宫腔镜下子宫纵隔电切术术后两种预防宫腔粘连方法的临床探讨

Clinical study of two methods for prevention of intrauterine adhesions after hysteroscopic transcervical resection of septum

目的探讨宫腔镜下子宫纵隔电切术(TCRS)术后宫腔内放置Foley球囊或宫内节育环预防宫腔粘连的临床疗效。方法 56例行TCRS患者,随机分为A组(27例)和B组(29例)。A组患者TCRS术后予放置Foley球囊及人工周期治疗;B组患者TCRS术后予放置宫腔节育环及人工周期治疗。术后3个月后行宫腔镜检查术, B组并同时取出宫内节育环,术中评估宫腔粘连情况,记录两组患者异常子宫出血及腰酸背痛情况,并比较两组患者随访期间妊娠情况。结果所有患者术后3个月均返院行宫腔镜检查术, B组所有患者均顺利取出宫内节育环,未发生节育环嵌顿等,所有患者均无子宫纵隔残留、宫腔积血,子宫内膜修复可, 1例患者出现子宫内膜息肉,术中同时予行子宫内膜息肉切除术。A组术后轻度宫腔粘连发生率为11.1%(3/27), B组为13.8%(4/29),两组术后轻度宫腔粘连发生率比较差异无统计学意义(P>0.05)。A组患者TCRS术后出现1例异常子宫出血,而B组出现8例异常子宫出血,两组比较差异具有统计学意义(P<0.05);A组TCRS术后未出现腰酸腹痛患者,但B组TCRS术后5例患者出现腰酸腹痛,两组比较差异具有统计学意义(P<0.05)。56例患者术后共妊娠49例(包括异位妊娠2例),妊娠52次,其中自然流产12次,活产38次,异位妊娠2次。患者TCRS术后妊娠的自然流产率由术前的90.2%(55/61)降为术后的23.1%(12/52),活产率由术前的8.2%(5/61)升高为术后的73.1%(38/52),差异均有统计学意义(P<0.05)。随访22～34个月,两组术后至首次妊娠间隔时间、妊娠率、自然流产率及活产率比较差异无统计学意义(P>0.05)。结论 TCRS术后放置球囊或宫内节育环在预防宫腔粘连、改善妊娠结局的效果无明显差异,但Foley球囊有放置时间短、并发症少,取出方便等优势。

Objective To discuss the clinical efficacy of Foley balloon or IUD on prevention of intrauterine adhesions after hysteroscopic transcervical resection of septum(TCRS). Methods A total of 56 patients with TCRS were randomly divided into group A(27 cases) and group B(29 cases). Group A received balloon placement and artificial cycle therapy after TCRS, and group B received intrauterine device placement and artificial cycle therapy after TCRS. Hysteroscopy was performed 3 months after operation. In group B, intrauterine contraceptive device were removed at the same time to evaluate intrauterine adhesions. The abnormal uterine bleeding and backache of the two groups were recorded, and the pregnancy of the two groups during the followup period was compared. Results All patients returned to hospital for hysteroscopy 3 months after operation. All patients in group B successfully removed the intrauterine device without incarceration of intrauterine device. All patients had no remnants of septum or hemorrhage in uterus. Endometrial repair was acceptable. Endometrial polyps were found in 1 case, and endometrial polyps were resected during the operation. The incidence of mild intrauterine adhesions was 11.1%(3/27) in group A and 13.8%(4/29) in group B. The difference was not statistically significant(P>0.05). There was 1 case of abnormal uterine bleeding after TCRS in group A and 8 cases of abnormal uterine bleeding in group B. There was a significant difference between the two groups(P<0.05). There was no abdominal pain after TCRS in group A, but 5 patients in group B had abdominal pain after TCRS. There was a significant difference between the two groups(P<0.05). There were 49 pregnant cases(including 2 ectopic pregnant cases) and 52 pregnancies in 56 patients, including 12 spontaneous abortions, 38 live births and 2 ectopic pregnancies. The spontaneous abortion rate of pregnant women after TCRS decreased from 90.2%(55/61) to 23.1%(12/52) and the live birth rate increased from 8.2%(5/61) to 73.1%(38/52) after TCRS. The difference was statistically significant(P<0.05). Following up for 22 ~ 34 months, there was no significant difference in postoperative to first trimester interval, pregnancy rate, spontaneous abortion rate and live birth rate between the two groups(P>0.05). Conclusion There is no significant difference in the effect of placement of balloon or intrauterine device after TCRS in preventing intrauterine adhesions and improving pregnancy outcome, but Foley balloon has the advantages of short placement time, less complications, and easy removal.