子宫肌壁间妊娠误诊分析及文献复习

Misdiagnosis Analysis of Intramural Pregnancy and Literature Review

目的探讨子宫肌壁间妊娠(intramural pregnancy, IMP)的发病原因、临床特点、诊治方法及误诊原因、防范措施。方法对曾误诊的IMP 10例的临床资料进行回顾性分析。结果本组9例有停经史,另1例无明确停经史。阴道不规则少量出血2例,阴道大量出血2例。有轻微下腹痛4例;严重腹痛以急腹症就诊5例;无腹痛1例。早期误诊为宫角妊娠3例,子宫瘢痕妊娠破裂2例,妊娠合并阑尾炎穿孔1例,妊娠滋养细胞疾病(GTD)1例,变性子宫肌瘤1例;可疑肌壁间妊娠2例。误诊时间40 d^3个月,平均62.8 d。采用开腹手术确诊治疗6例,腹腔镜手术确诊治疗2例,宫腔镜联合腹腔镜手术确诊治疗1例,MRI检查确诊药物保守治疗1例。10例治疗后均随访1~4个月,血人绒毛膜促性腺激素(HCG)皆下降至正常。结论临床上应结合病史、血HCG及影像学检查等对IMP进行诊断。临床遇及类似本文患者时不能盲目诊治,必要时可通过开腹手术或腹腔镜手术病理检查明确诊断治疗。

Objective To explore the pathogenesis, clinical characteristics, diagnosis and treatment measures, causes of misdiagnosis and preventive measures of intramural pregnancy(IMP). Methods The clinical data of 10 patients with IMP misdiagnosed were retrospectively analyzed. Results Nine patients in this group had a history of menopause, and one patient had no clear history of menopause. There were 2 cases of irregular vaginal bleeding, 2 cases of massive vaginal bleeding, and 4 cases of mild lower abdominal pain. Five cases of severe abdominal pain were treated as acute abdomen and 1 had no abdominal pain. Early misdiagnosis was made as 3 cases of uterine horn pregnancy, 2 cases of uterine scar pregnancy rupture, 1 case of pregnancy with appendicitis perforation, 1 case of gestational trophoblastic disease(GTD), 1 case of degenerative uterine fibroids, and 2 cases of suspected IMP. The duration of misdiagnosis was 40 d to 3 months, with an average of 62.8 d. Six patients underwent laparotomic surgery, 2 patients underwent laparoscopic surgery, 1 patient underwent hysteroscopic surgery combined with laparoscopic surgery, and 1 patient underwent conservative treatment with MRI. The blood human chorionic gonadotropin(HCG) of the all 10 patients was decreased to normal after follow-up for 1 to 4 months. Conclusion Correct diagnosis of IMP should be made in accordance with patients’ medical history, HCG monitoring and imaging examination. In case of similar patients in clinical practice, blind diagnosis and treatment is not recommended. The diagnosis and treatment can be confirmed by laparotomy or laparoscopy and postoperative pathological examination when necessary.