辅助生殖技术治疗后宫内外复合妊娠的诊治及妊娠结局分析

Diagnosis&treatment of heterotopic pregnancy after assisted reproduction and analysis of pregnancy outcome

目的分析辅助生殖技术(ART)治疗后宫内外复合妊娠患者的诊治现状及妊娠结局,以期提高对该疾病的诊疗水平。方法收集2011年1月至2021年8月于兰州大学第一医院生殖医学中心收治的35例ART治疗后宫内外复合妊娠患者的临床资料,分析患者的不孕病史、助孕方式、移植胚胎数、超声下异位妊娠部位、治疗方式及妊娠结局等。结果35例患者中,不同程度输卵管盆腔因素导致不孕32例(91.42%),梗阻性无精子症导致不孕3例(8.58%);新鲜周期IVF助孕12例(34.29%)、ICSI助孕5例(14.29%),解冻周期IVF助孕13例(37.14%)、ICSI助孕5例(14.29%);20例移植卵裂胚2枚(57.14%),9例移植卵裂胚3枚(25.71%),3例移植囊胚2枚(8.58%),3例移植囊胚3枚(8.58%)。35例患者中,7例(20.00%)无明显症状,9例(25.71%)表现阴道流血,10例(28.57%)出现下腹痛或腹胀,8例(22.86%)出现阴道流血伴下腹痛或腹胀,1例(2.86%)出血伴休克。35例患者均通过经阴道超声初步诊断,表现为附件区包块30例(85.71%),宫角妊娠5例(14.29%)。35例患者中宫内妊娠合并输卵管壶腹部妊娠19例(54.29%)、合并输卵管间质部妊娠8例(22.86%)、合并宫角妊娠5例(14.29%)、合并卵巢妊娠2例(5.71%)、合并输卵管峡部妊娠1例(2.86%)。28例于腹腔镜下行患侧输卵管或卵巢切除术,术后17例(60.71%)宫内妊娠存活,随访妊娠结局为早产4例、足月活产12例、继续妊娠1例;11例终止妊娠(均流产)。5例宫角妊娠患者,4例于腹腔镜下行患侧部分宫角切除术,术后1例宫内妊娠存活,随访妊娠结局为足月活产;3例终止妊娠(均流产);1例宫角妊娠因患者要求终止妊娠行人工流产钳刮术。2例(5.71%)患者选择保守治疗,其中宫内双胎妊娠早产1例,流产1例。本中心35例宫内外复合妊娠治疗后宫内妊娠总存活率为54.29%(19/35)。随访足月及早产婴儿健康状况良好,未发现胎儿畸形。结论对于既往因输卵管因素行ART助孕的患者,应强调重复阴道超声检查的必要性,不论有无腹痛、阴道出血、腹泻、肛门坠胀等症状,临床医生都应在首次阴道超声检查时警惕发生异位妊娠的可能性,做到早诊断、早治疗。

Objective:To analyze the status of diagnosis&treatment and pregnancy outcome of heterotopic pregnancy after assisted reproductive technology(ART).Methods:The clinical data of 35 patients with heterotopic pregnancy after ART treatment in the reproductive medicine center of the First Hospital of Lanzhou University from January 2011 to August 2021 were collected,and infertility history,mode of ART,number of embryos transferred,site of ectopic pregnancy under ultrasound,treatment method and pregnancy outcome were retrospectively analyzed.Results:Of the 35 patients,32(91.42%)were infertile due to various degrees of tubo-pelvic factors and 3(8.58%)due to obstructive azoospermia.Among them,12 patients(34.29%)assisted by IVF in fresh cycle,5 patients(14.29%)assisted by ICSI,13 patients(37.14%)assisted by IVF in frozen-thawed cycle,5 patients(14.29%)assisted by ICSI.Two cleaved embryos were transplanted in 20 patients(57.14%),three cleaved embryos in 9 patients(25.71%),two blastocysts in 3 patients(8.58%),and three blastocysts in 3 patients(8.58%).In 35 patients,7(20.00%)had no obvious symptoms,9(25.71%)presented with vaginal bleeding,10(28.57%)presented with lower abdominal pain or distention,8(22.86%)presented with vaginal bleeding with lower abdominal pain or distention,and 1 patient(2.86%)had bleeding with shock.All 35 patients were initially diagnosed by transvaginal ultrasound,and presented with 30(85.71%)adnexal masses and 5(14.29%)angular pregnancies.Among the 35 patients,19(54.29%)were intrauterine pregnancy combined with tubal ampullary pregnancy,8(22.86%)with tubal interstitial pregnancy,5(14.29%)with uterine horn pregnancy,2(5.71%)with ovarian pregnancy,and 1(2.86%)with tubal isthmus pregnancy.Twenty-eight patients underwent laparoscopic salpingectomy or oophorectomy on the affected side.Seventeen patients(60.71%)survived intrauterine pregnancy after surgery.The follow-up pregnancy outcomes were premature delivery in 4 patients,full-term live birth in 12 patients,and continued pregnancy in 1 patient,and pregnancy was terminated in 11 patients(all aborted).Of the 5 patients with horn pregnancy,4 patients were treated by laparoscopic partial hysterectomy on the affected side and 1 intrauterine pregnancy survived after operation with a full-term live birth at follow-up.Pregnancy was terminated in 3 patients(all abortions).One patient with horn pregnancy was terminated by abortion curettage at the request of patient.In 35 patients,two patients(5.71%)chose conservative treatment,including one premature delivery of intrauterine twin pregnancy and one miscarriage.The overall survival rate of intrauterine pregnancy after treatment was 54.29%(19/35)in 35 patients with heterotopic pregnancy at our center.Follow-up showed that full-term and preterm infants were in good health and no fetal malformations were found.Conclusions:The necessity of repeated vaginal ultrasound should be strengthened in patients with a previous history of ART for fallopian tubal disease.Clinicians should be alert to the possibility of heterotopic pregnancy at the time of the first vaginal ultrasound,regardless of the presence or absence of abdominal pain,vaginal bleeding,diarrhoea or anal distension,to enable early diagnosis and treatment.