剖宫产后子宫瘢痕憩室形成因素的研究进展

剖宫产后子宫瘢痕憩室(cesarean scar diverticula,CSD)是继发于剖宫产的一种妇科疾病,指剖宫产术后子宫切口肌层愈合不良,在子宫峡部出现突向浆膜层,并与宫腔相通的一个囊状缺陷,导致异常子宫出血、慢性盆腔痛、瘢痕妊娠、胎盘植入,甚至再次妊娠子宫破裂等严重并发症.目前CSD形成因素尚未完全阐明,可能...     

剖宫产子宫切口憩室的诊疗进展

近年来剖宫产率持续上升,在我国高达50％,剖宫产子宫切口憩室的发病率亦显著增加.临床表现为经期延长、阴道淋漓流血、不孕,再次妊娠时还可能引起子宫破裂,给患者带了巨大的痛苦.目前对于剖宫产切口憩室的治疗还没有丰富的经验,可采用激素保守治疗,但对药物难以缓解的患者最终需采用外科治疗来改善憩室局部液体的流通,甚至切除病灶.     

剖宫产子宫瘢痕憩室诊断和治疗进展

<正>近年来我国较高的剖宫产率导致了很多近远期手术相关问题,这些问题对子宫的影响乃至再次妊娠都带来一定危害,其中剖宫产子宫瘢痕憩室的形成就是我们必须面对的一个重要问题。剖宫产子宫瘢痕憩室又称剖宫产术后子宫瘢痕缺损(previous cesarean scar defect,PCSD),是指子宫下段剖宫产术后的子宫切口处形成一个与宫腔相通的憩室,由于憩室下端瘢痕的活瓣作用阻碍了经血的引流,从而出现一系列临床相关症状[1]。关于     

剖宫产瘢痕憩室对再次妊娠的影响及手术时机选择

为了探究剖宫产瘢痕憩室对再次妊娠的影响及再次妊娠的时机,文章从未经手术治疗的瘢痕憩室及经手术治疗后的瘢痕憩室两个方面,通过瘢痕愈合时间、子宫下段肌层厚度、母婴结局等方面讨论再次妊娠及手术的时机。综合大量文献得出瘢痕憩室对再次妊娠的影响有：继发不孕、瘢痕憩室妊娠、胎盘植入、子宫破裂。未经手术治疗的患者再次妊娠时机取决于临床表现及子宫下段厚度。经手术治疗后的患者再次妊娠时机与手术器械、手术方式密切相关。     

剖宫产瘢痕憩室经阴道手术治疗

近年来,随着剖宫产率的不断升高,剖宫产的远期并发症--剖宫产瘢痕憩室的发生率也逐渐上升。目前,关于剖宫产瘢痕憩室有药物治疗、宫腔镜手术、开腹或腹腔镜手术及经阴道手术治疗等多种治疗方式,其中经阴道手术具有手术简单、治疗彻底、创伤小等优点,被认为是值得推广的剖宫产瘢痕憩室的有效治疗方案。文章就采用经阴道手术治疗剖宫产瘢痕憩室的观点进行阐述。     

剖宫产瘢痕憩室的形成机制及诊断

剖宫产瘢痕憩室（CSD）是剖宫产术后的一个远期并发症。随着剖宫产率持续上升,CSD的发生率随之升高。部分患者因此出现异常子宫出血或剖宫产瘢痕妊娠,甚至发生大出血、孕期子宫破裂、凶险性前置胎盘等严重并发症危及母胎安全。CSD发病机制尚不明确,发生率也无确切数据。CSD的诊断目前国际上仍未形成统一定论。主要是根据病史,临床表现及辅助检查进行临床诊断。影像学检查以及宫腔镜检查已经成为临床上主要的诊断方法与确诊手段。     

