宫腔粘连分离术后预防再粘连的临床研究

<正>宫腔粘连(intrauterine adhesion,IUA)主要是由刮宫和感染引起的,临床主要表现为闭经或月经过少、周期性腹痛等。宫腔镜下行IUA分离术(transcervical resection of adhesions,TCRA)是在直视下有针对性地分离或切除IUA,是患者恢复正常月经、改善妊娠及分娩结局的标准方法,但术后可能发生宫腔再次粘连。2009年1月至2012年6月我院采用两种不同的治疗方法预防宫腔再次粘连,以探讨有效的预防方法。1资料与方法1.1一般资料选取上述期间江苏大学附属宜兴医院宫腔     

重度宫腔粘连分离术后预防再粘连方法的比较

目的评估宫腔镜宫腔粘连分离术后预防宫腔再粘连方法的疗效。方法回顾性分析2004年11月至2007年5月间郑州大学第三附属医院妇科内镜诊治中心122例宫腔镜下宫腔粘连切除术患者的临床资料。术后宫腔内放置节育环(IUD)58例为IUD组,宫腔注入几丁糖并IUD64例为IUD+几丁糖组;根据病程长短将IUD组分为Ia组(病程≤1年)和Ib组(病程1年),IUD+几丁糖组分为IIa组(病程≤1年)和IIb组(病程1年)。观察术后宫腔恢复情况、月经改善及妊娠情况。结果IUD和IUD+几丁糖组术后宫腔再粘连率分别为41.4%和23.4%(P0.05),其中Ia组(19.0%)明显低于Ib组(54.1%)(P0.05);IUD组月经改善率及妊娠率分别为74.1%和29.3%,IUD+几丁糖组分别为92.2%和48.4%,IUD组明显低于IUD+几丁糖组(P0.05),其中Ia组(90.0%、47.6%)明显高于Ib组(64.9%、18.9%)(P0.05)。IIa组术后宫腔再粘连率及妊娠率分别为8.7%和78.3%,IIb组分别为31.7%和31.7%,两组比较,差异均有统计学意义(P0.05);IIa组(100%)月经改善率与IIb组(87.8%)比较,差异无统计学意义(P0.05)。结论重度宫腔粘连切除术后宫腔内放置节育环加几丁糖可有效预防再粘连,提高月经改善率及妊娠率。     

中重度宫腔粘连分离术后预防宫腔再粘连的临床效果观察

目的:探讨中重度宫腔粘连分离术后预防宫腔再粘连的临床效果。方法:回顾性分析2013年1月至2014年6月在武汉大学人民医院就诊的119例经宫腔镜检查确诊为中重度宫腔粘连并行TCRA术患者的临床资料。术后宫腔放置Foley球囊导尿管+宫内节育器为A组,宫腔放置Foley球囊导尿管+宫内节育器+可吸收医用膜为B组,术后均使用人工周期。比较患者的术后月经改善、宫腔及妊娠情况。结果:中度宫腔粘连患者中,B组的治愈率高于A组(57.7%vs 31.0%,P=0.047),宫腔再粘连率低于A组(15.4%vs 44.8%,P=0.018);A、B组的妊娠率分别为40%、60%,差异无统计学意义(P=0.37)。重度宫腔粘连患者中,B组的治愈率高于A组(43.8%vs 18.8%,P=0.031),宫腔再粘连率低于A组(15.6%vs 46.9%,P=0.007);A、B组的妊娠率分别为11.1%和33.3%,差异无统计学意义(P=0.257)。结论:中重度宫腔粘连分离术后联合使用Foley球囊导尿管+宫内节育器+可吸收医用膜治疗效果优于Foley球囊导尿管+宫内节育器组。     

充水球囊预防重度宫腔粘连分离术后再粘连的疗效观察

宫腔粘连（intrauterine adhesions,IUA）又称Asherman综合征,多由对子宫基底膜的创伤及感染引起,主要症状为月经量异常（包括月经量减少和闭经等）,周期性下腹痛,不孕及复发性流产等。近年来,随着人工流产率的增加及宫腔镜技术的不断发展,宫腔粘连的发病率及诊断率不断提高。宫腔镜被认为是诊断宫腔粘连的金标准,而应用宫腔镜治疗宫腔粘连是安全而有效的。轻度宫腔粘连治疗效果较好,但中、重度粘连术后易复发,预后较差。本研究旨在探讨重度官腔粘连分离术后预防再粘连的有效方法。资料与方法     

