瘢痕子宫自发性完全性破裂9例临床分析

目的:探讨瘢痕子宫破裂的发病规律、临床表现和早期诊断及治疗。方法:回顾性分析浙江大学医学院附属妇产科医院2013年1月1日至2016年5月31日收治的瘢痕子宫自发性完全性破裂9例病例资料。结果:9例病例中子宫下段瘢痕破裂占33.3%(3例),宫体部瘢痕破裂占66.7%(6例);66.7%(6例)发生于临产前,其中83.3%(5/6)为宫体部破裂;5例有症状的病例中80.0%(4/5)在B超检查下有阳性发现,4例无症状病例中75.0%(3/4)为B超检查发现;7例晚期妊娠病例中胎儿死亡率为28.6%(2/7);所有病例产妇均存活,行子宫修补术保留子宫,术后子宫恢复良好。结论:子宫体部瘢痕较子宫下段瘢痕更容易破裂,且多发生于临产前;B超对子宫破裂的早期诊断具有重要价值;子宫修补术为首选手术方案。     

子宫瘢痕部位妊娠18例临床分析

目的:探讨剖宫产术后子宫瘢痕部位妊娠(CSP)的早期诊断及治疗方法.方法:对我院收治的1166例异位妊娠中18例CSP患者的临床资料进行回顾性分析.结果:CSP占同期异位妊娠的1.54%(18/1166).孕早期16例,孕中期2例.5例由外院转入,13例初诊临床表现无特异性,均有停经后阴道流血史,6例伴有腹痛.16例C...     

子宫动脉栓塞术治疗剖宫产后子宫瘢痕部位妊娠46例临床疗效分析

目的:探讨子宫动脉栓塞术治疗剖宫产后子宫瘢痕部位妊娠的价值。方法:对四川大学华西第二医院2008年3月至2010年3月剖宫产后子宫瘢痕部位妊娠行双侧子宫动脉栓塞治疗的46例患者的临床资料进行回顾性分析。结果:45例治疗有效,有效率97.8%(45/46)。36例患者介入治疗后行清宫术,35例术中和术后均无大出血,1例患者在栓塞治疗后22天因大出血切除子宫;另10例未行清宫术。所有患者血β-HCG平均1月降至正常,同时超声检查也恢复正常。术后并发症主要为发热(19例)和局部疼痛(41例)。结论:子宫动脉栓塞术是一种安全、有效治疗剖宫产后子宫瘢痕部位妊娠的方法。     

剖宫产术后瘢痕部位妊娠20例诊疗分析

目的:探讨预防、诊断和治疗刮宫产术后子宫切口瘢痕部位妊娠的有效方法.方法:对2003年6月-2008年7月收治的20例剖宫产瘢痕部位妊娠患者的临床资料进行回顾性分析.结果:超声检查为诊断子宫切口妊娠的主要依据.明确诊断后患者的治疗效果明显优于未确诊前开始治疗者.借助于妊娠部位血流阻断的处理方式好于直接进行吸宫.两组比较,结局差异具有统计学意义(P<0.05).结论:早期诊断是成功治疗剖宫产术后子宫切口瘢痕部位妊娠的关键,介入治疗是最快捷有效的治疗方法,经腹或经腹腔镜保守手术,以及全身或局部使用甲氨蝶呤(MTX)后吸宫的治疗效果明显优于单纯吸宫.     

剖宫产术后子宫瘢痕部位妊娠临床治疗效果分析

目的:为进一步探讨了解临床中对于剖宫产术后子宫瘢痕部位妊娠取得的临床效果,及其在临床中的表现特征、诊断和预后。方法:以我院在2007年6月至2010年10月期间收治的剖宫产手术后子宫瘢痕部位妊娠的36例患者,对其临床资料进行回顾性分析。结果:所有的患者均治疗痊愈,且治疗期间无严重并发症出现。结论:MTX静脉治疗、动脉介入栓塞治疗和子宫病灶切除术治疗CSP,均可取得满意的治疗效果。     

