宫内外复合妊娠腹腔镜手术治疗34例分析

目的:探讨宫内外复合妊娠(HP)腹腔镜治疗的有效性、安全性及对妊娠结局的影响。方法:回顾性分析2011年1月—2018年1月天津市中心妇产科医院收治的宫内妊娠合并输卵管妊娠共34例,探讨腹腔镜手术治疗的可行性和妊娠结局。结果:34例患者均为宫内妊娠合并单侧输卵管妊娠,其中特殊病例包括:宫内双胎妊娠合并右侧输卵管妊娠1例,宫内妊娠合并右侧输卵管间质部妊娠1例,双子宫右侧宫腔妊娠合并左侧输卵管妊娠1例。所有患者均行腹腔镜手术治疗,手术时间15～110 min,平均(45.21±8.33)min;术中出血5～200 m L,平均(33.04±10.12)m L,其中3例因术前腹腔出血超过800 mL行输血治疗。术后患者无发热、切口感染和术后并发症,超声检查提示宫内妊娠状态正常,患者恢复良好。除胚胎停育行人工流产1例和失访1例外,余33例新生儿(1例双胎妊娠分娩)均为活产,未见新生儿发育畸形。结论:对于妊娠早期的宫内妊娠合并单侧输卵管妊娠患者,腹腔镜手术去除输卵管异位妊娠安全有效,术后未增加医源性流产率及新生儿出生缺陷发生率。     

腹腔镜治疗宫内合并输卵管间质部妊娠21例效果分析

目的:探讨宫内合并输卵管间质部妊娠的腹腔镜治疗及妊娠结局。方法:回顾性分析我院腹腔镜治疗IVF-ET后宫内合并输卵管间质部妊娠21例,比较采用宫角切开取胚术(16例)与宫角切除术(5例)的治疗及妊娠结局。结果:21例患者总的手术时间为58.5±6.3分钟,术中出血量52.9±5.8 ml,术后住院时间4.7±0.4天。两组患者在异位妊娠包块破裂率、手术时间、术中出血量、术后住院时间及足月产率差异均无统计学意义(P0.05)。接受宫角切除术患者的异位妊娠包块平均直径大于接受宫角切开取胚术患者(2.5 cm vs 3.6 cm)。17例患者术后顺利分娩,除1例顺产外均行剖宫产,其中足月产11例,无一例患者发生子宫破裂。结论:腹腔镜治疗宫内合并输卵管间质部妊娠安全且妊娠结局良好。宫角切除术是目前主要的手术方式,但需注意子宫破裂;输卵管间质部妊娠包块较小时可选择行宫角切开取胚术。     

宫内合并宫角/输卵管间质部妊娠的手术治疗

目的:探讨宫内合并宫角/输卵管间质部妊娠手术治疗的安全性、有效性及妊娠结局。方法:收集2010年1月至2014年12月广东省妇幼保健院收治的5例宫内合并宫角/输卵管间质部妊娠患者的手术治疗信息,并随访妊娠结局。结果:5例患者中行开腹手术3例,腹腔镜手术2例;宫角楔形切除术2例,宫角切开取胚术3例,均无术后并发症发生。5例患者孕期无严重并发症发生,均活产,新生儿预后良好。结论:宫内合并宫角/输卵管间质部妊娠的手术治疗安全有效,产科结局良好。     

体外受精-胚胎移植术后宫内妊娠合并输卵管间质部妊娠6例临床分析

目的探讨体外受精－胚胎移植术(in vitro fertilization and embryo transfer, IVF-ET)后宫内妊娠合并输卵管间质部妊娠的临床特点和治疗方法。 方法回顾性分析2014年3月至2018年12月暨南大学医学院附属深圳市宝安区妇幼保健院妇产科收治IVF-ET后宫内妊娠合并输卵管间质部妊娠的6例临床资料及治疗方法。 结果6例患者均采用手术治疗,其中4例开腹手术,2例腹腔镜手术,发生早期流产1例,活产分娩5例,无子宫破裂及新生儿畸形发生。 结论宫内妊娠合并输卵管间质部妊娠主要依靠阴道超声诊断,手术治疗可获得良好妊娠结局,腹腔镜手术是安全可行的。     

