体外受精-胚胎移植术后宫内妊娠合并输卵管妊娠临床分析

Clinical analysis of intrauterine pregnancy combined with tubal pregnancy after in vitro fertilization and embryo transfer

目的分析体外受精-胚胎移植(in vitro fertilization and embryo transfer,IVF-ET)术后宫内妊娠合并输卵管妊娠的诊治及妊娠结局,探讨高危因素及应对策略。方法回顾性分析2012年3月至2020年1月中国人民解放军第四军医大学第二附属医院收治行IVF-ET后宫内妊娠合并输卵管妊娠的120例患者的临床资料。结果120例患者均接受辅助生殖技术(assisted reproductive technology,ART)后妊娠,均行剖腹探查术治疗,年龄为(32.5±7.9)岁,体质量指数(body mass index,BMI)为(22.6±3.15)kg/m2。①宫内妊娠合并输卵管妊娠的诊断:于IVF-ET后(28.00±6.77)d经子宫附件B超或剖腹探查术中诊断。120例患者中23例(19.2%)无临床症状,25例(20.8%)仅有阴道出血,36例(30%)仅有下腹痛,36例(30%)有阴道出血合并下腹痛。120例患者中13例(10.8%)出现休克行输血治疗。患者的临床症状主要为阴道流血及下腹痛。宫内妊娠合并输卵管妊娠的部位以输卵管壶腹部70例(58.3%)及输卵管间质部40例(33.3%)常见。②宫内妊娠合并输卵管妊娠患者的治疗:120例患者均为B超提示附件区异位妊娠影像学表现或行后穹窿穿刺术后行剖腹探查术。③宫内妊娠合并输卵管妊娠患者的宫内妊娠结局:术后有17例患者宫内妊娠于孕早期流产,3例因孕中期胎儿畸形行引产术终止妊娠,术后宫内妊娠流产率为16.7%(20/120),4例早产,其余96例均足月活产,宫内胎儿存活100例,总活产率为83.3%(100/120);手术治疗后足月活产率为96%(96/100),活产分娩者中早产率为4%(4/100)。宫内妊娠合并输卵管妊娠患者中66.7%(80/120)既往有输卵管切除手术史、85%(102/120)患者既往有盆腔病变史。宫内妊娠合并输卵管妊娠患者术后活产率与既往输卵管病变、盆腔病变无关,与术前B超提示宫外包块大小相关。剖腹探查术后合并输卵管间质部妊娠患者均行剖宫产术终止妊娠,孕期及产时均无子宫破裂、子宫动静脉瘘发生。结论输卵管病变史及盆腔病变史是宫内妊娠合并输卵管妊娠的高危因素。宫内妊娠合并输卵管妊娠诊断主要依靠阴道超声诊断结合患者的临床症状,对于行IVF-ET ART助孕的患者,尤其是合并输卵管手术史的患者应早期筛查,一旦确诊行手术治疗可获得良好的妊娠结局。

Objective The diagnosis,treatment and pregnancy outcomes of intrauterine pregnancy combined with tubal pregnancy after in vitro fertilization and embryo transfer(IVF-ET)were analyzed to discuss high-risk factors and coping strategies.Methods The clinical data of 120 patients with intrauterine pregnancy combined with fallopian tube pregnancy after IVF-ET in Second Affiliated Hospital of Air Force Military Medical University from March 2012 to January 2020 were retrospectively analyzed.Results All 120 patients received pregnancy after assisted reproductive technology(ART),and all underwent laparotomy.Their age was(32.5±7.9)years old,and their body mass index(BMI)was(22.6±3.15)kg/m2.①Diagnosis of intrauterine pregnancy combined with fallopian tube pregnancy:after IVF-ET(28.00±6.77)d by intrauterine annex B ultrasound or laparotomy exploration.Among 120 patients,23 patients(19.2%)had no clinical symptoms,25 patients(20.8%)had only vaginal bleeding,36 patients(30%)had only lower abdominal pain,and 36 patients(30%)had vaginal bleeding combined lower abdominal pain.13 of 120 patients(10.8%)had shock and received blood transfusion.The clinical symptoms of the patient were mainly vaginal bleeding and lower abdominal pain.Intrauterine pregnancy combined with tubal pregnancy was common in 70 cases(58.3%)of the fallopian tube ampulla and 40 cases(33.3%)of the interstitial part of the fallopian tube.②Treatment of patients with intrauterine pregnancy combined with tubal pregnancy:120 patients were diagnosed with B-ultrasound for ectopic pregnancy imaging in the attachment area or undergoing laparotomy after posterior fornix puncture.③Intrauterine pregnancy combined with tubal pregnancy outcomes:There were17 cases of intrauterine pregnancy abortion in the first trimester of pregnancy,3 cases of abortion due to fetal malformation in the second trimester,pregnancy termination,intrauterine pregnancy abortion rate of 16.7%(20/120),4 cases of premature delivery,the remaining 96 cases were full-term live births,100 cases of intrauterine fetal survivors,the total live birth rate was 83.3%(100/120);the full-term live birth rate after surgery was 96%(96/100),among live births,the premature birth rate was 4%(4/100).Among patients with intrauterine pregnancy and tubal pregnancy,66.7%(80/120)had a history of salpingectomy and 85%(102/120)had a history of pelvic disease.The postoperative live birth rate of patients with intrauterine pregnancy combined with tubal pregnancy was not related to previous tubal lesions and pelvic lesions,and was related to the size of extrauterine masses indicated by Bultrasound before surgery.All patients with tubal interstitial pregnancy after laparotomy were terminated by cesarean section.No uterine rupture and uterine arteriovenous fistula occurred during pregnancy and delivery.Conclusion The history of tubal lesions and pelvic lesions are high-risk factors for intrauterine pregnancy combined with tubal pregnancy.The diagnosis of intrauterine pregnancy combined with fallopian tube pregnancy mainly relies on vaginal ultrasound diagnosis combined with the clinical symptoms of patients.For patients undergoing IVF-ET ART to assist pregnancy,especially patients with a history of combined fallopian tube surgery,early screening should be performed.Once confirmed,surgical treatment can be performed to get a good pregnancy outcome.