇的分娩孕周均大于38周,胎儿体重2905～4000g。新生儿1分钟Apgar评分：9分2例;10分12例,无新生儿窒息。结论宫颈环切术是治疗子宫颈上皮内瘤变的安全有效方法,只要掌握手术指征和手术切除范围,对其后的妊娠生育是安全的。     

Pregnancy outcome in patients treated with cervical conization for cervical intraepithelial neoplasia

Objective

To examine the causal contribution of conization to premature delivery.

Methods

This was a retrospective, case-control, multicenter study of women who underwent conization in 5 hospitals in the Basque Country (Spain) from 1998 to 2007. Three study groups were established: group A, post-conization infant deliveries; control group B, pre-conization infant deliveries; and control group C, infant deliveries without conization.

Results

Comparing group A with group C, there was a higher rate of preterm delivery before 35 weeks (5.3% versus 1.6%), a lower mean birth weight (3156.2 g versus 3328.5 g), and a greater prevalence of infants under 2500 g (10.6% versus 3.7%). There were no significant differences between group A and group B: preterm delivery before 35 weeks (5.3% versus 4.8%), mean birth weight (3156.2 g versus 3119.4 g), and prevalence of infants under 2500 g (10.6% versus 10.6%).

Conclusion

Pregnancy in women post-conization was associated with a risk of preterm delivery. However, there were no significant differences between women who underwent conization before and those who underwent conization after delivery. Cervical conization does not necessarily increase the risk of preterm delivery in subsequent pregnancy. Conization should be considered an indicator of such risk because it is associated with pregnancy complications arising from socio-epidemiologic factors present in women requiring conization that are also present in women who have premature delivery.     

Occlusion of the external cervical os after conization in a postpuerperal amenorrheic woman

Introduction. Complete occlusion of the cervical canal following conization is an uncommon complication. Case report. We encountered a case in a woman with lactation amenorrhea who after conization to treat cervical intraepithelial neoplasia (CIN) 3 developed hematometra and did not resume menstruation. This case was diagnosed early by ultrasonic tomography and magnetic resonance imaging (MRI). Conclusion. Postpuerperal amenorrheic women should be managed with care because of the increased risk of occlusion of the cervical duct after conization.     

Pregnancy outcome in renal transplant recipients

Objective: To correlate pregnancy outcome with complications in pregnancy and transplantation-to-pregnancy interval in renal transplant recipients in Croatia. Method: Data on 23 pregnancies after prepregnancy stabilization of blood pressure and normalization of graft function were retrospectively analyzed. Result: The mean interval between transplantation and conception was 3.1 years. Primary renal disease was chronic glomerulonephritis in 7, chronic pyelonephritis in 7 and agenesis of right kidney and stenosis of left renal artery in 1 patient. There were 10 term and 5 preterm deliveries, 6 induced and 2 spontaneous abortions. The mean gestational age was 38.1 weeks and the mean newborn birthweight was 3015 g. The prematurity rate was 21.7%. Patients with arterial hypertension in pregnancy, elevated serum creatinine level and bacteriuria, as well as those with conception occurring less than 2 years after transplantation, had a higher rate of therapeutic and spontaneous abortions, preterm deliveries and low birth weight infants. Conclusion: The interval between transplantation and conception, as well as allograft function during pregnancy, seem to be of great importance for successful obstetric outcome in renal transplant patients.     

锥切术后早期阴道镜检查对处理切缘阳性患者的临床价值

目的:通过对高级别宫颈上皮内瘤变(CIN)锥切后切缘阳性的患者术后4~6周行阴道镜检查,探讨阴道镜检查对处理切缘阳性患者的临床价值。方法:选取2012年1月至2012年12月在南京医科大学第一附属医院宫颈病中心就诊并行宫颈环形电切术(LEEP)的CINⅡ~Ⅲ且切缘阳性的80例患者,术后4~6周均行阴道镜检查(接受活检或颈管掻刮),其中未发现异常者71例(研究组),9例≥CINⅠ病变残留;切缘阴性者137例(对照组)。研究组与对照组均于LEEP术后6个月复诊以评估病变残留。结果:(1)切缘阳性的80例患者中,锥切术后初次阴道镜检查发现9例≥CINⅠ病变残留,接受再次锥切或全子宫切除,最终发现3例CINⅠ、5例CINⅡ~Ⅲ及1例宫颈浸润癌。(2)术后6个月HR-HPV检测阳性47例中,病变残留6例;宫颈细胞学检查≥ASCUS 18例中,病变残留3例;HR-HPV、宫颈细胞学检测病变残留的敏感性分别为100%、50%,特异性为79.70%、91.35%。(3)对照组、研究组的病变残留率分别为2.19%(3/137)、4.23%(3/71),两组比较差异无统计学意义(P0.05)。(4)锥切术后4~6周行阴道镜检查对切缘阳性患者病灶残留的阴性预测值为95.77%(68/71),且无一例病理升级或浸润癌的发现。结论:术后早期阴道镜检查对锥切切缘阳性者具有可行性及实用性,不仅能及时发现病变残留并得以及时处理,且有较高的阴性预测价值,检查结果阴性者随访安全性高。     

Residual and recurrent lesions after conization for cervical intraepithelial neoplasia grade 3.