预防宫腔黏连再形成的研究现状与进展

宫腔黏连(intrauterine adhesions,IUA)是导致育龄期妇女月经异常和生育功能障碍的常见原因,近年随着宫腔内操作的增多,其发病率逐年上升。目前治疗IUA主要是经宫颈行宫腔镜黏连分离术(transcervical resection of adhesions,TCRA),但术后再黏连现象却颇为常见,成为困扰妇科领域的难题。现就预防IUA术后再黏连的研究现状作一综述。     

COOK球囊联合雌孕激素序贯治疗预防宫腔镜下宫腔粘连分离术后宫腔再粘连的临床效果观察

目的:探讨宫腔镜下宫腔粘连(IUA)分离术后COOK球囊联合雌孕激素对预防宫腔再次粘连的临床效果,并探讨COOK球囊留置的时间。方法:选择我院2016年4月至2017年10月中重度IUA患者227例,随机分为4组:其中A组55例放置COOK球囊作为观察组A组,7天后取出;B组68例放置COOK球囊作为观察组B组,3月后取出;C组64例放置"宫型"宫内节育器(IUD)为观察组C组,3个月后取出;D组40例仅行宫腔镜下IUA分离术,作为空白对照组D组。4组术后第2天开始均应用戊酸雌二醇片(2 mg,每天3次,口服)联合地屈孕酮片(10 mg,每天1次,口服)序贯治疗,连续用药3个周期。分别比较4组治疗前后子宫腔状态、月经情况、妊娠率、患者满意度及有无并发症等。结果:治疗3个月后,B组IUA改善率、月经改善率、妊娠率及患者满意度均高于A组、C组、D组,差异有统计学意义(P0.05);B组植入物脱落率和嵌顿率明显低于C组(P0.05);B组与C组细菌感染率差异无统计学意义(P0.05)。结论:宫腔内放置COOK球囊3个月联合雌孕激素序贯治疗预防宫腔镜下IUA分离术后宫腔再粘连的方法在临床上的安全性及有效性均值得肯定。     

宫腔粘连分离术后复发为重度宫腔粘连的因素分析

目的:探讨宫腔粘连(IUA)分离术后再次发生IUA且成重度粘连的危险因素。方法:前瞻性建立IUA复发患者的临床队列,根据美国生殖学会IUA评分标准分为非重度组和重度组,首先逐一分析可能相关的因素,然后对有统计学意义的因素进行多因素非条件Logistic回归分析。结果:2015年1月至2016年6月共295例复发性IUA患者参加研究。多因素分析发现初次发现IUA时为重度、刮宫后闭经史、多次IUA分离手术史者复发成重度粘连的风险明显增高,其OR值分别为12.12(95%CI 5.30~27.7),3.24(95%CI 1.60~6.57),1.69(95%CI 1.11~2.58)。结论:初次发现IUA时为重度或有刮宫后闭经史的患者行IUA分离手术后易复发为重度粘连;多次IUA分离也是IUA复发并成重度粘连的危险因素。     

宫腔粘连分离术后妊娠结局的临床分析

<正>宫腔粘连(intrauterine adhesions,IUA)是指创伤引起的子宫内膜基底层脱落和损伤导致子宫壁相互黏着形成的粘连。临床表现为闭经或月经较少、周期性腹痛、继发性不孕与妊娠异常。宫腔镜下行宫腔粘连分离术(transcervical resection of adhesions,TCRA)是目前公认的标准治疗方法。但     

短效避孕药联合医用透明质酸钠凝胶对人工流产术后宫腔粘连预防及恢复的影响

目的 分析短效避孕药联合医用透明质酸钠凝胶对人工流产术后宫腔粘连预防及恢复的影响。方法 选取本院208例人工流产术后患者为研究对象,根据随机数字表法分为两组,各104例。对照组接受雌孕激素序贯治疗,试验组接受短效避孕药联合医用透明质酸钠凝胶治疗,比较两组的宫腔粘连发生率、宫腔积液发生率、症状改善情况、性激素水平及术后恢复指标。结果 试验组宫腔粘连、宫腔积液发生率低于对照组（P<0.05）;试验组阴道出血时间短于对照组、术后14 d月经伴随症状量表评分低于对照组（P<0.05）;试验组术后14 d卵泡刺激素、黄体生成素和雌二醇水平高于对照组（P<0.05）;试验组月经来潮时间短于对照组,术后14 d血清人绒毛膜促性腺激素水平低于对照组、子宫内膜厚度大于对照组（P<0.05）。结论 短效避孕药联合医用透明质酸钠凝胶应用于人工流产术后,可降低宫腔粘连发生率,促进术后恢复。     

