剖宫产术后瘢痕部位妊娠20例诊疗分析

目的：探讨预防、诊断和治疗剖官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.     

输卵管妊娠保守性手术96例分析

目的探讨输卵管妊娠保守性手术及不同手术方式的近期效果及妊娠结局.方法对96例未破裂型输卵管妊娠中的77例行输卵管线型切开术,19例行输卵管伞端胚囊挤出术.绒毛种植部位注射甲氨蝶呤20～30rng.结果2.4%的患者发生持续性异位妊娠,均为行伞端挤出术患者.宫内妊娠率为41.5%,重复异位妊娠率为25.6%.对侧输卵管正常者,宫内妊娠率及重复异位妊娠率分别为70.5%和22.8%;当对侧输卵管异常或已被切除者,宫内妊娠率及重复异位妊娠率为7.9%和28.8%.结论绒毛种植部位注射甲氨蝶呤可降低持续性异位妊娠率,而伞端绒毛挤出术后发生持续性异位妊娠的可能性较大,应尽量避免.     

妊娠期急性脂肪肝的诊断与治疗

妊娠期急性脂肪肝(AFLP)是妊娠晚期一种特发性的严重并发症,孕产妇及围产儿死亡率高。该病缺乏特异性临床表现,需与妊娠期肝内胆汁淤积症等相鉴别,早期易误诊。肝活检是诊断AFLP的金标准,但根据病史、临床表现结合实验室及影像学检查,不必肝脏穿刺也可以做出临床诊断。迅速终止妊娠并给予支持治疗是主要治疗措施,对改善AFLP患者母胎结局至关重要。     

妊娠期单纯疱疹病毒感染与不良妊娠结局

单纯疱疹病毒(HSV)能引起生殖器官感染,妊娠合并HSV感染可造成胎儿宫内感染,引发流产、死胎、畸形、胎儿生长受限和新生儿感染等不良妊娠结局。此外,HSV感染还与输卵管妊娠及不孕等密切相关。文章阐述了妊娠合并HSV感染的流行病学、发病机制、临床特征、不良妊娠结局、诊断、预防和治疗的研究概况。     

预测子痫前期母婴结局生化指标研究进展

子痫前期(PE)是妊娠期特有疾病,指妊娠20周后出现血压升高和蛋白尿,或合并其他器官功能障碍。PE是一种动态性疾病,病情可呈持续性进展,导致不良妊娠结局,是威胁孕产妇及胎儿健康的重要原因之一。目前已有一些研究探讨了生化指标与PE孕妇妊娠结局之间的关系。本文就生化指标预测PE母婴结局的相关研究进展进行综述。     

输卵管妊娠保守性手术96例手术

目的：探讨输卵管妊娠保守性手术及不同手术方式的近期效果及妊娠结局。方法：对96例未破裂型输卵管妊娠中77例行输卵管线型切开术，19例行输卵管伞端胚囊挤出术。绒毛肿植部位注射甲氨蝶呤20－30mg。结果：2．4％的患者发生持续性异位妊娠，均为行伞端挤出术患者。宫内妊娠率为41．5％，重复异位妊娠率为25．6％。对侧输卵管正常者，宫内妊娠率及重复异位妊娠率分别为70．5％和22．8％；当时侧输卵管异常或已被切除者，宫内妊娠率又重复异位妊娠率为7．9％和28．8％。结论：绒毛种植部位注射甲氨蝶呤可降低持续性异位妊娠率，而伞端绒毛挤出术后发生持续性异位妊娠的可能性较大，应尽量避免。     

11例剖宫产疤痕妊娠临床分析和局部注射MTX疗效观察

目的 :总结剖宫产疤痕早期妊娠的临床资料 ,为临床提供诊断依据并探讨治疗方法。方法 :分析近 5年本院收治的剖宫产疤痕妊娠 11例。结果 :11例中 ,9例有停经后少量阴道流血 ,7例在未明确诊断前行人工流产术或药物流产。超声检查提示 ,11例中 5例剖宫产疤痕部位妊娠 ,其余 6例提示子宫下段前壁非均质包块。 11例均用甲氨蝶呤保守治疗成功。结论 :超声检查可提供重要诊断依据 ,用甲氨蝶呤治疗可有效杀死早期妊娠胚胎 ,未见明显副反应 ,是一种比较安全、有效的保守治疗方法。     

