宫颈环扎术治疗完全性纵隔子宫并双宫颈双阴道一例并文献复习

先天性子宫畸形合并宫颈功能不全发病率可高达30%。纵隔子宫作为一种先天性子宫畸形,育龄妇女患病率约为0.2%~2.3%;具有较高的不孕、流产和早产风险。报告1例完全性纵隔子宫并双宫颈双阴道患者,妊娠前宫腔镜下行子宫纵隔切除术,孕14周经阴道行双侧宫颈预防性环扎术,孕23⁺⁶周宫口开大,保守治疗,孕30⁺¹周早产临产拆线,最终自然分娩并抱婴回家的临床处置经过,并回顾总结近年国内外纵隔子宫合并妊娠的诊治进展。     

宫腔镜电切术治疗子宫纵隔12例临床分析

由副中肾管发育异常而引起的部分性或完全性子宫纵隔 ,是较常见的子宫畸形之一 ,传统的疗法包括经阴道切除或开腹手术治疗[1] 。我院妇科宫腔镜诊治中心 ,应用宫腔镜电切术治疗子宫纵隔 12例 ,收到了良好的效果 ,现将结果报道如下。一、资料与方法1 临床资料 :1998年 12月至 2 0 0 0年 6月我院宫腔镜诊治中心对 12例子宫纵隔患者进行宫腔镜手术 ,其中部分纵隔 7例、完全纵隔 5例。患者年龄 2 2～ 34岁 ,平均 2 8 6岁 ,10例有自然流产 (流产 1～ 6次 )或早产史 ,1例有胎儿宫内生长迟缓史 ,2例伴有原发不孕 ,不孕时间 1～ 8年。2 手术方法 :…     

宫腔镜电切术治疗完全中隔子宫双宫颈阴道纵隔64例生殖预后分析

目的 探讨宫腔镜下子宫中隔电切除术对完全中隔子宫、双宫颈、阴道纵隔患者的治疗效果。方法 2004年9月至2013年8月浙江大学医学院附属妇产科医院完全中隔子宫、双宫颈、阴道纵隔住院患者64例,均行宫腔镜下子宫中隔电切除术及阴道纵隔切除术,分为反复流产组（26例）和不孕组（38例）,电话或门诊随访妊娠结局。结果 反复流产组25例妊娠,累计妊娠31次,自然流产率由术前83.1%（54/65）下降为41.9%（13/31）,足月产率、早产率和活产率分别为35.5%（11/31）、19.3 %（6/31）和54.8%（17/31）,与术前比较差异均有统计学意义（P<0.05）;不孕组18例妊娠,妊娠率47.4%（18/38）,其中12例足月分娩。研究对象中早产及足月产共32例,早产率28.1%（9/32）,足月产率71.9%（23/32）。研究对象胎盘粘连、植入发生率21.9%（7/32）,产后出血发生率25.0%（8/32）。结论 宫腔镜下子宫中隔电切除术可提高完全中隔子宫、双宫颈、阴道纵隔患者的妊娠率及生殖预后。     

子宫纵隔手术的近期、远期并发症及生殖预后

子宫纵隔是女性生殖道畸形中最常见类型,引起不孕、反复流产、早产及胎膜早破,影响其妊娠结局,需手术矫治。经宫颈子宫纵隔切除术是治疗子宫纵隔的金标准方法,是宫腔镜手术成功的代表作。宫腔镜下子宫纵隔切除手术微创、安全、有效,能够明显改善其妊娠结局。手术并发症包括子宫穿孔、体液超负荷、出血、纵隔残留、宫腔粘连及远期妊娠子宫破裂等。本文主要探讨其发生原因及预防方法。虽然近、远期手术并发症罕见,但临床上不容忽视,提高手术安全性,才能体现宫腔镜手术微创优势。     

纵隔子宫的病因及诊治

纵隔子宫是先天性子宫畸形中最常见的类型,可能导致流产、早产和胎儿生长受限等不良妊娠结局。目前有关纵隔子宫的病因尚未明确,研究者试图通过基因水平、胚胎发育过程和子宫纵隔解剖结构的研究探究纵隔子宫的成因及导致不良妊娠结局的机制,但均不能完整揭示其形成原因,还需进一步探究。纵隔子宫可以通过超声诊断,随着诊断技术的发展,磁共振成像（magnetic resonance imaging,MRI）、三维超声技术使得纵隔子宫的诊断更为精准,但宫腔镜诊断仍是纵隔子宫诊断的金标准。由于目前子宫畸形的分类系统不同,对纵隔子宫的定义也有差异,因此往往导致不同的治疗结局,尽管有大量回顾性研究及前瞻性对照研究的数据支持采用经宫颈子宫纵隔切除术（transcervical resection of septum,TCRS）治疗纵隔子宫,但是否需要手术治疗仍需高质量的随机对照研究作为临床决策的支持。     