阴式手术治疗剖宫产瘢痕部位妊娠后再次妊娠39例临床分析

目的:探讨剖宫产瘢痕部位妊娠(CSP)经阴式手术治疗后再次妊娠的结局。方法:回顾性分析2016年1月至2019年2月在重庆市妇幼保健院接受阴式手术治疗且有再次妊娠计划的39例CSP患者的临床资料，并随访其妊娠结局。结果:39例CSP患者的年龄30.38±3.82岁，距前次剖宫产时间6.04±3.09年，平均流产次数1.9次，停经时间54.21±10.29天；手术时间42.62±11.05分钟，中位术中出血量50 ml(40,100 ml)。术后患者月经恢复可，经期平均4.82天(3～8天)。39例患者中28例(71.8%)成功妊娠，再次妊娠距离治疗间隔22.54±8.48月；25例为宫内妊娠，2例输卵管妊娠，1例为复发CSP;20例均行剖宫产分娩正常婴儿，新生儿体质量3102.50±56.53 g; 2例自然流产，3例稽留流产；2例输卵管妊娠患者行腹腔镜下输卵管开窗取胚术，1例复发CSP患者再次行阴式手术切除病灶。结论:对有生育要求的女性，阴式手术治疗CSP是有效和安全的，再次成功妊娠率较高，但还需要更大样本量和更长时间的随访进一步验证。     

输卵管妊娠腹腔镜两种术式对照分析

目的:观察腹腔镜两种手术方式治疗输卵管妊娠的结局和术后再妊娠情况,并探讨其影响因素.方法:对2002年1月至2005年12月天津市中心妇产科医院接受腹腔镜手术治疗输卵管妊娠的107例患者,分为保守性手术治疗组(A组)75例和输卵管大部分切除术治疗组(B组)32例患者,对比分析两组围手术期情况和术后再次宫内妊娠率、异位妊娠率;采用Logistic回归分析盆腔粘连情况等因素对保守性手术术后生育结局的影响.结果:A组术中出血量大于B组,手术时间长于B组,差异有统计学意义(P<0.05).随访3～6年,A组和B组再次宫内妊娠率分别为45%、34%,两组比较差异无统计学意义(P>0.05).在单因素分析中,腹腔镜保守性手术治疗输卵管妊娠术后宫内妊娠率分别与盆腔粘连情况、对侧输卵管闭锁与否相关(P<0.05).结论:腹腔镜下保守性手术再次宫内妊娠率高于腹腔镜下输卵管大部分切除术.盆腔粘连情况、对侧输卵管闭锁与否是术后宫内妊娠率的相关因素.对于严重盆腔粘连或患侧输卵管破坏严重而对侧输卵管正常者,不建议行保守性手术.     

宫内宫外复合妊娠腹腔镜手术治疗10例分析

目的:探讨腹腔镜手术治疗宫内宫外复合妊娠(HP)之异位妊娠病灶的宫内妊娠的结局.方法:回顾性分析我院10例宫内宫外复合妊娠之异位妊娠病灶经腹腔镜手术治疗后的临床结局.结果:10例宫内宫外复合妊娠全部行腹腔镜手术清除异位妊娠病灶,平均手术时间30分钟.平均术中出血量20 ml,术后均无并发症发生,伤口均Ⅱ/甲等愈合.10例患者中,7例已足月分娩,占70%;1例稽留流产,占10%;2例继续妊娠,占20%.结论:腹腔镜手术治疗宫内宫外复合妊娠之异位妊娠病灶是安全可行的,宫内妊娠结局良好.     

宫内妊娠合并输卵管间质部妊娠腹腔镜手术治疗的临床观察

目的评价宫内妊娠合并输卵管间质部妊娠(interstitial heterotopic pregnancy,IHP)腹腔镜手术治疗的效果及妊娠结局。方法回顾性分析了2011年1月至2015年12月期间,在北京大学第三医院生殖医学中心接受体外受精-胚胎移植(In Vitro Fertilization and Embryo Transfer IVF-ET)技术后发生IHP的患者中,经过腹腔镜下输卵管间质部妊娠病灶切开、绒毛组织清除、残腔内壁电凝和宫角缝合治疗的18名患者的临床资料及宫内妊娠结局。结果 18例患者中9例输卵管间质部妊娠病灶破裂,其中6例病变侧的输卵管已切除。平均手术时间(62.1±16.4)min,术中术后无并发症发生。2例分别于孕35周及孕36周早产,余16例均足月分娩。妊娠期间、分娩过程中及剖宫产术中均未发现持续性异位妊娠及子宫破裂。结论早期腹腔镜手术治疗宫内妊娠合并输卵管间质部妊娠是安全可行的。既往有患侧输卵管切除术史的患者更易发生病灶破裂。     

