宫腔镜下微型剪刀分离复发宫腔粘连的临床疗效观察

目的:分析评价宫腔镜下微型剪刀分离复发宫腔粘连的临床疗效。方法:选取宫腔镜电切术后1月复查发现再发宫腔粘连的患者65例,其中40例轻度粘连、25例重度粘连。患者均在门诊行宫腔镜下微型剪刀分离,术毕宫腔注入透明质酸钠凝胶,继续口服戊酸雌二醇周期治疗。术后2~3月复查宫腔镜同时再次分离粘连,进行疗效评价。术后3月期间观察子宫内膜厚度。结果:术后3月,轻度和重度宫腔粘连患者的总有效率分别为92.5%和84%。轻度粘连组术后第2月与第3月的有效率比较,差异有统计学意义(P0.05);中度粘连组比较,差异亦有统计学意义(P0.05)。术后3月,两组患者的子宫内膜厚度均增加,两组比较差异有统计学意义(P0.05);且每组的组间不同时间段内膜厚度比较,差异也有统计学意义(P0.05)。结论:重复宫腔镜下微型剪刀分离宫腔复发粘连可作为宫腔镜电切分离粘连术后的辅助手段,提高治疗效果。     

黄体中期宫腔镜检查对宫腔粘连分离术后内膜功能恢复的评估

目的:黄体中期宫腔镜检查对宫腔粘连分离术后内膜功能恢复的评估。方法:收集2009年10月至2014年3月在广东省计划生育专科医院宫腔镜中心进行宫腔粘连分离术治疗的宫腔粘连患者82例,术后于黄体中期(排卵后6~8天)行宫腔镜复查,宫腔形态恢复正常者根据宫腔镜下子宫内膜血管的形态和腺体开口分为内膜佳组与内膜差组。比较两组B超检查内膜厚度及分型,黄体中期血清雌二醇(E2)、孕酮(P)的水平,免疫组织化学技术检测子宫内膜雌激素受体(ER)、孕激素受体(PR)的表达,随访妊娠率及妊娠结局等。结果:1宫腔粘连分离术后复查宫腔形态满意72例,其中,内膜佳组49例,内膜差组23例。2内膜佳组排卵日、黄体中期B超检查内膜厚度分别为8.2±1.0 mm、8.0±0.8mm,较内膜差组7.1±1.2mm、7.0±1.0mm明显增加,差异均有统计学意义(P0.01);内膜佳组排卵日A型内膜率为24.5%(12/49),较内模差组4.3%(1/23)明显增加,差异有统计学意义(P0.05)。两组患者黄体中期血E2、P水平比较差异均无统计学意义(P0.05)。内膜佳组黄体中期子宫内膜腺上皮ER表达及间质PR表达均较内膜差组增强,差异均有统计学意义(P0.05)。3内膜佳组临床妊娠率及足月分娩率分别为59.1%(29/49)、55.1%(27/49),内膜差组分别为13.0%(3/23)、4.3%(1/23),两组比较差异有统计学意义(P0.01)。结论:宫腔粘连分离术后黄体中期宫腔镜内膜血管及腺体检查是一种较好的评估子宫内膜功能恢复的方法,对预测妊娠结局有一定的价值。     

宫腔镜下纵隔子宫电切术治疗不同类型纵隔子宫的对比研究

目的:评估不同类型纵隔子宫经宫腔镜纵隔子宫电切术后的生殖结局，探讨经宫腔镜下纵隔子宫电切术后患者的生育力是否与纵隔子宫的类型有关。方法:回顾性分析2012年7月至2020年7月广州医科大学附属第三医院因纵隔子宫经宫腔镜下纵隔子宫电切术患者共179例，分为A组(完全纵隔子宫组)56例，B组(不全纵隔子宫组)123例，比较两组患者经宫腔镜下纵隔子宫电切术术后治疗效果、妊娠结局和术后并发症。结果:术前A组56例患者有4例活产(6.90%),在经宫腔镜下纵隔子宫电切术后1～5年随访期内，活产率升高至66.18%,早期流产率由术前的82.76%下降至29.41%,差异均有统计学意义(P<0.001)。B组123例患者术前有13例活产(8.44%),术后活产率升高至71.63%,早期流产率由78.57%下降至21.99%,差异均有统计学意义(P<0.001)。两组患者经宫腔镜纵膈子宫电切术后不孕率、早期及晚期流产率、异位妊娠率、活产率、早产率、剖宫产率比较差异无统计学意义(P>0.05)。两组患者手术时间、术中出血量、术后并发症差异均无统计学意义(P>0.05)。结论:宫腔...     