纵隔子宫研究进展

纵隔子宫是最常见也是妊娠结局最差的子宫畸形类型，由于纵隔血供差，子宫腔变形伴发宫颈机能不全造成胚胎着床和发育障碍，导致不孕，反复流产和早产等妊娠异常现象。纵隔子宫多因症状隐匿致漏诊和误诊。由于超声。腔道造影，内窥镜和核磁共振等影像技术不断发展，纵隔子宫检出率提高，合并不孕或反复流产等纵隔子宫患者通过宫腔镜矫形手术可改善妊娠结局。     

宫腔镜联合腹腔镜手术治疗完全纵隔子宫伴阴道纵隔的临床疗效

目的:探讨宫腔镜联合腹腔镜手术治疗完全纵膈子宫伴阴道纵隔的临床效果。方法:回顾性分析我院妇科微创中心行腹腔镜监护下宫腔镜子宫纵隔切除+阴道纵隔切除术的40例完全纵隔子宫伴阴道纵隔患者的临床资料,并随访其术后妊娠结局。结果:40例患者成功随访1~6年,术后累计妊娠46次,自然流产率由术前的87.3%下降到30.4%,足月活产率由0.0%上升到58.7%,无胎盘植入、胎盘粘连等妊娠期并发症发生。结论:宫腔镜联合腹腔镜手术安全有效,可明显改善纵隔子宫合并阴道纵隔患者的妊娠结局,不增加孕期并发症,建议在临床上推广应用。     

纵隔子宫研究进展

纵隔子宫是最常见也是妊娠结局最差的子宫畸形类型。由于纵隔血供差，子宫腔变形伴发宫颈机能不全造成胚胎着床和发育障碍，导致不孕，反复流产和早产等妊娠异常现象。纵隔子宫多因症状隐匿致漏诊和误诊。由于超声，腔道造影，内窥镜和核磁共振等影像技术不断发展，纵隔子宫检出率提高。合并不孕或反复流产等纵隔子宫患者通过宫腔镜矫形手术可改善妊娠结局。     

宫腔镜子宫纵隔切开术治疗纵隔子宫

诊断纵隔子宫的金标准仍然是宫腔镜联合腹腔镜手术。文章阐述宫腔镜子宫纵隔切开术的手术技巧,回顾分析190例纵隔子宫患者术后的妊娠结局。宫腔镜下子宫纵隔切开术可减少流产率,提高活产率。宫腔镜下子宫纵隔矫形手术安全,并发症少,可明显改善纵隔子宫合并不良孕产史患者的妊娠结局。     

电视宫腔镜下子宫纵隔电切术与剪除术效果比较

我院自1996年2月至2003年12月开展了电视宫腔镜下子宫纵隔切除术,收到了较好的效果。现报道如下。1临床资料1.1一般资料因子宫畸形而要求手术病例共68例,其中子宫纵隔患者48例(完全纵隔2例,不完全纵隔46例)。年龄21～33岁。原发不孕3例,继发不孕3例,除原发不孕3例外,均有自然流产或早产史,45例患者中人工流产11次,自然流产113次,胎死宫内4例,早产7例(新生儿死亡6例)。自然流产平均(2.35±1.23)次(1～5次),22例自然流产≥3次。20例行宫腔镜下微型剪刀子宫纵隔剪除术(微型剪刀组),28例行宫腔镜下子宫纵隔电切术(电切组)。1.2方法(1)术前准备:…     

Reproductive outcome of women with rare Müllerian anomaly: report of 2 cases

Two patients had a rare uterine anomaly characterized by longitudinal vaginal septum, double cervix, and incomplete septum of the uterus with normal fundus. This report is, to our knowledge, the third in the literature. There are some other works describing a similar anomaly, with a complete uterine septum. These cases challenge the classic unidirectional theory of müllerian development and support an alternative bidirectional hypothesis. After definitive diagnosis, the vaginal and uterine septa were successfully resected. Both patients conceived spontaneously and had an uneventful obstetric outcome. Surgical treatment might be an alternative treatment in the case of infertility or recurrent pregnancy loss in patients with such a rare müllerian anomaly. The hysteroscopic uterine reunification should be the preferable surgical method and can improve the poor reproductive outcome.     

Management and reproductive outcome of complete septate uterus with duplicated cervix and vaginal septum: review of 21 cases

Aim

To evaluate the reproductive outcomes of complete septate uterus with duplicated cervix and vaginal septum.