微型腹腔镜手术在输卵管复通中的应用

目的:探讨微型腹腔镜手术在输卵管吻合复通中的应用价值。方法:回顾性分析66例输卵管绝育术后因需生育而行吻合复通术的患者资料,将其中36例利用微型腹腔镜完成输卵管复通术者(腹腔镜组),并与同期完成的开腹下输卵管复通术30例(开腹组)作对比研究。结果:所有患者手术均顺利完成,术后随访5～ 48个月。腹腔镜组宫内妊娠27例,异位妊娠2例,未孕7例,宫内妊娠率75.00%,总妊娠率80.56%。开腹组宫内妊娠15例,异位妊娠3例,未孕12例,宫内妊娠率50.00%,总妊娠率60.00%。宫内妊娠率、总妊娠率组间差异有统计学意义(P<0.05)。合并盆腔粘连者,术后宫内妊娠率、总妊娠率组间比较,差异有统计学意义(P<0.05)。结论:与开腹手术相比,微型腹腔镜手术用于输卵管复通具有损伤小、出血少、术后恢复快、术后宫内妊娠率提高的优势,尤其适合于合并盆腔粘连的患者。     

腹腔镜手术治疗宫内外同时妊娠21例临床分析

目的:评估腹腔镜手术在宫内外同时妊娠(HP)诊断和治疗中的价值,探讨对HP患者实施腹腔镜手术的手术技巧。方法:回顾性分析2003～2010年在我院接受腹腔镜手术治疗的21例HP患者的临床资料。结果:21例患者中有20例为输卵管妊娠(均行患侧输卵管切除术),1例为宫角妊娠(行宫角妊娠取出术)。部分患者同时行盆腔粘连松解术和(或)对侧输卵管结扎术。所有手术均经腹腔镜顺利完成,无中转开腹,无术中重大并发症发生。术后有20例患者接受不同时间的保胎治疗,17例成功分娩,1例怀孕8个月,2例保胎失败,保胎成功率达90.0%(18/20)。结论:腹腔镜手术不仅可早期确诊可疑HP患者,减少异位妊娠对宫内胚胎的影响,还可同时对异位妊娠进行有效治疗,对休克型及少见的HP的治疗亦安全可行。腹腔镜手术是治疗HP的理想手术方式。     

Live twin birth after successful treatment of a ruptured heterotopic pregnancy by laparoscopy

We report a case of a live twin birth after laparoscopic treatment of a ruptured heterotopic pregnancy. A 29-year-old woman, with a history of right salpingectomy for ectopic pregnancy, became pregnant after transfer of three embryos at in vitro fertilization treatment. At the ninth week of gestation, she was admitted to our clinic with abdominal pain. Ultrasonographic examination revealed a triplet heterotopic pregnancy consisting of an intrauterine twin pregnancy and an ectopic pregnancy in the left fallopian tube. An immediate laparoscopy was planned and left salpingectomy was performed. In the postoperative period, intrauterine twin pregnancy continued uneventfully; at the 35th week of gestation, two healthy infants with birth weights of 2,206 and 2,426 g were delivered. Heterotopic pregnancies must be kept in mind after assisted reproductive techniques. Early diagnosis allows successful laparoscopic treatment without sequel. Laparoscopic surgery is an appropriate method to manage selected patients with heterotopic tubal pregnancy.     