宫腔粘连术后应用三腔导管负压冲洗引流装置的临床疗效观察

目的:探讨宫腔三腔导管负压冲洗引流装置在宫腔镜下宫腔粘连分离术(TCRA)后的应用效果。方法:选择收集2017年8月至2018年8月在郑州大学第三附属医院就诊并经宫腔镜检查确诊为中、重度宫腔粘连,近期有生育要求并愿意治疗和随访的患者60例,随机数字法分为两组:A组30例,术后放置宫腔三腔导管负压冲洗引流装置治疗;B组30例术后放置二腔球囊导管治疗。观察时间为术后6个月。比较两组患者术后再粘连率、内膜恢复情况、月经评分及妊娠率。结果:在二次宫腔镜探查时A组有效率为93.3%,B组为83.4%,差异均有统计学意义(P<0.05);再粘连率分别为6.7%及16.7%。术后6个月A组内膜厚度及术后经量评分中位数值均高于B组,差异有统计学意义(P<0.05);术后6个月两组妊娠率差异无统计学意义(P>0.05);两组阴道总引流液量差异有统计学意义(P<0.05),而宫腔感染率、脱管率差异无统计学意义(P>0.05)。结论:宫腔镜下宫腔粘连分离术后应用宫腔三腔导管负压冲洗引流装置相比普通二腔球囊,可降低患者再粘连率,增加患者子宫内膜厚度,改善月经情况。     

月经周期不同时期行宫腔粘连分离术后行辅助生殖技术妊娠结局分析

目的:分析在不同月经周期行宫腔粘连分离术对术后行辅助生殖技术(ART)妊娠结局的影响。方法:回顾分析2015年1月至2018年12月在山东大学生殖医学研究中心行宫腔粘连分离术后行ART的124例中重度宫腔粘连(IUA)不孕症患者的临床资料,根据患者手术日月经天数,分为增殖期组(74例)和分泌期组(50例)。比较两组患者的临床资料和妊娠结局,分析患者妊娠结局的相关影响因素。结果:宫腔粘连分离术后行ART患者的总临床妊娠率为63.7%;增殖期组与分泌期组的临床妊娠率比较,差异无统计学意义(67.6%vs 58%,P0.05)。两组患者的流产率与活产率比较,差异均无统计学意义(P0.05)。logistic回归模型分析显示,患者移植前子宫内膜厚度与宫腔粘连美国生育协会(AFS)评分为妊娠结局的影响因素(P0.05)。宫腔粘连分离手术日月经天数、患者年龄、不孕症类型与临床妊娠率均无相关性(P0.05)。结论:IUA患者在子宫内膜增殖期与分泌期均可行宫腔粘连分离术,术后行ART的妊娠结局无统计学差异。     

冷器械联合周期性球囊扩张治疗宫腔粘连在体外受精助孕中的临床效果分析

目的:探讨冷器械联合周期性球囊扩张术治疗宫腔粘连(IUA)在体外受精-胚胎移植(IVF-ET)中的临床效果。方法:对175例经宫腔镜检查确诊为IUA的患者行冷刀分离粘连,术后继续每间隔1周进行球囊扩张术并联合雌、孕激素人工周期治疗。治疗后行冻融胚胎移植。比较IUA轻度组(95例)、中度组(65例)及重度组(15例)患者的一般情况及临床结局。结果:(1)3组患者治疗后子宫内膜厚度均比治疗前增厚(P<0.01),3组治疗前后子宫内膜厚度的差值比较,差异有统计学意义(P<0.05),重度IUA组子宫内膜的差值最大。(2)治疗后,共有163例(93.14%)患者恢复正常宫腔形态,12例患者行再次IUA分离术,其中轻度IUA组(97.89%)和中度IUA组(93.89%)宫腔形态恢复正常的比例显著高于重度IUA组(60.00%);轻度IUA组月经恢复正常的比例(84.21%)高于中度IUA组(66.15%)和重度IUA组(33.33%)。(3)人工替代周期准备内膜并行冻融胚胎移植后整体临床妊娠率为54.29%(95/175),继续妊娠率为40.00%(70/175)。3组间移植胚胎数目、胚胎类型、胚胎种植率、临床妊娠率、继续妊娠率、早期流产率及异位妊娠率差异均无统计学意义(P>0.05)。结论:宫腔镜下冷刀联合周期性球囊扩张术有利于子宫内膜的改善,对于IVF助孕合并宫腔粘连的女性有一定的临床效果,尤其是轻度粘连者可能效果更佳。     

