中重度宫腔粘连术后妊娠率及其影响因素分析

Analysis of pregnancy rate and its influencing factors after surgeries for moderate to severe intrauterine adhesions

目的探讨中重度宫腔粘连(intrauterine adhesions,IUA)患者行宫腔镜宫腔粘连分离术(transcervical resection of uterine adhesions,TCRA)后妊娠率及相关影响因素。方法选择2013年3月至2015年4月首都医科大学附属北京妇产医院有生育要求的中重度IUA患者(IUA评分≥5分)162例,随访术后妊娠情况,对可能影响妊娠率的因素进行分析。结果1TCRA术后平均随访(21.2±5.7)个月,患者术后月经改善率为82.1%(133/162);95.7%(155/162)的患者术后IUA评分较术前降低;术后妊娠率为43.2%(70/162),其中,中度(IUA评分5~8分)49.0%(53/108),重度(IUA评分9~12分)31.4%(17/54);活产率为58.5%(41/70),其中,中度为58.5%(31/53),重度为58.8%(10/17),41例活产中自然分娩12例,剖宫产29例(70.7%);其中3例胎盘残留、2例前置胎盘。2影响妊娠率的因素:残留内膜面积是影响术后妊娠率的独立因素(OR=0.141,95%CI:0.069~0.289;P<0.001);二探评分、粘连程度、术后月经量与妊娠率显著相关(P<0.05);年龄、妊娠相关刮宫次数、防粘连措施与妊娠率无关(P>0.05)。3妊娠时限:88.5%的妊娠患者均在术后1年内妊娠(62/70),累计妊娠率在术后18月后无增长。结论中重度IUA术后妊娠率较低,残留内膜面积是影响术后妊娠率的关键因素,TCRA术中应规范操作,强调对残留内膜的保护。

Objective To investigate the pregnancy rate and its influencing factors after transcervical resection of uterine adhesions （TCRA） in patients with moderate to severe intrauterine adhesions（IUA）. Methods 162 patients with moderate to severe intrauterine adhesions who underwent TCRA in Beijing Obstetrics and Gynecology Hospital affiliated of Capital Medical University from March 2013 to April 2015 were chosen, followed up pregnancy outcomes after the surgery. Then evaluated the possible factors influencing pregnancy rates. Results ①The average follow - up time after TCRA was （ 21.2 ± 5.7 ） months, 82. 1% （ 133/162 ）patients had an improvement in menstrual blood volume and 95.7% （155/162） of the patients had lower IUA scores postoperatively; The overall pregnancy rate was 43.2% （70/162）, with 49. 0% （53/108） and 31.4% （17/54） in those with moderate and severe adhesions respectively. The overall live birth rate was 58.5% （41/70）, 58.5% （31/53） in moderate cases while 58.8% （10/17） in severe cases; Of 41 cases of live birth ,29 patients （70. 7 % ） underwent cesarean section, placenta previa developed in two patients and three had placenta remnants. ② The factors affecting pregnancy rate ： Residual endometrial area was the independent factor influencing postoperative pregnancy rate （OR = 0. 141, 95% CI： 0.069 -0. 289; P 〈 0.001 ）; the degree of adhesions, IUA score and postoperative menstrual blood volume were statistically significant associated to pregnancy rate （ P 〈 0. 05 ）. ③ The time before pregnancy ： 88.5% （62/70） of patients achieved pregnancy within 1 year after surgery, the cumulative pregnancy rate after 18 months have barely increased. Conclusion The rate of pregnancy in moderate to severe IUA patients after surgeries is relatively low. Residual endometrial area is a keyfactor in postoperative pregnancy rate. We need to emphasize the standardization of TCRA surgery as well as the protection of residual endometrium.