7～8mm宫腔镜在重度宫腔粘连分离术后预防再粘连中的应用

目的评估重度宫腔粘连分离术后应用7～8mm宫腔镜定期监测在预防官腔再粘连中所起的作用。方法回顾性分析浙江省宁波市第六医院2009年6月至2012年5月宫腔镜下重度宫腔粘连分离术102例患者的临床资料,术后官腔先放置充水球囊后放IUD者53例为球囊放环组;闭经者术后每2周实施1次7～8mm宫腔镜监测,月结来潮者在月经干净3～7d监测1次官腔粘连情况,共49例为宫腔镜监测组。观察宫腔再粘连情况,并跟踪月经改善及妊娠情况。结果术后3个月球囊放环组官腔镜探查再次粘连率为26．42％,宫腔镜监测组为6．12％（P〈0．01）;两组月经改善情况分别为81.13％和95．92％（P〈0．05）;球囊放环组妊娠率33．96％,宫腔镜监测组妊娠率38．78％,差异无统计学意义（P〉0．05）。结论重度宫腔粘连分离术后应用7～8mm宫腔镜定期监测可以有效预防再粘连,提高月经改善率,但未能显著提高妊娠率。     

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。     

宫形球囊和宫内节育器预防宫腔镜下子宫中隔切除术后宫腔粘连的比较

目的：探讨宫形球囊和宫内节育器（IUD）对预防宫腔镜下子宫中隔切除术（TCRS）术后宫腔粘连的临床效果。方法：收集2016年2月-2017年12月于首都医科大学附属北京妇产医院妇科微创中心行TCRS的65例患者的临床资料进行回顾性分析,A组（n=30）术后放置宫形球囊并给予人工周期治疗,B组（n=35）术后放置宫形IUD并给予人工周期治疗。术后3个月行宫腔镜检查,B组患者同时取出IUD。并记录患者月经情况、异常子宫出血情况、腰腹部不适情况。结果：2组均未发现宫腔粘连。术后3个月内A组患者未发生腰酸腹痛、异常子宫出血情况;B组患者发生IUD嵌顿2例（5.71%）,发生腰酸腹痛6例（17.14%）,子宫异常出血10例（28.57%）,取出IUD后症状均缓解。2组腰酸腹痛和子宫异常出血情况差异均有统计学意义（P=0.027;P=0.001）。结论:宫形球囊和IUD预防TCRS术后宫腔粘连的效果基本相同,但宫形球囊放置时间短、不良反应少、取出方便而更具优势。     

Effectiveness of Hyaluronic Acid Gel and Intrauterine Devices in Prevention of Intrauterine Adhesions after Hysteroscopic Adhesiolysis in Infertile Women

Study ObjectiveTo compare the recurrence rate, post-treatment American Fertility Society (AFS) score, ongoing pregnancy rate, and endometrial thickness of 3 secondary prevention therapies in preventing recurrent intrauterine adhesions (IUAs) and increasing pregnancy rates in infertile women after hysteroscopic adhesiolysis.DesignA retrospective study.SettingA private fertility hospital.PatientsA total of 200 consecutive infertile women, with the desire to have a baby and were diagnosed as having IUAs detected by hysterosalpingogram, who underwent hysteroscopic adhesiolysis for IUAs from January, 2018 to May, 2020.InterventionsWomen who underwent hysteroscopic adhesiolysis received hormone therapy, and one of the 3 secondary preventions: hyaluronic acid (HA) gel alone, intrauterine devices (IUDs) alone, or HA gel + IUD.Measurements and Main ResultsOf the 200 women included in the final analysis, 121 received HA alone, 59 were treated with IUD alone, and 20 received HA gel + IUD combination. The mean post-treatment AFS score for IUAs was significantly lower in the HA gel + IUD group than the HA alone or the IUD alone groups (adjusted p = .01 and p = .02, respectively). Multivariable analysis revealed a significantly lower recurrence rate in the women after treatment with HA gel + IUD than HA alone (adjusted odds ratio, 0.19; 95% credible interval [CreI], 0.03–0.88). Women treated with HA gel + IUD also had reduced post-treatment AFS scores compared with HA alone (β coefficients, ?0.83; 95% CreI, ?1.64 to ?0.01). For ongoing pregnancy rates after in vitro fertilization, the adjusted odds ratio for HA gel + IUD vs HA alone was 2.03 (95% CreI, 0.44–11.00) and for IUD alone vs HA alone was 1.13 (95% CreI, 0.41–3.29), indicating nonsignificant differences. There were no differences observed in endometrial thickness on the day of embryo transfer among the 3 groups.ConclusionThe investigation of the primary outcome in reducing the recurrence rate IUA after treatment demonstrated that a combination of HA gel + IUD provides greater prevention of recurrent IUAs and may decrease post-treatment AFS scores for infertile women undergoing hysteroscopic adhesiolysis. However, for the secondary outcome of increasing pregnancy rates, there was no improvement in the ongoing pregnancy rates after in vitro fertilization.     