两种方法预防宫腔粘连分离术后再粘连疗效分析

目的:探讨中重度宫腔粘连患者行宫腔镜粘连分离术后两种不同治疗方法预防再粘连的效果。方法:选取2010年1月至2013年12月江苏大学附属宜兴医院妇产科治疗的中重度宫腔粘连64例患者为研究对象,其中32例宫腔粘连分离术后给予传统治疗(对照组),即宫腔放置宫内节育器+口服戊酸雌二醇,32例术后给予以宫腔镜检查为主的综合治疗(研究组),即每月重复宫腔镜检查+宫腔注入透明质酸钠+口服戊酸雌二醇。观察两组患者术后子宫内膜厚度、月经量改善、分离粘连次数及受孕情况。结果:研究组术后分离粘连次数≥2次的例数少于对照组,月经改善率及妊娠率均高于对照组,差异有统计学意义(P0.05);研究组重度宫腔粘连患者术后分离粘连次数≥2次的例数少于对照组重度宫腔粘连患者,月经改善率高于对照组,差异均有统计学意义(P0.05)。结论:宫腔粘连分离术后以每月重复宫腔镜检查为主的综合治疗可以有效预防特别是重度宫腔粘连分离术后再粘连,缩短子宫内膜恢复的时间,从而改善月经情况。     

宫腔冲洗引流在重度宫腔粘连患者宫腔镜下宫腔粘连分离术后的应用效果研究

目的:评价宫腔冲洗引流在重度宫腔粘连患者宫腔镜下宫腔粘连分离术(TCRA)后的临床应用效果。方法:选择2019年1～12月在郑州大学第三附属医院就诊的重度宫腔粘连患者86例作为研究对象,根据术后预防再粘连的方法不同分为3组:A组30例,术后放置二腔球囊导管引流,B组30例,术后放置三腔球囊导管+0.9%氯化钠液冲洗引流,C组26例,术后放置三腔球囊导管+抗生素冲洗引流。比较3组患者宫腔引流量、子宫内膜厚度、月经评分、宫腔形态、满意度、妊娠结局及不良反应发生情况。结果:术后6个月3组患者子宫内膜厚度、月经评分、宫腔形态均较术前改善,差异均有统计学意义(P<0.05);B、C两组术后总引流液量、子宫内膜厚度、月经评分、宫腔形态改善率均高于A组,差异有统计学意义(P<0.05),B、C两组间比较,差异无统计学意义(P>0.05);3组不良反应、妊娠情况、满意情况比较差异无统计学意义(P>0.05)。结论:TCRA后放置三腔球囊导管行冲洗引流相比放置二腔球囊导管被动引流更能有效预防重度宫腔粘连术后再粘连的发生,增加患者子宫内膜厚度,有效改善月经情况,采用0.9%氯化钠液或抗生素冲洗宫腔对比术后治疗效果无明显差别。     

雌激素不同给药方式在宫腔粘连治疗中的疗效

目的:探讨皮贴雌激素对宫腔粘连患者血清雌二醇、子宫内膜修复及妊娠率的影响。方法:选取2015年9月至2016年12月于郑州大学第二附属医院行宫腔镜下宫腔粘连分离术的患者80例,随机分为皮贴组和口服组,术后分别给予雌激素皮贴4mg/d、戊酸雌二醇4mg/d。观察两组用药前后的血雌二醇浓度、子宫内膜厚度以及术后妊娠率。结果:两组用药前一般情况、宫腔粘连评分、血雌二醇浓度、子宫内膜厚度比较,差异均无统计学意义(P0.05)。皮贴组用药后血雌二醇水平[(208.10±79.26)pg/ml]高于口服组[(169.90±51.40)pg/ml],排卵期子宫内膜厚度[(6.41±0.81)mm]高于口服组[(6.05±0.80)mm],差异均有统计学意义(P0.05)。皮贴组的术后妊娠率高于口服组,但差异无统计学意义(P0.05)。皮贴组的不良反应发生率低于口服组,差异有统计学意义(P0.05)。结论:宫腔粘连术后使用皮贴雌激素能有效增加血清雌二醇浓度,促进子宫内膜修复,是一种高效、低副作用的治疗方法。     