Management strategies of heterotopic pregnancy following in vitro fertilization-embryo transfer

ObjectiveThe purpose of this study was to evaluate the efficiency and safety of different treatment modalities for heterotopic pregnancy (HP) in vitro fertilization-embryo transfer (IVF-ET) cycles to avoid influence on intrauterine pregnancy (IUP).Materials and methodsCases of HP (n = 90) were from the IVF/ICSI registry database at the Reproductive Hospital Affiliated to Shandong University. An additional 360 women were randomly selected as controls. The primary outcome to examine the risk factors, diagnostic modalities and the impact of different treatment modalities for HP.ResultsOur results showed that surgical treatment had a certain effect on improving the live-birth rate, although the effect was not statistically significant (87.9% vs. 70.8%, P = 0.055). The risk factors for HP included previous tubal surgery and hydrosalpinx. Fourteen days after embryo transfer, the serum levels of β-human chorionic gonadotropin (β-hCG) and estradiol (E2) were lower in the HP group than in the IUP group (P < 0.05). Furthermore, age and endometrial thickness showed a significant difference between the early abortion and the live-birth groups of HP.ConclusionsIn our retrospective study, we supported early surgical laparoscopic intervention to minimize the incidence of abortion of IUP, which resulted in a better live-birth rate. A history of ectopic pregnancy and previous tubal surgery may increase the risk of HP. Low levels of serum β-hCG and E2 on the 14th day after embryo transfer could indicate the incidence of HP.     

425例妊娠合并卵巢肿瘤患者的诊治分析

目的:探究分析妊娠合并卵巢肿瘤的病理和诊治特点,以及不同手术方式对妊娠结局的影响。方法:以南方医科大学附属深圳市妇幼保健院2010年9月—2016年9月收治的425例妊娠期卵巢肿瘤患者为研究对象,回顾性分析其临床资料,包括发现时间、病理类型、手术方式以及妊娠结局等。结果:妊娠期卵巢肿瘤患者中,囊性成熟性畸胎瘤是最常见的病理类型,其次是子宫内膜异位囊肿及黏液性囊腺瘤;妊娠期有30例(7.10%)患者发生并发症,其中蒂扭转最常见,其次是恶变及破裂出血;妊娠期卵巢肿瘤手术主要有腹腔镜和开腹手术2种,腹腔镜组的失血量([39.62±28.25)mL vs.(68.50±33.60)mL,t=2.563,P=0.015]、住院时间([6.46±2.03)d vs.(9.90±1.92)d,t=4.925,P<0.001]均小于开腹组。此外,腹腔镜组的平均手术孕周也小于开腹组([12.71±3.71)周vs.(16.71±4.89)周,t=2.490,P=0.018]。而2组之间的剖宫产率、低出生体质量儿发生率、早产率和流产率比较,差异均无统计学意义(均P>0.05)。妊娠期恶性肿瘤在及时且个体化的处理后预后较好。结论:妊娠期卵巢肿瘤需首先排除恶性可能,早发现、早处理预后较好。妊娠期手术治疗是安全的,推荐有手术指征者选择手术干预。腹腔镜和开腹手术对妊娠结局影响均较小,可以个体化选择手术方式。     

A rare case of heterotopic quintuplets pregnancy

ObjectiveWe report a rare case of heterotopic pregnancy and high-order pregnancy occurring simultaneously following the use of the assisted reproductive technique (ART).Case reportA 29-year-old woman, Gravida 2 Para 1, became pregnant after receiving intrauterine insemination (IUI). She came to our emergency room due to diffuse low abdominal pain at seven weeks of gestational age. Transabdominal sonography (TAS) revealed a quadruplet intrauterine pregnancy with an enlarged left adnexa and intrapelvic fluid accumulation. Simultaneous occurrence of high-order pregnancy and left tubal pregnancy with internal hemorrhage was suspected. The patient received an emergent laparoscopic resection of the affected Fallopian tube and recovered well for the remaining hospitalization course. Afterwards, she received fetal reduction procedure and eventually gave birth to twin babies.ConclusionGynecologist should increase the awareness of heterotopic pregnancy in patients receiving ART. On the other hand, reproductive endocrinologist should reduce the risk of high-order pregnancy without compromising pregnancy rate.     