剖宫产后瘢痕子宫妊娠的处理

为了探讨剖宫产术后瘢痕子宫妊娠的诊断和治疗 ,作者对台湾某医院的该类病例进行了回顾性研究。所有病例均使用阴道超声诊断 ,3种方法进行保守治疗以保留子宫 :甲氨蝶呤 (MTX)的局部病灶注射或全身用药 ,清宫以及剖宫产瘢痕处异位妊娠病灶的楔形切除。结果 :剖宫产瘢痕子宫妊娠的发生率为 1:2 2 16 ,在异位妊娠中所占比例为 6 .1%。平均发生年龄为 32岁 (2 7～ 4 1岁 ) ,从前次剖宫产到此次瘢痕子宫妊娠时间间隔为 6个月至 12年 ,诊断孕周为 5～ 12 + 4 周 ,5例中可见胎心搏动 ,所有病例均有阴道流血 ,其中 6例伴随腹痛。 1例因疑诊为不全…     

剖宫产术后子宫切口瘢痕妊娠的临床治疗研究

目的:探讨剖宫产术后子宫切口瘢痕妊娠的临床治疗方法方法:选取2009年2月至2010年11月于我院就诊的剖宫产术后子宫切口瘢痕妊娠患者16例,其中4例患者服用甲氨蝶呤(MTX)+米非司酮行药物治疗,5例患者行行子宫病灶切除术,6例患者行子宫动脉栓塞术后行清宫术,1例行子宫全切术结果:行药物治疗的4例患者中3例保守治疗成功,1例后行子宫病灶切除术,行手术治疗的患者均治愈出院结论:药物治疗、子宫病灶切除术、子宫动脉栓塞+清宫术、子宫全切术治疗子宫切口瘢痕妊娠均有一定疗效,根据患者病情,选择适当的治疗方法,能改善患者病情,提高治愈率。     

剖宫产瘢痕妊娠的诊断及处理

目的:探讨剖宫产瘢痕妊娠的发病机制、早期诊断以及恰当的治疗方法。方法:回顾分析1994年1月至2006年5月北京协和医院收治的25例剖宫产瘢痕妊娠患者的临床资料,包括:患者的发病年龄,孕产次,发病至剖宫产术的间隔时间,首发症状,发病部位,诊断过程,辅助检查、治疗方法,经过及结局。结果:剖宫产瘢痕妊娠占同期异位妊娠的1.1%,与同期正常妊娠数之比为1:1368。25例患者的平均年龄31.4岁,92%的患者仅有一次剖宫产手术史,发病至末次剖宫产术的间隔时间为4月至15年,最常见的临床表现为停经和阴道流血,其中11例发生阴道大出血。16例(64%)患者分别误诊为宫内早孕(14例)和滋养细胞肿瘤(2例)而给予相应处理,仅9例治疗前确诊。通过剖宫产病史,妇科检查和超声、磁共振等辅助检查综合分析可作出诊断。治疗方法包括全子宫切除和保守性治疗(全身或孕囊内甲氨蝶呤注射和保守性手术)。25例患者均治愈出院。结论:剖宫产瘢痕妊娠较少见,临床易误诊,对有剖宫产手术史的患者应结合妇科检查及辅助检查以早期诊断,强调根据患者情况予以个体化治疗,可获得较好疗效。     

子宫动脉栓塞在剖宫产子宫瘢痕部位妊娠治疗中的应用

目的:探讨选择性子宫动脉栓塞治疗剖宫产子宫瘢痕部位妊娠的应用价值.方法:对10例剖宫产子宫瘢痕部位妊娠的患者行选择性双侧子宫动脉栓塞,6例联合甲氨蝶呤灌注用药.结果:10例患者均顺利实施了子宫动脉栓塞,清宫时出血量少,疗效满意.结论:子宫动脉栓塞是治疗剖宫产子宫瘢痕部位妊娠的一种有价值的方法.     