剖宫产术后瘢痕子宫再次妊娠93例分娩方式探讨

目的:探讨剖宫产术后瘢痕子宫再次妊娠分娩方式的选择.方法:回顾性分析2007年1月1日至2011年10月31日我院收治的剖宫产术后瘢痕子宫再次足月妊娠93例的临床资料,分析瘢痕子宫足月分娩方式的选择.结果:93例孕妇中有38例行阴道试产,试产率为40.86％,试产成功率84.21％ (32/38),再次剖宫产率65.59％(61/93),子宫破裂发生率1.08％(1/93).阴道分娩组的产后24小时出血量及新生儿体重明显低于剖宫产组,差异有统计学意义(P＜0.05);两组孕妇在年龄、孕周、新生儿窒息发生率、产褥病率方面相比较,差异无统计学意义(P＞0.05).结论:对符合阴道分娩条件的剖宫产术后瘢痕子宫再次妊娠孕妇给予阴道试产机会是可行的.     

腔镜手术治疗剖宫产子宫瘢痕憩室的临床疗效分析

目的:分析两种手术方式治疗剖宫产子宫瘢痕憩室(PCSD)的疗效及预后影响因素.方法:收集57例PCSD患者,26例残余肌层厚度(RMT)≥3mm的患者采用宫腔镜PCSD电切"开渠"术(宫腔镜组),31例RMT<3 mm的患者采用宫腹腔镜联合PCSD修补术(腹腔镜组),随访术后症状恢复情况.结果:两组的术后月经期时间均较...     

瘢痕子宫再次妊娠致子宫破裂危险因素的临床研究

<正>子宫破裂系产科的急症,严重威胁母儿生命。随着近年剖宫产率的大幅提高,瘢痕子宫孕妇孕期及分娩期需面临子宫破裂的风险,其分娩方式的选择成为产科工作者棘手的问题。通过回顾分析我院2002年~2010年收治的32例子宫破裂患者的临床资料,探讨子宫破裂发生的危险因素、尤其是剖宫产后瘢痕子宫发生子宫破裂的危险因素,指导临床对子宫破裂的认识、诊断及积极防治,避免母儿的不良结局。1资料与方法1.1一般资料2002年至2010年在我院分娩的产妇中行剖宫产者35446例,其中瘢痕子宫4191例;经阴道分娩者     

剖宫产术后再次妊娠阴道试产与选择性重复剖宫产母婴安全性的Meta分析

目的:系统性分析剖宫产术后再次妊娠阴道试产(trial of labor after previous cesarean delivery,TOLAC)与选择性重复剖宫产(elective repeat cesarean delivery,ERCD)的母婴安全性。方法:检索Cochrane临床对照试验数据库(CENTRAL)、Medline、Embase、Ovid、万方数据库、中国知网(CNKI)等数据库。收集1989—2016年有关TOLAC和ERCD的临床研究文献,采用Rev Man 5.2软件对有关数据进行统计分析。结果:共纳入11篇文献,共计91 975例研究对象,其中试验组(TOLAC组)51 428例,对照组(ERCD组)40 547例。TOLAC组发生子宫破裂风险较ERCD组高,差异有统计学意义(RR=2.78,95%CI:1.24~6.22,P=0.01);TOLAC组子宫切除的风险比ERCD组低,差异有统计学意义(RR=0.57,95%CI:0.44~0.74,P0.000 1);而孕妇产褥感染风险(RR=1.10,95%CI:0.78~1.56,P=0.58)、孕妇输血风险(RR=1.09,95%CI:0.62~1.92,P=0.75)以及孕妇死亡风险(RR=0.71,95%CI:0.26~1.92,P=0.50),2组差异无统计学意义;新生儿窒息(RR=2.30,95%CI:1.74~3.03,P0.000 01)及围生儿死亡(RR=1.71,95%CI:1.29~2.25,P=0.000 1),TOLAC组均比ERCD组高,差异有统计学意义。结论:在临床上,为了降低剖宫产率,应该鼓励剖宫产术后再次妊娠者进行阴道试产。为了降低相关风险,产前需要进行充分评估,产时严格且规范监测,最大限度保证母婴安全,同时还要合理、科学地评估每次剖宫产的指征。     