早期妊娠合并甲状旁腺功能亢进一例并文献复习

目的探讨妊娠合并甲状旁腺功能亢进疾病的临床特点，治疗方案、治疗时机及母儿结局。 方法根据南方医科大学附属小榄医院收治的1例及近5年文献报道47例妊娠合并甲状旁腺功能亢进患者的临床资料，对该病的临床特点、治疗方案、治疗时机及母儿结局进行分析。 结果本例患者33岁，妊娠6周因妊娠剧吐收住入院，经过治疗病情反复未能好转，发现血钙升高，进一步诊断妊娠合并甲状旁腺功能亢进，患者要求终止妊娠，3个月后行甲状旁腺切除手术，随访半年患者血钙及甲状旁腺素水平恢复正常。文献检索的47例妊娠合并原发性甲状旁腺功能亢进早孕期及中孕期行甲状旁腺切除术分别为4例和21例，总体母胎结局较好，其术前的血钙水平差异无统计学意义。 结论妊娠合并甲状旁腺功能亢进严重危害母胎安全，漏诊误诊风险高，患者结合临床实际可早孕期选择药物治疗，降低血钙水平，待中孕期后选择手术治疗，可有效减少母胎并发症发生。     

双羊膜囊三胎妊娠围产期管理及妊娠结局9例分析

目的:通过围产期管理策略及妊娠结局分析,探讨双羊膜囊(DA)三胎妊娠最佳临床治疗方案。方法:回顾性分析2012年1月至2020年3月四川大学华西第二医院产科收治的9例DA三胎孕妇临床资料。结果:9例DA三胎中4例为双绒毛膜双羊膜囊(DCDA)三胎,5例为单绒毛膜双羊膜囊(MCDA)三胎。分别于孕12～18⁺⁵周经产前超声诊断。孕期规律产检的病例大多数围产期结局预后良好,而2例产检不规律病例围产期结局差。3例DCDA三胎分别于孕16周、17周和17⁺¹周行选择性减胎术(心腔内注射氯化钾),其中2例合并联体双胎,1例合并多发畸形。共2例行畸形胎儿体内激光治疗,1例为DCDA三胎合并双胎动脉反向灌注序列征(TRAPS),另一例为MCDA三胎合并双胎儿TRAPS。9例DA三胎共分娩11例活产儿,体健,存活至今。结论:DA三胎应早期诊断,临床诊疗中需由多学科团队进行详细评估及监测。依据个体化差异,规范产前检查,严密监护胎儿情况,必要时实施选择性减胎术及适时终止妊娠以获得良好的围产期结局。     

Prediction of location of gestational sac for pregnancy of unknown location at first sight during exploratory surgery using the ratio of hCG in haemoperitoneum and venous serum

Objective

To evaluate a practical method to predict the location of gestational sacs for pregnancy of unknown location (PUL) during exploratory surgery.

Study design

Sixty-nine cases of PUL with a positive pregnancy test and haemoperitoneum but unknown location of the gestational sac at first sight on exploratory surgery were analysed at the Department of Obstetrics and Gynaecology, Shanghai Jiaotong University. The level of hCG in the haemoperitoneum and venous serum were measured, and the ratio of hCG in haemoperitoneum and venous serum (Rp/v-hCG) was calculated. Rp/v-hCG < 1.0 was taken to suggest an intrauterine gestational sac, and Rp/v-hCG > 1.0 was taken to suggest an abdominal gestational sac. The sensitivity and specificity of Rp/v-hCG for predicting the location of the gestational sac were evaluated prospectively.

Results

Among 69 cases of PUL, 17 cases (17/69) were ultimately diagnosed as abdominal gestational sacs before 9 weeks of gestation, and 52 cases (52/69) were ultimately diagnosed as intrauterine gestational sacs. The diagnostic sensitivity and specificity of Rp/v-hCG at the time of exploratory surgery for predicting the location of the gestational sac were 94.1% and 100%, respectively (kappa = 0.96; P = 0.039). The rate of missed diagnosis was 5.9%. The location of the gestational sac was determined during the initial exploratory procedure for 15 cases (15/17) with an abdominal gestational sac (1 case of splenic pregnancy was diagnosed during secondary surgery) and 37 cases (37/52) with an intrauterine gestational sac. With the exception of gestational sacs located in the pouch of Douglas (52.9%, 9/17), the gestational sacs (47.1%, 8/17) located in the other places were difficult to find.