A Randomized,Multi-Center,Clinical Trial to Assess the Efficacy and Safety of Alginate Carboxymethylcellulose Hyaluronic Acid Compared to Carboxymethylcellulose Hyaluronic Acid to Prevent Postoperative Intrauterine Adhesion

Study ObjectiveTo estimate the efficacy of alginate carboxymethylcellulose hyaluronic acid (ACH) gel to prevent intrauterine adhesions after hysteroscopic surgery in comparison with carboxymethylcellulose hyaluronic acid (CH) gel, which is known as an effective adhesion inhibitor.DesignRandomized, multicenter, single-blind, clinical trial (Canadian Task Force classification I).SettingTertiary university hospital.PatientsOne hundred eighty-seven patients with a surgically treatable intrauterine lesion (myomas, polyps, septa, intrauterine adhesion, dysfunctional uterine bleeding).InterventionsPatients were randomized to 2 groups: hysteroscopic surgery plus intrauterine application of ACH or CH.Measurements and ResultsThe rate of adhesion formation and the adhesion severity score with type and extent were calculated 4 weeks after surgery. The ACH group had results that were comparable to the CH group in terms of the development of intrauterine adhesions at 4 weeks follow-up. The adhesion severities were not different between the 2 groups. In a subgroup without baseline intrauterine adhesion, the ACH group showed a lower intrauterine adhesion rate than the CH group (p = .016).ConclusionsACH had a comparable efficacy to CH in terms of the adhesion rate and severity. In the case of no baseline intrauterine adhesion, intrauterine application of ACH after hysteroscopic surgery had a lower rate of intrauterine adhesion than application of CH.     

宫腔镜子宫中隔切除术后3种治疗方法预防宫腔粘连的疗效及生殖预后观察

目的:探讨宫腔镜下子宫中隔切除(transcervical resection of septum,TCRS)术后预防宫腔粘连形成及改善妊娠结局的最佳治疗方案。方法:TCRS术后患者116例随机分为4组:A组(n=30),术后行人工周期;B组(n=31),术后宫腔放置宫内节育器(IUD);C组(n=27),术后放置IUD+行人工周期;D组(n=28),术后不采取任何干预措施。术后3个月再次行宫腔镜检查,观察宫腔是否发生粘连及粘连分布,随访至术后24个月,记录月经恢复情况及妊娠结局。结果:A组排除9例(6例失访,3例漏服药物),B组排除6例(4例失访,2例IUD脱落),C组排除2例(1例失访,1例IUD下移),D组排除5例(均为失访)。4组术后3个月宫腔粘连发生率依次为:14.2%(1/7)、37.5%(3/8)、22.2%(2/9)、9.1%(1/11);随访至术后24个月,妊娠率分别为:33.3%(7/21)、32.0%(8/25)、36.0%(9/25)、47.8%(11/23);流产率分别为:4.8%(1/21)、12.0%(3/25)、8.0%(2/25)、4.3%(1/23),宫腔粘连发生率、妊娠率和流产率组间均无统计学差异(P>0.05)。结论:TCRS术后进行人工周期、IUD、IUD+人工周期3种治疗方法对防止宫腔粘连形成及提高妊娠率、改善妊娠结局方面无明显益处,且治疗效果差别不大,术后不必将其作为常规治疗方法。     

Oxidized,Regenerated Cellulose Adhesion Barrier Plus Intrauterine Device Prevents Recurrence After Adhesiolysis for Moderate to Severe Intrauterine Adhesions

Study Objective

To compare the efficacy of an oxidized, regenerated cellulose adhesion barrier (Interceed; Ethicon, Somerville, NJ) combined with an intrauterine device (IUD) versus an IUD alone for preventing adhesion recurrence following hysteroscopic adhesiolysis for moderate to severe intrauterine adhesions (IUAs).

