非妊娠期肝硬化女性子宫异常出血临床特征及宫腔镜电切术疗效评价

Clinical characteristics and the therapeutic effect evaluation of hysteroscopic electric resection of abnormal uterine bleeding in non-pregnant women with liver cirrhosis

目的观察非妊娠期肝硬化女性子宫异常出血的临床特征以及探讨宫腔镜电切术的疗效。方法回顾性分析首都医科大学附属北京地坛医院妇产科2014年2月11日至2020年12月20日收治的152例子宫异常出血的非妊娠期患者,均行宫腔镜电切术。根据患者病史、症状、乙型肝炎病毒病原学、肝功能、凝血功能及超声诊断结果,将入组患者分为肝硬化组(22例)、慢性乙型肝炎组(67例)和对照组(63例)。分析3组患者的一般临床资料包括术前出血时长、术前出血量、住院时长、止血时长、输血以及急性出血患者比例、实验室检查结果[纤维蛋白原(FIB)、凝血酶原时间(PT)、凝血酶时间(TT)、活化的部分凝血活酶时间(APTT)、血红蛋白(Hb)、血小板(PLT)],病理以及治疗总有效率。术前出血时长、术前出血量、住院时长、止血时长和实验室检查等计量资料两组间比较采用t检验或Mann-Whitney检验,多组间比较采用方差分析或KW检验;输血以及急性出血患者比例和病理以及治疗总有效率等计数资料采用Pearson卡方检验、连续校正卡方检验或Fisher’s确切概率法检验。结果肝硬化组、慢性乙型肝炎组和对照组患者术前出血时长、术前出血量、住院时长、止血时长、输血患者比例以及急性出血患者比例差异有统计学意义(F=9.34、P<0.001,F=7.54、P<0.001,F=7.64、P=0.01,F=5.67、P=0.02,χ^(2)=8.64、P=0.01,χ^(2)=5.75、P=0.02);且肝硬化组患者上述指标显著高于慢性乙型肝炎组(t=6.01、P=0.02,t=7.44、P=0.01,t=5.90、P=0.02,t=11.23、P<0.001,χ^(2)=10.45、P<0.001,χ^(2)=11.32、P<0.001)。肝硬化组、慢性乙型肝炎组和对照组患者凝血功能指标(FIB、PT、TT、APTT、Hb和PLT)差异均有统计学意义(F=11.36、P<0.001,F=8.35、P<0.001,F=8.33、P=0.01,F=15.64、P<0.001,F=7.34、P=0.01,F=10.36、P<0.001)。肝硬化组(13.64%和9.09%)、慢性乙型肝炎组(2.99%和1.49%)和对照组(3.17%和0.00%)患者子宫内膜非典型增生和子宫内膜癌的发生率差异均有统计学意义(χ^(2)=4.97、P=0.02,χ^(2)=8.61、P=0.01)。三组患者宫腔镜电切术治疗后的总有效率(90.48%、89.55%和90.91%)差异无统计学意义(χ^(2)=1.21、P=0.32);肝硬化组、慢性乙型肝炎组和对照组患者治疗后子宫异常出血的复发率(22.72%、20.89%和7.94%)差异有统计学意义(χ^(2)=7.45、P=0.01)。3组患者进行宫腔镜电切术术中和术后均未出现并发症。结论肝硬化可加重非妊娠期子宫异常出血的症状,宫腔镜电切术治疗非妊娠期肝硬化女性子宫异常出血安全有效,但存在一定复发风险。

Objective To investigate the clinical features of abnormal uterine bleeding of non-pregnancy women with liver cirrhosis and analyze the therapeutic effect of hysteroscopy.Method Data of 152 non-pregnant patients with abnormal uterine bleeding treated in the Department of Obstetrics and Gynecology of Beijing Ditan Hospital,Capital Medical University from February 11st,2014 to December 20th,2020 were analyzed,retrospectively.The 152 patients were divided into cirrhosis group(22 cases),chronic hepatitis B group(67 cases)and control group(63 cases)according to the patients’medical history,symptoms,etiological examination of hepatitis B virus,liver function,coagulation function and ultrasonic diagnosis results.The general clinical data of the three groups(length of preoperative bleeding,preoperative bleeding volume,hospitalization duration,hemostasis duration,ratio of cases with blood transfusion and acute bleeding),laboratory examination results[fibrinogen(FIB),prothrombin time(PT),thrombin time(TT),activated partial thromboplastin time(APTT),hemoglobin(Hb)and platelets(PLT)],pathology analysis and treatment effective of the three groups were analyzed,respectively.Comparison of every two groups for length of preoperative bleeding,preoperative bleeding volume,hospitalization duration,hemostasis duration and results of laboratory test were performed by t-test or Mann-Whitney test,and comparison between multiple groups for the above indexes were performed by analysis of ANOVA or KW test;the ratio of patients with acute bleeding and total treatment efficiency were calculated by Pearson Chi-square test,continuous correction Chi-square test or Fisher’s exact probability test.Results The length of preoperative bleeding,hospitalization duration,hemostasis duration,ratio of cases with blood transfusion and acute bleeding of cirrhosis group,chronic hepatitis B group and control group were significantly different(F=9.34,P<0.001;F=7.54,P<0.001;F=7.64,P=0.01;F=5.67,P=0.02;χ^(2)=8.64,P=0.01;χ^(2)=5.75,P=0.02),and the above indicators of patients in cirrhosis group were significantly higher than those of chronic hepatitis B group(t=6.01,P=0.02;t=7.44,P=0.01;t=5.90,P=0.02;t=11.23,P<0.001;χ^(2)=10.45、P<0.001;χ^(2)=11.32,P<0.001).The levels of FIB,PT,TT,APTT,Hb and PLT of patients in cirrhosis group,chronic hepatitis B group and control group were significantly different(F=11.36,P<0.001;F=8.35,P<0.001;F=8.33,P=0.01;F=15.64,P<0.001;F=7.34,P=0.01;F=10.36,P<0.001).The incidence of endometrial atypical hyperplasia and endometrial cancer of patients in cirrhosis group(13.64%and 9.09%),chronic hepatitis B group(2.99%and 1.49%)and control group(3.17%and 0.00%)were significantly different(χ^(2)=4.97,P=0.02;χ^(2)=8.61,P=0.01).Total efficiency of the three groups were 90.48%,89.55%and 90.91%,with no significant difference(χ^(2)=1.21,P=0.32);the recurrence rate of abnormal uterine bleeding were 22.72%,20.89%and 7.94%of patients in cirrhosis group,chronic hepatitis B and control group,with significant difference(χ^(2)=7.45,P=0.01).There were no complications during or after hysteroscopic hysterotomy among the patients of the three group.Conclusions Liver cirrhosis could aggravate the symptoms of abnormal uterine bleeding during non-pregnancy.Hysteroscopic electrosurgical treatment of abnormal uterine bleeding for women with non-pregnancy cirrhosis is safe and effective,but with a certain risk of recurrence.