Methods

Twenty-one patients who have complete septate uterus with duplicated cervix and vaginal septum were retrospectively reviewed in this study. In Group I, 11 patients with a poor reproductive outcome (spontaneous miscarriage or infertility) or dyspareunia underwent hysteroscopic metroplasty and removal of vaginal septum with the preservation of cervical septum. In Group II, 10 patients without a history of spontaneous miscarriage did not undergo hysteroscopic transection of the uterine septum. Of 10, four underwent vaginal septum incision due to dyspareunia, two underwent mere laparoscopic pelvic adhesiolysis because of infertility, and four without symptoms had no intervention. The primary endpoints included the pregnancy rate and outcomes of pregnancies.

Results

In Group I, the pregnancy rate after surgery is 81.8 % (9/11). Of nine women who conceived, six had term delivery, one encountered induced abortion due to the malformation of the fetal heart, and two had ongoing pregnancy. In Group II, among six patients accepting surgery, three had term delivery. The pregnancy rate after operation is 50 % (3/6).

Conclusions

The uterine septum may not necessarily be transected for patients who have complete septate uterus with duplicated cervix and vaginal septum, and meanwhile have no a history of poor reproductive outcome.     

Septate uterus with a double cervix and longitudinal vaginal septum

OBJECTIVE: To report the clinical features of 9 cases and review the previously reported 8 cases of an uncommon müllerian anomaly, characterized by the presence of a complete uterine septum with cervical duplication and represent a a longitudinal vaginal septum. STUDY DESIGN: Retrospective clinical study. RESULTS: Nine patients aged 21-32 presented to our clinic with complaints of dyspareunia, dysmenorrhea, and primary or secondary infertility. All 9 patients displayed a single uterus with smooth fundal contour, double cervix and longitudinal vaginal septum. Some additional abnormal findings were associated with these anomalies in some patients: polycystic ovaries in 3 cases and different degrees of endometriosis in 2 cases. Most of the patients had normal tubal patency. CONCLUSION: According to a MEDLINE search, only 8 cases of septate uterus with cervical duplication and a longitudinal vaginal septum have been reported to date. We report 9 more cases, which suggest that this atypical septate uterus type is probably more frequent than reported. These cases support the bidirectional müllerian theory and may imply the presence of another type of mullerian anomaly.     

Light-Guided Hysteroscopic Resection of Complete Septate Uterus With Preservation of Duplicated Cervix

The objective of the present study, performed at a tertiary university hospital, was to propose a novel method of hysteroscopic resection of complete septate uterus with preservation of duplicated cervix. The retrospective study included 5 women with complete septate uterus and cervical duplication and who also experienced infertility with or without pregnancy loss. All patients underwent bougie-guided or light-guided hysteroscopic perforation of the uterine septum above the endocervix, followed by septum resection. The success rate of complete uterine septum perforation under bougie guidance was 60% (3 of 5 procedures), and of light guidance was 100% (2 procedures). After hysteroscopic septum resection, 2 of 5 women achieved pregnancy within 3 months and delivered uneventfully at term. It is concluded that light guidance is superior to bougie guidance for hysteroscopic perforation of complete septate uterus with preservation of the duplicated cervix.     

阴道斜隔综合征的诊断与治疗

阴道斜隔综合征是双宫体、双宫颈、双阴道,一侧阴道完全或不完全闭锁的先天性畸形,多伴有闭锁阴道侧的泌尿系统畸形,以肾脏缺如多见。超声检查简便、无创是诊断阴道斜隔综合征的首选检查。磁共振成像(MRI)具有良好的组织分辨力及多参数、多方位成像功能,影像学表现更具特征性。手术是治疗阴道斜隔综合征唯一有效的方法。目前最根本的手术方式是阴道斜隔切除术。手术要点在于确定阴道斜隔部位和斜隔孔。手术时机以月经期为宜。阴道斜隔要切除充分,并保证引流通畅,防止阴道切口粘连、狭窄。宫腹腔镜联合手术不仅可以明确阴道斜隔综合征的诊断与分型,也可同时准确的治疗。阴道斜隔侧子宫尚有妊娠可能,应尽量避免切除,以提高患者的受孕能力。     