宫腔手术后预防宫腔粘连的研究现状

宫腔粘连（intrauterine adhesion,IUA）是宫腔手术后常见并发症,是导致子宫性不孕的主要原因。对于IUA最重要的是进行预防,术后口服避孕药及宫内节育器的置入在临床上应用广泛,同时具有避孕的作用。使用球囊导尿管需住院治疗,且术后应用广谱抗生素预防上行感染。防粘连产品的应用需考虑患者经济因素。羊膜移植的有效性有待进一步研究证实。早期门诊宫腔镜检查是预防IUA的发展趋势。     

宫腔手术后预防宫腔粘连的研究现状

宫腔粘连(intrauterine adhesion,IUA)是宫腔手术后常见并发症,是导致子宫性不孕的主要原因.对于IUA最重要的是进行预防,术后口服避孕药及宫内节育器的置入在临床上应用广泛,同时具有避孕的作用.使用球囊导尿管需住院治疗,且术后应用广谱抗生素预防上行感染.防粘连产品的应用需考虑患者经济因素.羊膜移植的...     

Short- and Long-term Outcomes of Postoperative Intrauterine Application of Hyaluronic Acid Gel: A Meta-analysis of Randomized Controlled Trials

ObjectiveTo systematically evaluate the role of hyaluronic acid (HA) gel and its derivatives in the postoperative prevention of intrauterine adhesions (IUA) and to assess whether HA gel could improve the pregnancy rate.Data SourcesA structured search was performed in PubMed, Cochrane, Scopus, Web of Science, and Embase on February 2, 2022.Methods of Study SelectionWe chose medical subject headings and relevant terms from other articles for the database search. The following intervention was selected: HA gel or related derivatives vs placebo in randomized controlled trials (RCTs). The following outcomes were selected: the rate and severity of IUA after intrauterine operations and pregnancy rate. After the full-text screening, 12 articles were included in the final analysis. The study quality and risk of bias were assessed with the Cochrane tool (www.training.cochrane.org/handbook).Tabulation, Integration, and ResultsData from 12 articles on 1579 patients were extracted and analyzed by 2 independent reviewers. According to the meta-analysis, HA gel could decrease the risk of IUA (risk ratio [RR], 0.50; 95% confidence interval [CI], 0.37–0.67; p = .005; I² = 59%) after intrauterine operations. Subgroup analysis revealed a significant positive impact of HA gel on both groups receiving dilatation and curettage (RR, 0.42; 95% CI, 0.30–0.59; p = .86; I² = 0) or hysteroscopic surgery (RR, 0.55; 95% CI, 0.38–0.80; p = .007; I² = 66%). The sensitivity analysis showed that heterogeneity could be improved significantly by removing one study. The severity of IUA (mean difference = –0.92; 95% CI, –1.49 to –0.34; p <.00; I² = 89%) was lower in the intervention group. Subgroup and sensitivity analyses did not significantly improve the heterogeneity. When the studies are classified by the volume of HA gel, 10 mL (RR, 0.40; 95% CI, 0.27–0.60; p = .96; I² = 0) and 5 mL (RR, 0.34; 95% CI, 0.14–0.82; p = .36; I² = 0) were effective in treating IUA. In contrast, HA gel <5 mL was not sufficient to prevent IUA (RR, 0.66; 95% CI, 0.43–1.01; p = .02; I² = 71%; p = .05). The pregnancy rate was also improved by the use of HA gel (RR, 1.39; 95% CI, 1.13–1.72; p = .37, I² = 0).ConclusionHA gel helps prevent IUA and decreases the severity of IUA after intrauterine surgery. A greater volume (≥5 mL) of HA gel is recommended to prevent IUA, according to this analysis. Moreover, HA gel can increase the pregnancy rate after intrauterine surgery. However, these conclusions should be interpreted with caution because of the inadequate quality of some RCTs with relatively small sample sizes and sample heterogeneity. Large RCTs are required to verify these conclusions in the future.