剖宫产切口愈合不良的治疗方法

剖宫产切口愈合不良亦称剖宫产切口憩室（previous cesarean scar defect,PCSD）,是剖宫产术后远期并发症之一,可以引起经期延长、不孕、瘢痕妊娠等临床表现,发病率有增高趋势。常用的辅助检查为经阴道超声或盐水灌注宫腔声学造影。治疗方法以微创手术为主,包括宫腔镜、腹腔镜、阴式手术。宫腔镜是最微创的手术方式,通过电切憩室周边的瘢痕组织利于憩室内经血引流,同时电凝憩室内膜组织减少不规则出血,还可改善子宫内膜环境有利于妊娠,但因有电损伤及子宫穿孔等风险,适合于残余肌层大于2 mm的患者,术后妊娠者需要按照子宫破裂高危人群进行管理。而对于瘢痕憩室处子宫肌壁厚度＜2 mm的患者建议采用腹腔镜手术或经阴道手术,通过切除瘢痕憩室后再次缝合,可有效改善症状。     

剖宫产后子宫瘢痕憩室治疗方式的研究进展

子宫瘢痕憩室（cesarean scar diverticula,CSD）近年发病率增高,主要由剖宫产术后的子宫切口愈合不良引起,是剖宫产手术的主要远期并发症,可引起育龄期女性异常子宫出血、经期延长、慢性盆腔痛和不孕等。目前临床上CSD治疗方式众多,口服避孕药、左炔诺孕酮宫内节育器及中药等保守药物治疗可在一定程度上改善患者经期延长的症状,宫腔镜、腹腔镜、经阴道修复、宫腹腔镜联合和宫腔镜辅助经阴道修复等手术治疗是目前CSD的主要治疗方式,术后能改善患者症状,降低CSD合并继发性不孕及瘢痕妊娠的发生率,但目前仍缺乏统一的术式选择标准,手术方式的选择、手术治疗的效果也存在争议,有待进一步研究。综述了CSD治疗方式选择、具体手术方法、不同治疗方式之间的疗效区别等内容。     

剖宫产切口憩室及其相关临床问题

近年来剖宫产切口憩室(cesarean scar diverticulum,CSD)发病率逐渐增加,引起临床关注。CSD作为剖宫产术的一种远期并发症,临床上主要表现为经期延长、阴道出血淋漓不净,另可能引起下腹隐痛、不孕甚至发生再次妊娠晚期子宫破裂等。临床上诊断主要根据患者典型临床表现结合辅助检查,超声检查最为常用。磁共振成像(MRI)是最准确的辅助检查,宫腔镜下检查最为直观,另有子宫输卵管造影(HSG)等。目前治疗措施主要为激素保守治疗和手术治疗,手术包括经腹、经阴道手术、宫腔镜手术、腹腔镜术或联合手术。经腹手术已少用,宫腔镜治疗微创且直观,适用于MRI测量憩室距离子宫浆膜层2 mm者,憩室处子宫肌壁厚度2 mm者多采用腹腔镜或经阴道手术或联合手术。就目前临床上CSD及其具体相关临床问题进行综述。     

剖宫产后子宫瘢痕妊娠的研究现状

随着中国二胎政策的放开,越来越多的剖宫产妇女面临着子宫瘢痕妊娠风险。瘢痕妊娠发展到后期可能发生大出血、子宫破裂等严重并发症,故应在疾病早期发现及干预。早期瘢痕妊娠的症状是停经后的阴道出血及腹痛,结合人绒毛膜促性腺激素水平、超声表现、核磁共振成像或宫腔镜等方法可将其确诊并进一步分型。近年来,研究人员重点对瘢痕妊娠发病机制、高危因素及治疗方法进行了探索,复发性瘢痕妊娠的高危因素及诊治也是学者们关注的焦点。     

Are Women’s and Obstetricians,Views on Mode of Delivery Following a Previous Cesarean Section Really OCEANS Apart?