冷冻胚胎移植前应用宫腔镜检查联合子宫内膜轻创术的意义

目的:探讨宫腔镜检查联合子宫内膜轻创术对冷冻胚胎移植(FET)后的临床妊娠结局的影响。方法:选择2013年3月至2014年3月行FET治疗的不孕患者165例为研究对象,其中在FET前行宫腔镜检查联合子宫内膜轻创术95例为宫腔镜组,直接行FET治疗的70例为对照组。比较两组的临床妊娠率、胚胎种植率和不良妊娠率(包括早期流产、胚胎停育、异位妊娠);并对宫腔镜组中宫腔镜检查结果正常与异常(子宫内膜炎、子宫内膜息肉及增生、宫腔粘连)患者的临床妊娠结局进行比较。结果:宫腔镜组的临床妊娠率(57.89%)、胚胎种植率(38.51%)明显高于对照组(42.86%、26.15%),差异有统计学意义(P0.05);两组不良妊娠率比较,差异无统计学意义(P0.05)。宫腔镜组中宫腔异常的发生率为50.53%,宫腔异常组中各种类型患者经治疗后的临床妊娠率、胚胎种植率分别与宫腔正常组比较,差异均无统计学意义(P0.05)。结论:宫腔镜检查联合子宫内膜轻创术可以提高FET周期的临床妊娠率、胚胎种植率。宫腔异常的患者经宫腔镜治疗后可改善子宫内膜的容受性。     

子宫动脉栓塞后宫腔粘连生殖预后分析——附26例报告

目的：探讨子宫动脉栓塞（uterine artery embolization,UAE）后宫腔粘连患者的生殖预后。方法：2008年5月—2014年3月首都医科大学附属复兴医院宫腔镜中心行宫腔镜下宫腔粘连分离术治疗UAE后患者26例,分析宫腔粘连分离术后美国生育学会（American Fertility Society,AFS）评分、月经恢复情况以及生殖预后。结果：仅38.5%（10/26）的患者术后月经较术前有改善;88.5%（23/26）的患者术后AFS评分较术前降低;26例患者中有2例自然妊娠,妊娠率7.7%,其中1例最终以妊娠早期胚胎停育而终止妊娠,另1例目前妊娠早期先兆流产,无1例活产。结论：UAE术后宫腔粘连的患者宫腔粘连分离术后生殖预后差,其原因可能与UAE后子宫血管灌注不良影响术后内膜再生有关。     

雌、孕激素受体表达与宫腔粘连分离术后雌孕激素治疗疗效的相关性研究

目的:研究宫腔粘连(IUA)患者子宫内膜组织中雌激素受体(estrogen receptor,ER)、孕激素受体(progesterone receptor,PR)的表达,探讨其与术后雌孕激素治疗疗效的关系。方法:采用免疫组化法检测55例中重度IUA患者子宫内膜组织的ER、PR表达;患者均行宫腔镜下IUA分离术,术后给予雌孕激素周期治疗。随访患者的月经改善情况,结合宫腔镜复查结果,分析PR、ER受体与预后的相关性。结果:ER、PR在腺体及间质中的表达均无显著差异(P=0.727,P=0.453);PR低表达组、高表达组患者术后雌孕激素治疗的有效率分别为63.64%和54.55%,两组比较无显著差异(P=0.503);ER低表达组、高表达组患者术后雌孕激素治疗的有效率分别为33.33%和70.27%,两组比较差异显著(P=0.018)。结论:患者子宫内膜PR的表达不能预测预后;ER表达水平与疗效呈正相关,其可能成为IUA术后雌孕激素治疗疗效的预测指标。     

Dominant factors affecting reproductive outcomes of fertility-desiring young women with intrauterine adhesions

Purpose

To identify the dominant factors affecting reproductive outcomes of fertility-desiring young women with intrauterine adhesions (IUA) after hysteroscopic adhesiolysis.

Methods

This prospective observational study included 104 cases of women with IUA. Logistic regression analysis was applied to analyze the value of the location and extent of adhesions, the number of previous uterine cavity surgery, menstrual patterns, and second look hysteroscopy time.