子宫瘢痕妊娠14例临床分析

目的:探讨子宫瘢痕妊娠的诊断与治疗。方法:回顾分析我院14例子宫瘢痕妊娠病例的临床表现,辅助检查和治疗方法。结果:12例患者为人流、引产、清宫术后,经彩超、血β-HCG测定后确诊,2例误诊为滋养叶细胞肿瘤,手术后确诊。2例直接清宫,6例化疗后清官,4例手术治疗,2例行子宫动脉介入化疗并栓塞。均好转或痊愈。结论:子宫瘢痕妊娠的诊断彩超为金标准。治疗应个体化,提高对该病的认识,使早期诊断和成功的保守治疗成为可能。     

Subsequent pregnancy outcome after conservative treatment of a previous cesarean scar pregnancy

BACKGROUND: To assess pregnancy course and outcome after conservative treatment of a cesarean scar pregnancy. METHODS: During an 8-year period, 15 cases of cesarean scar pregnancies were diagnosed at our institution. Seven of the 14 patients for whom we successfully preserved the uterus became pregnant within 3 years after termination of the scar pregnancy. The year of diagnosis, conservative method and gestational age for these five patients were recorded. Delivery method, time interval between the scar pregnancy and subsequent pregnancy, and maternal and neonatal outcome were evaluated. RESULTS: Seven pregnancies (eight live and one dead baby) were noted. The mean interval between the ectopic pregnancy and subsequent pregnancy was 13.3 months (range 0-34 months). One patient, who became pregnant 3 months after the scar pregnancy was found, suffered uterine rupture at 38.3 weeks' gestational age. Two patients with placental accrete, and one of them who continued the existing intrauterine twin pregnancy after transvaginal sono-guided aspiration of the scar pregnancy received a cesarean hysterectomy at 32 weeks of gestation. The remaining four pregnancies were uneventful, followed by early cesarean sections at 36 weeks. CONCLUSION: The results of this first series of seven subsequent pregnancies after conservative treatment of scar pregnancies are promising. An early cesarean section before over-extension of the uterus and spontaneous labor can help to prevent uterine rupture. Placenta accrete is another severe morbidity of these patients in addition to uterine rupture. Thus a cesarean hysterectomy may be the choice of treatment.     

Laparoscopic Management of Partial Molar Caesarean Scar Ectopic Pregnancy

Study ObjectiveTo demonstrate laparoscopic management of a molar scar ectopic pregnancy.DesignStepwise demonstration of the technique with narrated video footage.SettingCesarean scar ectopic pregnancy and molar pregnancy are 2 separate extremely rare pathologies with an incidence range from 1/1800 to 1/2500 of all pregnancies for the former [1,2]. The concurrence of both cesarean scar ectopic and molar pregnancy is furthermore exceptionally rare, and there are only 8 reported cases of cesarean scar molar pregnancy in literature till date [3]. There is a high risk of uterine rupture, uncontrolled hemorrhage, hysterectomy, and significant maternal morbidity owing to thin myometrium and fibrous scar after cesarean section [4,5]. Knowledge and awareness about this clinical condition aid in early diagnosis and reduced morbidity. Here, we present a rare case of cesarean scar ectopic pregnancy that was operated for failed medical management and diagnosed to be molar scar ectopic pregnancy intraoperatively.InterventionsTotal laparoscopic approach to molar scar ectopic pregnancy excision involved the following steps, strategies to minimize blood loss, and complete enucleation of tissue: (1) Hysteroscopy to localize the scar ectopic and its type and size (2) Bladder dissection to expose scar (3) Intramyometrial injection of vasopressin (4) Use of harmonic scalpel to delineate the gestational sac (5) Complete evacuation of products of conception (6) Excision of scar tissue (7) Uterine repair in 2 layersConclusionThere are only 8 reported cases of cesarean scar molar pregnancy in literature till date, and all patients had at least 2 previous uterine curettages with abnormally increased β-hCG levels. The clinical manifestations were varied, the most common symptom being vaginal bleeding for a period >1 month, including our case [3]. Considering the limitations of ultrasound, magnetic resonance imaging, and serum hCG levels in the differential diagnosis of molar cesarean scar pregnancy from normal cesarean scar pregnancy, postoperative specimen should be sent for histologic examination [6]. As seen in our case, the possibility of molar pregnancy at cesarean scar ectopic site should be kept in mind in cases with rising β-hCG levels despite continuous medical interventions, which was being medically managed for 3 months. Our case is the first to be successfully managed with laparoscopic surgery as the previously reported cases were managed with suction evacuation, chemotherapy, laparotomy, or hysterectomy [3].     