新鲜胚胎与冻融胚胎移植后引起宫内外同时妊娠69例临床分析

目的探讨辅助生殖技术(ART)引起宫内外同时妊娠(HP)的影响因素。方法采用单因素及多因素Logistic回归分析的方法对经辅助生殖助孕治疗后发生HP的69例(新鲜胚胎移植35例,冻融胚胎移植34例)患者的临床资料进行回顾性分析。结果同期新鲜周期组临床妊娠6 616例,其中HP患者35例(0.53%);冻融周期组临床妊娠3 516例,其中HP患者34例(0.97%),冻融周期组中HP发生率与新鲜胚胎周期组比较,差异有统计学意义(P=0.01);HP组与宫内双胎妊娠对照组和单纯异位妊娠对照组年龄、不孕年限、获卵数、G n用量、h C G注射日的血清E2值、孕酮值、内膜厚度、移植管距宫底距离、不孕类型之间比较,差异均无统计学意义(P0.05)。HP组中有宫腔操作史46.37%(32/69),高于宫内双胎妊娠的26.25%(42/160),差异有统计学意义(P0.05);HP组中输卵管妊娠史有39.13%(27/69),高于宫内双胎妊娠的23.12%(37/160),差异有统计学意义(P0.05)。结论 ART中获卵数、Gn用量、h CG注射日的血清E2值、孕酮值、内膜厚度、移植管距宫底距离、不孕类型对HP的发生影响不大,既往有输卵管妊娠史、宫腔操作史及冻融周期中人工周期治疗方案与H P的发生有明显的相关性。     

腹腔镜手术与开腹手术治疗输卵管妊娠的临床对照研究

目的 :比较腹腔镜手术与传统开腹手术治疗输卵管妊娠的临床价值及副作用。方法 :将根据临床表现及B超检查等诊断为输卵管妊娠的 15 9例随机分为 2组 ,腹腔镜组 81例 ,传统开腹组 78例 ,分别用腹腔镜及常规开腹手术治疗 ,比较两组手术治疗的术中及术后情况。结果 :两组在手术时间、hCG转阴天数等方面差异无显著性 ,术中失血量、术后排气时间、术后病率、术后是否使用止痛药、住院天数等方面差异有显著性。结论 :输卵管妊娠患者选用腹腔镜手术优于传统开腹手术     

Re-evaluation of the indication for and limitation of laparoscopic salpingotomy for tubal pregnancy

OBJECTIVE: We investigated the outcome of laparoscopic salpingotomy for tubal pregnancy by follow-up hysterosalpingography (HSG) or second-look laparoscopy (SLL) and reexamined the indication for and limitation of this conservative surgery. STUDY DESIGN: From April 1991 to December 2003, we treated 181 cases of tubal pregnancy using laparoscopic salpingotomy. The tubal patency was assessed by either HSG or SLL performed at 3 months post-surgery. The patients with a successful initial operation and confirmed ipsilateral patent tubes at follow-up were classified as truly successful cases (group I). Even after successful operation, if the treated tubes were found to be occluded, they were considered as unsuccessful cases. Therefore, those cases that were unsuccessful at initial surgery as well as at follow-up were categorized as group II. RESULTS: One hundred and thirty-four cases (74%) were successfully treated by salpingotomy at initial laparoscopy and 85 of them (63.4%) were found to be truly successful at follow-up (group I). The remaining 47 cases (26.0%) were unsuccessful at initial surgery and 18 (13.4%) cases at follow-up (group II). Thirty-one other patients refused to accept a tubal patency test or were not examined for personal reasons or were lost to follow-up. No difference in surgical outcome was observed between these two groups of patients with regard to gestational age, intra-operative hemorrhage, size or anatomic location of the pregnancy mass, and pre-operative adhesions of the fallopian tube. However, pre-operative serum levels of hCG were significantly higher in group II than in group I. In addition, the unsuccessful cases were more frequently associated with positive fetal heart beat (FHB), tubal rupture, and pre-operative serum levels of hCG of more than 10,000 IU/l (p<0.05, chi2 test). The log-rank test indicated a higher pregnancy success rate in group I (p<0.05) than in group II in those who desired future pregnancy. CONCLUSION: Laparoscopic salpingotomy may be practised as conservative surgery for proximal ectopic pregnancy, and gestational mass size is not as important and is not a relative contraindication for conservative laparoscopic surgery, as previously reported. Low pre-operative HCG levels, absence of FHB, absence of tubal rupture initially or minimal rupture may be considered suitable parameters for successful surgery and for achieving future pregnancy.     