OBJECTIVES: To evaluate the importance of regular and long-term follow-up of patients who had conization for cervical intraepithelial neoplasia grade 3 (CIN 3); and to assess the risk of residual/recurrent lesions of the cervix uteri. METHODS: Retrospective analysis of 934 patients with CIN 3 who underwent conization over the period 1 January 1985-31 December 1997. The analysis included 38 (4.1%) patients who had involved resection margins and 896 (95.9%) patients who had free resection margins. RESULTS: Twenty-three out of 934 (2.5%) patients had another operation (reconization in 17 and hysterectomy in six) whereas one patient had a biopsy. Residual or recurrent lesion after conization was found in 23 patients out of 934 (2.5%). Three patients had invasive cervical cancer (0.3%), 19 had CIN 3 (2.0%) and one patient had CIN 1 (0.1%). One of the 24 patients (4.2%) was diagnosed with no lesion after repeated operation. Eleven patients out of 38 (28.9%) with involved resection margins during the first conization had residual/recurrent disease, compared with eight out of 896 patients (0.9%) who had free resection margins. CONCLUSION: Another operation is recommended only in cases when, on the basis of cytological, colposcopical and histological findings, the gynecologist suspect the residual/recurrent lesions.     

Pregnancy after bariatric surgery is not associated with adverse perinatal outcome

OBJECTIVE: The purpose of this study was to investigate the pregnancy outcome of patients after bariatric surgery. STUDY DESIGN: A population-based study was performed that compared all pregnancies of patients with and without previous obesity operations between the years 1988 and 2002. Stratified analyses with the Mantel-Haenszel technique and a multiple logistic regression model were performed to control for confounders. RESULTS: Of the 159210 deliveries that were performed during the study period, 298 deliveries were to patients after bariatric operations. No significant differences regarding obstetric characteristics or pregnancy outcome were noted between the open (n=159) and laparoscopic procedures (n=139). With the use of a multivariable analysis, the following conditions were associated significantly with a previous bariatric operation: previous cesarean delivery (odds ratios, 1.4; 95% confidence interval, 1.1-2.0; P=.024), fertility treatments (odds ratios, 2.3; 95% confidence interval, 1.6-3.8; P<.001), premature rupture of membranes (odds ratios, 1.9; 95% confidence interval, 1.3-2.7; P=.001), labor induction (odds ratios, 2.1; 95% confidence interval, 1.6-2.7; P<.001), fetal macrosomia (birth weight, >4 kg; odds ratios, 2.1; 95% confidence interval, 1.4-3.0; P<.001), and obesity (odds ratios, 8.8; 95% confidence interval, 6.1-12.9; P<.001). No significant differences were noted between the groups regarding other pregnancy complications such as placental abruption, placenta previa, labor dystocia, or perinatal complications (such as meconium-stained amniotic fluid, perinatal mortality, congenital malformations and low Apgar scores at 1 and 5 minutes). However, there were higher rates of cesarean delivery among the bariatric operation group (25.2% vs 12.2%; odds ratios, 2.4; 95% confidence interval, 1.9-3.1; P <.001). When controlled for possible confounders (such as previous cesarean delivery, obesity, fertility treatments, premature rupture of membranes, labor induction, diabetes mellitus, hypertensive disorders and fetal macrosomia) by the Mantel-Haenszel technique, the correlation between previous bariatric surgery and cesarean delivery remained significant. CONCLUSION: Previous bariatric surgery, although an independent risk factor for cesarean delivery, is not associated with adverse perinatal outcome.     

Pregnancy outcome in pituitary tumors

Objective  To observe the maternal and perinatal outcome in pituitary tumor (macro- and micro-adenoma) during pregnancy. Methods  A retrospective analysis of a total of 19 cases of pituitary tumor group 1 (10 macroadenoma), and group 2 (9 microadenoma), during pregnancy over last 3 years in our unit were evaluated for pregnancy outcome, comparing maternal and perinatal outcome in the two groups using statistical analysis (Chi square test and Fischer exact t test). Results  The mean age was 27.1 years in group 1 (macroadenoma), 29.2 years in group, parity was 0.2 and 0.55, respectively, in the two groups. Mean pituitary size 14.85 cm³ in group 1 and 0.22 cm³ in group 2. While there was no significant difference in infertility, menstrual disorder in the two groups, galactorrhea, headache, seizures and blurring of vision were more common in macroadenoma group. More patients required medications (cabergoline/bromocriptine) in group 1 with significantly more women had worsening of their symptoms (raised intracranial tension, seizures) in group 1 than in group 2. Mean gestation and birthweight were better in group 2 (37.6 vs. 36.1 weeks and 2,849 vs. 2,401 g). While vaginal delivery could be achieved in 88.8% women in microadenoma group (group 2), 80% women required cesarean delivery in macroadenoma group (group 1), a highly significant difference (P value 0.005), there were no perinatal death in any group. Conclusion  Pituitary tumor during pregnancy if properly treated is associated with excellent maternal and perinatal outcome but macroadenoma is associated with lower gestation, birth weight and increased cesarean delivery rate.     

Pregnancy and perinatal outcome in women with hyperthyroidism

Objective

To investigate pregnancy outcome for patients with treated hyperthyroidism.

Methods

A population-based study was performed comparing all singleton pregnancies of women with and women without hyperthyroidism at the Soroka University Medical Center, Be'er-Sheva, Israel, between January 1988 and January 2007. Stratified analysis, using a multiple logistic regression model, was performed to control for confounders.

Results

During the study period, there were 185 636 singleton deliveries in the medical center. Of these, 189 (0.1%) were from women with hyperthyroidism. Using multivariate analysis with backward elimination, the following risk factors were significantly associated with hyperthyroidism: placental abruption; cesarean delivery; and advanced maternal age. No significant differences regarding perinatal outcome were noted between the groups. Women with hyperthyroidism had significantly higher rates of cesarean delivery than did women without hyperthyroidism (20.1% vs 13.1%; P < 0.004), even after controlling for confounders.

Conclusions

Treated hyperthyroidism was not associated with adverse perinatal outcome. However, hyperthyroidism was found to be an independent risk factor for cesarean delivery.