29例剖宫产瘢痕妊娠诊断及治疗方式的探讨

目的探讨子宫下段剖宫产瘢痕妊娠的临床发病特点、诊断标准及其治疗策略的选择,为临床合理诊治提供依据。方法收集2007年1月至2010年6月华中科技大学同济医学院附属同济医院妇科病房收治的29例子宫下段剖宫产瘢痕妊娠患者的临床资料,分析其临床发病特点、诊断及其治疗过程。结果子宫下段剖宫产瘢痕妊娠发病率为1.43/1000次妊娠。29例患者均有停经,27例(93.10%)患者有不同程度的阴道出血,其中19例(65.52%)患者出血总量超过500ml,5例(17.24%)患者因失血过多致失血性休克,26例(89.66%)患者血β-hCG(14.03～200000U/L)水平升高。29例均由盆腔三维彩色多普勒超声检测诊断,诊断准确率100%。治疗方法中,药物治疗23例(成功3例,成功率10.34%),清宫术7例,双侧髂内动脉栓塞或结扎21例,剖宫产瘢痕妊娠病灶切除术18例。治疗后监测血β-hCG水平恢复正常时间为2～7周,平均(4.01±0.23)周,无严重不良反应。结论子宫下段剖宫产瘢痕妊娠的治疗方法多样化,其中甲氨蝶呤药物联合双侧髂内动脉结扎和剖宫产瘢痕妊娠病灶切除手术方法出血较少且疗效显著。应争取早期确诊,并及时选择合理的治疗方法。     

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.     

Endometrial implantation factors in women with submucous uterine fibroids

Uterine fibroids are benign tumours, which are associated with subfertility and early pregnancy loss. This study was carried out to examine the effect of submucous fibroids on concentrations of glycodelin, insulin-like growth factor binding protein-1 (IGFBP-1), interleukin-6 (IL-6), interleukin-10 (IL-10), tumour necrosis factor α (TNFα) and osteopontin in uterine flushings. Premenopausal women with a certain diagnosis of submucous fibroid confirmed on three-dimensional saline infusion sonohysterography were recruited into the study. The control group included women without ultrasonic evidence of any uterine or endometrial pathology. All women had uterine flushings performed 7days post LH surge. Enzyme linked immunoassays were performed to analyse glycodelin, IL-6, IL-10, TNFα and osteopontin, whilst immunoradiometric assay was used to analyse IGFBP-1. In 23 women with submucous fibroids, the concentrations of glycodelin and IL-10 in uterine flushings were significantly lower compared with 17 women in the control group (P=0.002; P=0.007, respectively). There were no significant differences between the two groups in concentrations of IGFBP-1, IL-6, TNFα and osteopontin. Women with submucous fibroids had significantly lower concentrations of glycodelin and IL-10 in mid-luteal phase uterine flushings. This finding may explain the association with submucous fibroids and adverse reproductive outcomes. Uterine fibroids are small growths from the muscle of the uterus (womb). Submucous fibroids protrude into the cavity of the womb. We do not know what causes fibroids to form and grow. In most women, fibroids cause no symptoms and they are sometimes detected on routine gynaecological examination. In some women, however, fibroids can cause heavier and longer menstrual periods. Another problem associated with fibroids is bleeding between periods. The effect of fibroids on fertility is not clear, but some doctors believe that they may also cause infertility and early miscarriage. This study tried to see whether presence of submucous fibroids has any effect on various substances produced by the lining of the womb to facilitate development of early pregnancy. Women with a confirmed diagnosis of submucous fibroids were asked to attend the clinic and have the uterine cavity flushed with a special solution 7days after ovulation. The fluid, which was taken back from the womb, was then analysed to measure the amounts of substances that favour pregnancy development. Women with a normal uterine cavity were also asked to have the uterine cavity flushed to act as a comparison. The study showed that the uterine cavities of women with submucous fibroids were producing decreasing amount of substances favourable to early pregnancy development. We speculate that this may explain why some women with submucous fibroids have difficulties falling pregnant. Our findings should be helpful to doctors advising women with submucous fibroids who wish to start a family.     