Conclusions

Rp/v-hCG should be considered when exploratory surgery reveals no visible gestational sacs at first sight. If Rp/v-hCG is >1.0, more careful pelvic or abdominal exploration is required, rather than dilation and curettage, to locate abdominal gestational sacs.     

体外受精-胚胎移植术后复合妊娠研究进展

复合妊娠（heterotopic pregnancy,HP）是一种极其危险的异位妊娠,自然受孕者中HP的发生率并不高,但随着近年体外受精-胚胎移植（in vitro fertilization and embryo transfer,IVF-ET）术以及促排卵技术的普及,HP的发生率较前有所上升。HP患者早期一般仅有腹痛、阴道出血等非特异性症状,且由于宫内妊娠囊的存在使得宫外妊娠囊特别容易误诊和漏诊,从而易导致患者宫外妊娠囊继续发展,引起腹腔内大出血甚至休克等危及生命的严重后果。因此,充分了解HP的相关危险因素,在行ET术或促排卵技术前采取相应的预防HP发生的措施、发生HP后尽早进行确诊及确诊后采取有效的治疗对改善患者的预后显得尤为重要。综述近年IVF-ET后HP的诊断及管理措施进展。     

剖宫产瘢痕妊娠研究进展

剖宫产瘢痕妊娠（CSP）是一种特殊类型的异位妊娠,随着剖宫产率的增加,其发病率也在逐年增高。如不能对其进行及时诊治,将会出现大量出血、甚至子宫破裂等并发症,严重威胁患者生命。目前,CSP的发病机制、诊断及治疗尚无统一标准,对其发病机制的研究有助于CSP的预防,早期诊断及合理的治疗方法可以避免严重的并发症发生。     

A case of retroperitoneal ectopic pregnancy following IVF-ET in a patient with previous bilateral salpingectomy

The numbers of ectopic pregnancies have increased because of the popularization of assisted reproductive techniques. However, the retroperitoneal space is an exceptional location for ectopic pregnancy because the entrance to the retroperitoneal space is unknown. A woman 31 years of age who had received bilateral salpingectomy because of a right tubal ectopic pregnancy and a left hydrosalpinx 4 years earlier was treated by in vitro fertilization and embryo transfer (IVF-ET). Ultrasonography and magnetic resonance imaging (MRI) revealed a gestational sac attached to the inferior vena cava in the midabdomen of the retroperitoneal space. Single-dose methotrexate administration was administered twice. However, because of sudden upper abdominal pain with a drastic decline of hemoglobin, an emergent laparotomy was performed. The hematoma and a gestational sac were removed from the aorta and inferior vena cava. Ectopic pregnancy following IVF-ET in a patient with bilateral salpingectomy is likely to be the cause of implantation at this unusual site. An unusual ectopic pregnancy has a high risk of life-threatening massive bleeding. Intensive transabdominal ultrasound scanning and whole abdominal MRI should be performed for the early diagnosis of unruptured ectopic pregnancy.     

宫内宫颈复合妊娠一例

复合妊娠发病率低,临床表现缺乏特异性,与普通异位妊娠一样,可伴有腹痛、阴道不规则出血等,有的患者甚至没有任何症状,而且由于宫内妊娠囊的存在,易忽略异位妊娠囊,因此早期诊断困难,常误诊为早期流产。回顾重庆市妇幼保健院（我院）近5年移植周期数据（共41 596个移植周期）,仅2020年收治1例宫内妊娠合并宫颈妊娠患者。该患者既往有多次宫腔操作史,并多次行宫腔粘连分离术,新鲜周期因子宫内膜薄而取消移植,后来院行冻融胚胎移植助孕,解冻并移植卵裂期胚胎2枚,患者因移植术后反复阴道不规则出血就诊,早期急诊以“先兆流产”收入院行保胎治疗,后B超证实系宫内宫颈复合妊娠,患者保留宫内妊娠意愿强烈,遂行减胎术保守治疗（2次减胎术）,最终分娩1女活婴。本病例提示复合妊娠易漏诊和误诊,应尽早明确诊断,如病情稳定、孕周小,减胎术是一种有效的治疗手段。     