15例双胎反向动脉灌注序列症的自然病程及围生儿预后探讨

目的:了解双胎反向动脉灌注序列症(TRAP序列症)的自然病程,分析其围生儿预后。方法:回顾性分析我院2008年7月至2011年12月收治的TRAP序列症15例患者的临床资料,对足月产、早产、流产及平均分娩孕周等资料进行统计,分析无心畸胎/供血儿的腹围比(AC比值)、脐动脉搏动指数(UA-PI)比、供血儿心脏情况等,并追踪供血儿出生后1年的健康状况。结果:15例TRAP序列症患者无心无头型11例,无心无脑型4例。10例孕早期超声检查误诊为双胎之一死亡(3例)、胎儿水肿(2例)和颈部淋巴水囊瘤(5例)。供血儿情况:羊水过多2例(1例引产,1例自然流产);心功能不全2例(1例因合并先天性心脏病引产,1例早产);羊水过多合并心功能不全1例(自然流产)。无心畸胎情况:无心畸胎血流自然阻断2例(13.3%),其中1例孕37周突发宫内死胎,1例继续妊娠(情况稳定);无心畸胎血流微弱(UA-PI比值<0.7)8例(53.3%),其中自然流产2例,引产1例,分娩活胎3例(追踪1年,3例新生儿均健康),继续妊娠2例(情况稳定);无心畸胎血流丰富5例(33.3%)(均引产)。另外无心畸胎出现迅速增长(AC比值>50%)共10例(66.7%),其中引产7例,自然流产1例,仅2例剖宫产分娩存活。结论:无心畸胎较小、血流不丰富者,自然病程良好。出现无心畸胎迅速生长、供血儿心力衰竭或水肿,提示胎儿死亡风险高或预后不良。     

腹腔镜保守性手术治疗输卵管妊娠的效果及其影响因素分析

目的 探讨腹腔镜保守性手术治疗输卵管妊娠的效果及其影响因素.方法 2003年1月至2008年12月,对北京安贞医院妇产科226例输卵管妊娠者行腹腔镜保守性手术治疗,152例于术后3～6个月行子宫输卵管造影,其中6例接受了再次腹腔镜探查,以评价手术侧输卵管是否通畅.第1次腹腔镜手术成功207例,手术失败19例;术后3～6个月行子宫输卵管造影,第1次腹腔镜手术成功的207例患者中,患侧输卵管通畅者89例(A组);第1次腹腔镜手术失败、术中及术后改行输卵管切除术(19例)及手术后随访检查患侧输卵管不通者(63例)共计82例(B组).再以妊娠包块最大径线5 cm或血清人绒毛膜促性腺激素(hCG)水平≤2000 IU/L,>2000～<5000 IU/L,≥5000 IU/L为界,分别计算输卵管通畅率.两组患者年龄、孕次、停经时间、输卵管妊娠的侧别及部位、是否破裂、是否合并盆腔粘连等方面比较,差异均无统计学意义(P>0.05).结果 226例患者中,207例患者第1次腹腔镜手术成功,手术成功率为91.6%(207/226),术后3～6个月随访152例,失访55例.A、B组患者术前血清hCG中位水平分别为980(55～12 000)、3150(570～40 000)IU/L,两组比较,差异有统计学意义(P<0.01);A、B组患者输卵管妊娠包块最大径线分别为(3.4±1.3)、(5.0±1.7)cm,两组比较,差异也有统计学意义(P<0.01).A组患者术前中位腹腔内出血量为200(0～1500)ml,B组为300(0～1600)ml,A组活胎率为2%(2/89),B组为11%(9/82),两组比较,差异均有统计学意义(P<0.05).两组共171例患者中,妊娠包块最大径线<5 cm者103例,术后患侧输卵管通畅率为65%(67/103),妊娠包块最大径线≥5 cm者68例,术后患侧输卵管通畅率为32%(22/68),两者比较,差异有统计学意义(P<0.01);血清hCG水平≤2000 IU/L、>2000～<5000 IU/L、≥5000 IU/L者术后患侧输卵管通畅率分别为72%(73/102)、29%(12/42)和15%(4/27),3者分别比较,差异也有统计学意义(P<0.05);logistic回归分析结果显示,术前血清hCG水平(OR=0.277,P<0.01)、输卵管妊娠包块最大径线(OR=0.577,P<0.01)、腹腔内出血量(OR=0.999,P<0.05)均为手术成功率的影响因素.结论 腹腔镜保守性手术对输卵管妊娠希望保留输卵管功能的患者具有安全性和可行性;术前血清hCG水平、输卵管妊娠包块大小及腹腔内出血量是影响手术效果的重要因素.