Results

In the total 104 patients with IUA, 91 patients (87.5%) had a history of at least one previous uterine cavity surgery. Hypomenorrhoea and amenorrhoea were two most common presenting menstrual abnormalities occurring in 59 (56.7%) and 28 (26.9%) cases, respectively. The clinical pregnancy rate was 60.6% (63/104) and the live birth rate was 39.4% (41/104). Pregnancy rate was higher in patients having mild IUA (81.5%) as compared to moderate (61.3%) or severe type (20.0%) (p?<?0.001). The bivariate and binary logistic regression analysis revealed that the location and extent of adhesions were the independent parameters related to the reproductive outcome after hysteroscopic adhesiolysis for fertility-desiring women with IUA (p?=?0.011 and p?=?0.003, respectively), but not the number of previous uterine cavity surgery, menstrual patterns, and second look hysteroscopy time (p?=?0.232, p?=?0.239 and p?=?0.120, respectively).

Conclusion

The extent and location of IUA are the dominant factors affecting reproductive outcomes, which are possibly regarded as a potential predictor evaluating prognosis of IUA after hysteroscopic adhesiolysis.

     

A clinicohysteroscopic scoring system of intrauterine adhesions

We propose a new scoring system for intrauterine adhesions (IUA) that may predict the prognosis after hysteroscopic adhesiolysis. We analyzed hysteroscopic findings and clinical data of patients diagnosed as having IUA by reviewing previously published hysteroscopic classifications of IUA. The data were subjected to evaluation according to the most popular classifications in addition to the proposed classification using a scoring system for different parameters. The results obtained by the proposed scoring system matched well with other classifications regarding grade I and III IUA. But in the cases with moderate IUA (grade II), there was overlap between the classifications (sensitivity 58.3%) which can be attributed to considering the menstrual and reproductive history. Further studies are needed to assess its prognostic value.     

Auto–Cross-Linked Hyaluronic Acid Gel for Prevention of Intrauterine Adhesions after Hysteroscopic Adhesiolysis: A Randomized Controlled Trial

Study ObjectiveTo investigate auto–cross-linked hyaluronic acid gel for the prevention of intrauterine adhesion (IUA) recurrence after hysteroscopic adhesiolysis.DesignA single-center, double-blinded randomized controlled trial.SettingA tertiary university hospital.PatientsTwo hundred seventy-two patients with moderate-to-severe (American Fertility Society [AFS] score ≥5) IUAs underwent hysteroscopic adhesiolysis.InterventionsThe patients were randomized to receive standard care along with auto–cross-linked hyaluronic acid gel after surgery (treatment group) or standard care only (control group). All patients had second-look hysteroscopy at 4 weeks and hormonal therapy for 2 cycles after surgery.Measurements and Main ResultsTwo hundred sixty patients were eligible and randomized; 245 patients successfully completed the study (n = 122 in treatment group, and n = 123 in control group). The primary outcome measure was IUA recurrence at second-look hysteroscopy. The secondary outcome measures included an improvement in the AFS score and menstrual pattern. There was no significant difference with regard to IUA recurrence (31.1% vs 39.8%) or median AFS score at second-look hysteroscopy (2, interquartile range 2, 3, 4 vs 2, interquartile range 2, 3, 4) or improvement in the menstrual pattern at 3-month follow-up (87.7% vs 76.4%), in the treatment and control groups, respectively.ConclusionThe application of auto–cross-linked hyaluronic acid gel did not seem to improve IUA recurrence after hysteroscopic adhesiolysis.     

Small-diameter hysteroscopy with Versapoint versus resectoscopy with a unipolar knife for the treatment of septate uterus: a prospective randomized study