合并阴道纵隔双宫颈的完全中隔子宫27例临床分析

目的：探讨宫腹腔镜联合矫治合并阴道纵隔双宫颈的完全子宫中隔的临床效果。方法：收集2012—2013年首都医科大学附属北京妇产医院妇科微创中心27例宫腹腔镜联合矫治合并阴道纵隔双宫颈的完全中隔子宫患者的临床资料,其中原发不孕7例,自然流产10例,稽留流产3例,不良孕史7例。结果：27例患者一次手术成功率为100%,未发生术中、术后并发症。27例随访30～53个月,平均（41.56±6.33）个月。足月活产18例,早产1例,自然流产2例,未孕3例,因胎儿畸形引产1例,术后1例失访,3例术后因个人或疾病原因暂无妊娠计划,一直避孕。本组患者妊娠率由术前52.17%（11/23）上升至术后86.96%（20/23, χ2=6.33,P=0.01）,而活产率由术前0（0/23）上升至术后82.61%（19/23,P=0.000）,流产率由术前47.83%（11/23）下降至术后8.70%（2/23, χ2=6.86,P=0.008）,差异均有统计学意义。结论：宫腹腔镜联合矫治合并阴道纵隔双宫颈的完全中隔子宫安全、有效,能显著改善患者生殖预后,提高妊娠率和活产率,降低流产率。     

Septate uterus associated with cervical duplication and vaginal septum

A woman had an unusual müllerian anomaly with a septate uterus, cervical duplication, and longitudinal vaginal septum. Gynecologists should be aware of the possibility of cervical duplication associated with uterine septum and not didelphic uterus, as this disorder in a patient with infertility or recurrent miscarriages can be treated surgically by resection of the uterine and vaginal septum. Embryologic explanations may account for the occurrence of the anomaly.     

Septate uterus with double cervix and longitudinal vaginal septum. A case report.

BACKGROUND: Congenital uterine anomalies in the general population are estimated to have an incidence of 0.001-10%. The septate uterus, the most common form of structural uterine anomaly, has the highest reproductive failure rate. A rare developmental variant is a septate uterus with cervical duplication and a complete longitudinal vaginal septum. The existence of this anomaly challenges classical müllerian developmental theory. Traditional transabdominal metroplasty has been replaced by operative hysteroscopy in the surgical correction of a septate uterus, with laparoscopy aiding in the diagnosis and contributing to the safety and efficiency of the procedure. CASE: A 28-year-old, nulliparous woman with a septate uterus with cervical duplication and complete longitudinal vaginal septum was diagnosed by combined laparoscopy and hysteroscopy. Excision of the complete longitudinal vaginal septum followed by hysteroscopic partial resection of a thick uterine septum with laparoscopic assistance was performed. However, because of the septum's broad base and the rigidity of the operative resectoscope, we opted to proceed with transabdominal metroplasty. CONCLUSION: Only six cases of septate uterus with cervical duplication and complete longitudinal vaginal septum have been reported. Although its counterpart, the septate uterus, has effects on preterm labor, fetal presentation, infertility and spontaneous abortion, its reproductive outcome has not been assessed. Review of the literature suggests that surgical correction in the setting of poor reproductive outcome has been beneficial. Laparoscopically assisted hysteroscopic resection of the uterine septum is a safe, effective surgical technique of uterine reunification and is preferable to transabdominal methods. However, in certain cases, conventional transabdominal metroplasty may still be required.     

The diagnosis and reproductive outcome after surgical treatment of the complete septate uterus, duplicated cervix and vaginal septum

OBJECTIVE: This study was undertaken to evaluate the diagnostic management and the reproductive outcome after surgical repair of a rare reproductive malformation. STUDY DESIGN: Sixteen women with a complete septate uterus, double cervix, and a longitudinal vaginal septum were referred for evaluation. Presenting complaints were chiefly pregnancy loss in parous women (n=9) and dyspareunia in nulligravid women (n=7). The combination of hysterosalpingography, ultrasonography, and/or magnetic resonance imaging was used to correctly identify the anomaly in 15 of the 16 cases. Both hysteroscopic (n=11) and transabdominal (n=5) surgical techniques were used to repair the uterine septum. RESULTS: In no case was the correct diagnosis made before referral; the uterus didelphys was the most common misdiagnosis. The preoperative pregnancy loss was 81%. Postoperatively, 12 women conceived for a total of 17 pregnancies; there were 14 term live births or ongoing pregnancies in the third trimester (82%), with a first trimester spontaneous abortion rate of 18%. In 9 women who conceived after hysteroscopic surgery, term live births occurred in 9 of 12 (75%) conceptions. A modified Tompkins metroplasty was performed in 5 women with subsequent term live births or ongoing third trimester pregnancies in 5 of 5 (100%) patients. CONCLUSION: The identification of a duplicated cervix and a vaginal septum is consistent with several uterine malformations, which leads to frequent misdiagnosis and errors in management. Significant pregnancy wastage, obstetric complications, and dyspareunia are common, and surgical treatment is therefore advisable. Making the best choice between hysteroscopic or transabdominal metroplasty depends on the anatomic features of the cervix and the uterine cavity, but optimal patient management requires familiarity with both techniques.