Purpose

Most women with one previous cesarean section (CS) are suitable for either a vaginal birth after CS (VBAC) or an elective repeat CS. Previously, nurse-led prenatal education and support groups have failed to have an impact on the mode of delivery, which women opted for after one CS. A novel one-stop obstetrician-led cesarean education and antenatal sessions (OCEANS) has been developed to inform and empower women in their decision-making following one previous CS. The objective of our study was to evaluate how OCEANS influences the mode of delivery for women who have previously had one CS.

Study Design

Two-hundred and sixty-six women who had a single previous lower segment CS were invited to attend OCEANS, which is a 1-h discussion group of women between 5 and 15 in number, facilitated by an experienced obstetrician. Data were collected prospectively on women who were invited to attend OCEANS over a 12-month period commencing on the 1st January 2012.

Results

188 (71 %) attended the group, while 20 (8 %) canceled their appointment and 58 (22 %) did not keep their appointment. Those who attended OCEANS were 38 % more likely to opt for a VBAC than those who did not attend. There was no difference in the rates of successful vaginal delivery between women who attended OCEANS and those who did not (56 vs. 61 %, p = 0.55).

Conclusions

While nurse-led prenatal education and support groups have no impact on mode of delivery after one CS, a dedicated obstetrician-led clinic increases the rate of those opting for VBAC by 38 %. Such clinics may be a useful tool helping in empowering women in their decision-making and reduce the rate of CSs.     

Risk of uterine rupture in labor induction of patients with prior cesarean section: an inner city hospital experience

OBJECTIVE: This study was undertaken to determine the risk of uterine rupture in patients induced with oxytocin or misoprostol after 1 or more previous cesarean sections. STUDY DESIGN: Patients with 1 or more previous cesarean sections who delivered after 28 weeks' gestation between 1996 and 2002 were identified by database. Among 3533 total patients, rates of uterine rupture were compared among 4 groups: oxytocin induction (n = 430), misoprostol induction (n = 142), spontaneous labor (n = 2523), and repeat cesarean section without labor (n = 438). Statistical analysis included chi(2) test, Fisher exact test, unpaired t test, and Mantel-Haenszel test. RESULTS: Rate of rupture was increased in all inductions compared with that of the spontaneous labor group. Among patients with 1 prior cesarean, rupture rates with misoprostol and oxytocin induction were 0.8% and 1.1%, respectively. CONCLUSION: Induction of labor with oxytocin or misoprostol is associated with a higher rate of uterine rupture compared with those who deliver after spontaneous labor. After 1 prior cesarean, rupture rate with misoprostol induction is not increased compared with oxytocin induction.     

Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture

Objective

To evaluate the best available evidence regarding the association between single-layer closure and uterine rupture.

Methods

The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched for relevant observational and experimental studies that included women with a previous single, low, transverse cesarean delivery who had attempted a trial of labor (TOL). The risks of uterine rupture and uterine dehiscence were assessed by pooled odds ratios (OR) calculated with a random effects model.

Results

Nine studies including 5810 women were reviewed. Overall, the risk of uterine rupture during TOL after a single-layer closure was not significantly different from that after a double-layer closure (OR 1.71; 95% confidence interval [CI] 0.66-4.44). However, a sensitivity analysis indicated that the risk of uterine rupture was increased after a locked single-layer closure (OR 4.96; 95% CI 2.58-9.52, P < 0.001) but not after an unlocked single-layer closure (OR 0.49; 95% CI 0.21-1.16), compared with a double-layer closure.

Conclusion

Locked but not unlocked single-layer closures were associated with a higher uterine rupture risk than double-layer closure in women attempting a TOL.