STUDY OBJECTIVE: To compare 2 procedures for metroplasty: resectoscopy with monopolar knife versus small-diameter hysteroscopy fitted with a Versapoint device. DESIGN: Prospective randomized study (Canadian Task Force classification I). SETTING: Endoscopic gynecology units at tertiary care university hospitals. PATIENTS: One hundred-sixty patients with septate uterus and a history of recurrent abortion or primary infertility undergoing hysteroscopic metroplasty from 2001 to 2005. INTERVENTIONS: Hysteroscopic resection of the uterine septum performed with either a 26F resectoscope with unipolar knife (80 women, group A) or a 5-mm diameter hysteroscope with Versapoint device (80 women, group B). All patients were managed expectantly, with follow-up lasting 1 year. MEASUREMENTS AND MAIN RESULTS: Operative parameters (operative time, fluid absorption, complications, need for second intervention) and reproductive outcome parameters (pregnancy, abortion, term and preterm delivery, modality of delivery, cervical cerclage) were measured. Operative time and fluid absorption were significantly greater in group A than in group B (23.4 +/- 5.7 vs 16.9 +/- 4.7 minutes and 486.4 +/- 170.0 vs 222.1 +/- 104.9 mL, respectively). The cumulative complication rate was significantly lower in group B than in group A. No difference in any of the reproductive parameters was observed between the 2 groups: pregnancy and delivery rates were 70% and 81.6% in group A vs 76.9% and 84% in group B. Nine women (18.4%) from group B and 8 women (16%) from group B experienced spontaneous abortions. Most patients (54/82) delivered by cesarean section without differences according to the hysteroscopic technique used for metroplasty (65% in group A vs 67.7% in group B) or to the gestational age (65.1% of term and 68.7% of preterm deliveries). CONCLUSIONS: Small-diameter hysteroscopy with bipolar electrode for the incision of uterine septum is as effective as resectoscopy with unipolar electrode regarding reproductive outcome and is associated with shorter operating time and lower complication rate.     

The nature of intrauterine adhesions following reproductive hysteroscopic surgery as determined by early and late follow-up hysteroscopy: clinical implications

Objective To evaluate the rate and characteristics of postoperative intrauterine adhesions (IUA) that might be formed following hysteroscopic reproductive surgery from both a gross and a histologic perspective as determined by early and late follow-up diagnostic hysteroscopy. Methods Retrospective analysis of 61 women wishing a pregnancy and suffering from a significant intrauterine pathology affecting their reproductive outcome were reviewed. All patients were treated hysteroscopically. Subsequently, they were randomly assigned to perform a follow-up diagnostic hysteroscopy at a variable intervals from their initial surgery. Multiple hysteroscopic-guided biopsies from IUA, when present, were obtained in several cases. Twenty patients were in the early group and had follow-up hysteroscopy performed 2–4 weeks after the initial operation. The late diagnostic group consisted of 41 patients with follow-up hysteroscopy at about 12 months (8–16 months). The two groups were similar to composition. Postoperatively, none of the early diagnostic group underwent hysterosalpingography (HSG) whereas all of the late group performed HSG 4 months following the initial surgery, which showed at least one-third of the cavity free of adhesions. When adhesions were present, no effort was made to lyse them. Results At follow-up hysteroscopy, 25% of both groups had no significant adhesions. Grade I adhesions (thin, filmy) occurred in 60% of the early hysteroscopy patients and in only 12% of the late group (P < 0.05). Grade II adhesions were present in 10% of the early group and in up to 41% in the late group (P < 0.05), whereas Grade III adhesions were present in only 5% of the early hysteroscopy group, but in 22% of the late one (P < 0.05). Correlation between hysteroscopic and histologic findings were good in most of cases in both groups. Follow-up to determine the subsequent reproductive outcome revealed similar conception rates in both groups. Conclusion The IUA that might be formed immediately following hysteroscopic reproductive surgery are histologically different from those appearing a longer time after the original operation. Routine early follow-up hysteroscopy can influence the prognosis resulting from the original surgery.     

The incidence of placenta related disease after the hysteroscopic adhesiolysis in patients with intrauterine adhesions

ObjectiveTo analyze the correlation between placenta related disease of pregnant women with antecedent hysteroscopic adhesiolysis due to intrauterine adhesions (IUA).Materials and methodsThis is a single center, non-randomized, open-label, retrospective cohort Study. 74 patients who had adhesiolysis and hormone therapy for IUA and progressed into the third trimester were group A and 296 without IUA were group B. The main outcome measure is the incidence of placenta related disease including placenta accreta spectrum, placenta previa, placental abruption, intrauterine growth restriction (IUGR), and pregnancy-induced hypertension (PIH). The second outcome is the perinatal, and intrapartum complications.ResultsPatients in group A had a higher frequency of prior pregnancy times (2.51 ± 1.56 vs.1.84 ± 1.06, p = 0.001) and lower frequency of prior delivery times (0.20 ± 0.41 vs. 1.30 ± 0.51, p < 0.05) than group B at baseline. At delivery, there is no difference between the incidence of PIH and IUGR between two groups. However, a significantly higher frequency of placenta accreta (17.6% vs. 1.4%, OR = 15.56, 95% CI 4.91–49.34), placenta increta (5.4% vs. 0.7%, OR = 8.4, 95% CI 1.51–46.78), placenta previa (8.1% vs. 2.0%, OR = 4.265, 95%CI1.33–13.63) and postpartum hemorrhage (21.6% vs. 3.4%, OR = 7.890, 95% CI 3.41–18.26) were observed in group A than in group B.ConclusionsCompared to general population, the rates of placenta accreta, placenta increta, placenta previa, postpartum hemorrhage are higher among the IUA patients after hysteroscopic adhesiolysis, and special attention is needed at the termination of the pregnancy.     