经阴道彩色多普勒超声诊断剖宫产切口瘢痕妊娠的临床价值

目的探讨经阴道彩色多普勒超声诊断剖宫产切口瘢痕妊娠(CSP)的临床价值。方法收集2012年10月至2014年10月沈阳市妇婴医院收治的64例经阴道超声诊断为剖宫产切口瘢痕妊娠患者的影像及临床资料,分析其超声声像图特征及与临床结局的关系。结果超声诊断为CSP的64例患者中59例(92.2%)经病理证实,5例为难免流产。根据超声声像图特征将59例CSP分为2型:孕囊型(41例)和混合回声型(18例)。孕囊型分为3个亚型:I型妊娠囊边缘位于切口处(24例),Ⅱ型妊娠囊陷入切口内(15例),Ⅲ型妊娠囊向膀胱方向凸出(2例)。I型治疗以宫腔镜为主,Ⅱ型、Ⅲ型及混合回声型治疗以腹腔镜为主。结论经阴道彩色多普勒超声为诊断CSP的有效方法,正确的超声分型及对切口瘢痕厚度的准确测量有助于临床医生选择更加适合患者的个体化治疗方案。     

疤痕子宫妊娠合并胎盘植入1例报告

疤痕子宫妊娠时,孕囊着床于切口周围易合并胎盘植入,多普勒超声有较好的临床诊断价值,可根据植入面积及深度、出血量等情况行保守治疗或根治性手术,但应避免大出血,尽量保留生育功能。本文报道1例疤痕子宫妊娠合并胎盘植入,并结合文献复习,探讨其诊治方法。     

Combined pelvic sonography and serum beta hCG, versus laparoscopy for the diagnosis of stable patient suspected of ectopic pregnancy

The role of sonography in stable patients suspected of ectopic pregnancy is to establish the diagnosis using positive, suggestive or negative signs. Establishing whether or not intrauterine gestation is present is crucial, as is the detection of any extrauterine abnormality. Sonography may be normal in ectopic pregnancy or when it is not abnormal findings are frequently nonspecific. Therefore, the sonographic results must be correlated and integrated with the clinical history and findings as well as with other diagnostic procedures. The combination of ultrasound scanning with beta hCG was found highly contributory to the determination of the existence of an ectopic pregnancy. Understanding the objectives and limitations of each diagnostic test involved is essential for logical and optimal sequences of diagnostic procedures to be employed in patient management. During a twenty-month period, 138 patients were examined due to clinical suspicion of "sub-acute" ectopic pregnancy. Sixty-one patients were managed according to a non-invasive protocol composed of: a) ultrasound scanning alone and b) ultrasound scanning combined with serum beta subunit hCG. Ultrasonograms for ectopic pregnancy diagnosis were coded: positive (fluid in cul-de-sac or extrauterine sac); suggestive empty uterus, adnexal mass and pseudo-gestational sac) and negative (intrauterine gestational sac and normal pelvis). Surgical procedure was carried out immediately on nine patients with positive signs; all of them had ectopics. Suggestive signs were found in twenty-two patients. beta subunit hCG was determined prior to interventive procedure; ectopic pregnancy was revealed in eighteen of them. Among thirty patients with negative signs, only two patients (7% of this sub-group or 3.5% of the general group) had ectopics.(ABSTRACT TRUNCATED AT 250 WORDS)     

Conservative Management of Retroperitoneal Ectopic Pregnancy by Computed Tomographic–guided Methotrexate Injection in the Gestational Sac: 2 Case Reports and Literature Review

Retroperitoneal ectopic pregnancy (REP) is an extremely rare type of ectopic pregnancy. Currently, surgery is the most widely used treatment method although it involves a high likelihood of intraoperative hemorrhage. In this case report, we describe a safe and effective alternative method for managing epigastric REP. We conducted a retrospective analysis of the clinical data of 2 patients with REP in the epigastrium who were treated at our hospital using our nonsurgical method. The treatment involved conservative management by computed tomographic–guided methotrexate injection in the gestational sac. We also present a literature review of 26 case reports and discuss the clinical features and various methods for treating REP. Our experience with the successful treatment of 2 patients suggests that the novel approach of computed tomographic–guided methotrexate injection in the gestational sac may be a safe and effective approach to manage REP. Further studies are warranted to confirm our findings.