早期腹腔妊娠的诊断和治疗

腹腔妊娠是指胚胎或胎儿位于输卵管、卵巢及阔韧带以外的腹腔内。腹腔妊娠误诊率高、死亡率高,严重影响母婴健康。早期诊断及治疗可显著改善患者预后。文章主要从腹腔妊娠的分类、早期的腹腔妊娠的诊断和治疗方面进行阐述。     

Effect of early pregnancy on a previous lower segment cesarean section scar.

OBJECTIVE: To summarize the manifestation, diagnosis, and early management of early pregnancy on a previous cesarean section scar. METHOD: Fifteen cases of early pregnancies implanted on previous cesarean section scars were diagnosed and treated in two obstetrical centers. RESULTS: The 15 patients had light, painless vaginal bleeding and their serum beta-subunit human chorionic gonadotropin (beta-HCG) was elevated. The interval between cesarean section and admission ranged from 6 months to 12 years (7.1+/-3.6 years). Doppler and real-time ultrasonic examinations demonstrated an enlargement of the previous cesarean section scar in the lower segment, a gestational sac or a mixed mass attached to the cicatrix, and a very thin myometrium between the gestational sac and the bladder wall. Serum beta-HCG dropped to normal in 12 of the 15 patients following treatment with crystalline trichosanthin injected into the cervix followed by oral mifepristone, intramuscular injections of methotrexate, or other appropriate treatment. Two patients underwent total hysterectomy due to massive vaginal bleeding. The remaining patient was misdiagnosed with choriocarcinoma and also had total hysterectomy. CONCLUSION: Pregnancy on a previous lower segment cesarean section scar is rare but very dangerous. Early diagnosis and effective conservative drug treatment may be instrumental in decreasing the occurrence of uterine rupture.     

Treatment of viable cesarean scar ectopic pregnancy with suction curettage.

OBJECTIVE: Pregnancy in previous cesarean scar is the rarest form of ectopic pregnancy. All reported cases in the literature that were treated with uterine curettage either become unsuccessful or complicated. We aimed to present a case of cesarean scar ectopic pregnancy that was successfully treated with suction curettage without any additional therapy. CASE: A 32-year-old asymptomatic woman, gravida 2, para 1 was referred to our hospital with the possible diagnosis of cervical ectopic pregnancy. Transvaginal and transabdominal sonographic examination revealed the diagnosis of viable ectopic pregnancy in a previous cesarean scar. Suction curettage with carman canulles was performed under transabdominal ultrasonographic guidance. beta-hCG decreased progressively postoperatively. CONCLUSION: Suction curettage under ultrasonography guidance can be used in termination of selected cases (early diagnosed, without symptoms that necessitates emergency intervention) of cesarean scar pregnancy.     

IFPA Meeting 2010 Workshops Report II: Placental pathology; trophoblast invasion; fetal sex; parasites and the placenta; decidua and embryonic or fetal loss; trophoblast differentiation and syncytialisation

Workshops are an important part of the IFPA annual meeting. At IFPA Meeting 2010 diverse topics were discussed in twelve themed workshops, six of which are summarized in this report. 1. The placental pathology workshop focused on clinical correlates of placenta accreta/percreta. 2. Mechanisms of regulation of trophoblast invasion and spiral artery remodeling were discussed in the trophoblast invasion workshop. 3. The fetal sex and intrauterine stress workshop explored recent work on placental sex differences and discussed them in the context of whether boys live dangerously in the womb.4. The workshop on parasites addressed inflammatory responses as a sign of interaction between placental tissue and parasites. 5. The decidua and embryonic/fetal loss workshop focused on key regulatory mediators in the decidua, embryo and fetus and how alterations in expression may contribute to different diseases and adverse conditions of pregnancy. 6. The trophoblast differentiation and syncytialisation workshop addressed the regulation of villous cytotrophoblast differentiation and how variations may lead to placental dysfunction and pregnancy complications.     

经腹小切口筋膜内子宫切除手术方法的探讨

目的:探讨经腹小切口筋膜内子宫切除术的优越性。方法:选择116例患子宫良性病变行子宫切除术为研究组,选择同期传统腹式筋膜外子宫切除术116例为对照组。结果:两组手术时间、出血量及手术效果方面有显著差异。结论:经腹小切口筋膜内子宫切除术较传统腹式筋膜外子宫切除式具有切口小、手术损伤小、出血少、术后恢复快等优越性。