Asherman��s syndrome after removal of placenta remnants: a serious clinical problem

Intrauterine adhesions (IUA) or Asherman’s syndrome is thought to develop after trauma to the uterine cavity by destruction of the basal layer of the endometrium. IUA can result in menstrual disorders, infertility, and complication during pregnancy and delivery. IUA formation is multifactorial, with pregnancy being an important etiologic factor. Performing a postpartum exploration/evacuation or curettage can lead to adhesion formation. We present three patients who presented with a menstrual disorder after postpartum surgical intervention on suspicion of placental remnants. Hysteroscopic evaluation revealed severe intrauterine adhesions with complete obliteration of the uterine cavity. Repeated and extensive hysteroscopic adhesiolysis is performed to acquire a cavity with a normal appearance. Besides the puerperal uterus, the time of surgical performance is crucial in the risk for adhesion formation. Performing a late surgical intervention, as from 24–48 h after delivery, leads to an increased risk for adhesion formation. Prevention of IUA can be established by an accurate indication for late postpartum surgical interventions. When performing a late surgical intervention, hysteroscopic surgery is preferable. Firstly, hysteroscopy allows the possibility for identification of placental remnants, and secondly, the possibility for selective removal, thus avoiding unnecessary trauma to the endometrium compared to blindly curettage. Caution is advised when performing a late puerperal surgical intervention. An accurate indication is essential, and when needed, hysteroscopic surgery is preferable, minimizing trauma to the endometrium.     

中-重度宫腔粘连分离术后妊娠结局分析

目的:探讨中-重度宫腔粘连(IUA)患者宫腔镜下宫腔粘连分离术(TCRA)术后妊娠结局及相关影响因素。方法:选择2014年1月-2016年12月因生育障碍于首都医科大学附属北京妇产医院就诊的中-重度IUA患者(评分≥5分)145例,随访TCRA术后妊娠结局,对可能影响妊娠的因素进行分析。结果:①145例中-重度IUA患者行TCRA术后妊娠率46.9%(68/145),其中自然妊娠率为54.4%(37/68),人工辅助妊娠率为45.6%(31/68);继发性不孕、既往不良孕史、原发性不孕者术后妊娠率分别为45.8%(33/72)、48.3%(28/58)和46.7%(7/15);中度、重度粘连者术后妊娠率分别为64.9%(48/74)和28.2%(20/71);妊娠相关刮宫≥3次、<3次者术后妊娠率分别为36.6%(34/93)和65.4%(34/52);术前月经正常、经量减少、闭经者术后妊娠率分别为73.1%(19/26)、48.8%(40/82)和24.3%(9/37),术后月经正常者及经量减少者妊娠率分别为54.6%(59/108)和28.6%(8/28);28例再粘连患者中,仅有2例轻度粘连患者妊娠(7.1%,2/28)。41.2%(28/68)妊娠患者于孕12周前出现胚胎停育或自然流产,58.8%(40/68)获得活产儿,平均孕周(38±1)周(32~41周),新生儿平均体质量(3 467±461)g(1 800~4 400 g)。产科并发症中,前置胎盘2例,产后出血6例,输血2例,无子宫破裂发生。②采用逐步进入回归模型进行多因素Logistic回归分析,发现妊娠相关刮宫次数、术前粘连程度、术后再粘连与否是预测术后妊娠结局的独立因素(P<0.05)。结论:中-重度IUA即使行TCRA恢复宫腔形态后,术后妊娠率仍不满意,特别是IUA复发的患者妊娠率更低。术中注意对残留内膜的保护,采取有效措施促进TCRA术后内膜再生、预防再粘连形成是治疗的关键。