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。

Analysis of Pregnancy Outcome of Moderate and Severe Intrauterine Adhesions after Transcervical Resection of Intrauterine Adhesions

Objective：To investigate the pregnancy outcomes and its related influencing factors of moderate and severe intrauterine adhesions after transcervical resection of intrauterine adhesions(TCRA). Methods: One hundred and forty-five patients with moderate-to-severe IUA (IUA score ≥5) with fertility dysfunction who were diagnosed at the Beijing Obstetrics and Gynecology Hospital of Capital Medical University from January 2014 to December 2016 were selected. The pregnancy outcome after TCRA was followed-up and the factors that may affect pregnancy were analyzed. Results: ①Among 145 patients with moderate to severe IUA, the pregnancy rate after TCRA was 46.9% (68/145), the natural conception rate was 54.4% (37/68), and artificial assisted conception rate was 45.6%(31/68); The pregnancy rate of secondary infertility was 45.8%(33/72), that of the adverse pregnancy history and the primary infertility was 48.3%(28/58), 46.7%(7/15) respectively. The postoperative pregnancy rate in patients with moderate IUA and severe IUA were 64.9% (48/74) and 28.2% (20/71), respectively. The pregnancy rate of patients with pregnancy-related curettage ≥ 3 times was 36.6%(34/93), while the others was 65.4% (34/52). The pregnancy rates of patients with normal menstruation, menstruation reduction and amenorrhea preoperatively were 73.1%（19/26）, 48.8% (40/82) and 24.3%(9/37), respectively. The pregnancy rate of of patients with normal menstruation, menstruation reduction postoperatively was 54.6% (59/108) and 28.6% (8/28) respectively. Among 28 patients with re-adhesion, only two patients with mild adhesions were pregnant (7.1%, 2/28). 41.2% (28/68) of pregnancies had abortion or spontaneous abortion before 12 weeks of gestation and 58.8% (40/68) were reached to live births, with the mean gestational age of 38±1 weeks (32 to 41 weeks), and mean body weight of 3 467± 461 g (1 800 to 4 400 g). For obstetric complications, there were 2 cases of placenta previa, 6 cases of postpartum hemorrhage, and 2 cases of blood transfusion. No uterine rupture occurred. ②Multivariate logistic regression was performed by stepwise regression.Only pregnancy-related curettage, preoperative adhesion, and postoperative re-adhesion were found to be independent predictors of postoperative pregnancy outcomes (P＜0.05). Conclusions: Even after TCRA surgery to restore uterine cavity morphology, the pregnancy rate of moderate to severe IUA is still low, especially the patients with recurrence of IUA. So pay attention to the protection of residual endometrium during surgery, and take effective measures to promote endometrium regeneration and prevention of re-adhesion after surgery are the key to treatment.