發(fā)布時間：2018-05-28 07:26

  本文選題：復(fù)發(fā)性流產(chǎn) + 子宮解剖因素　； 參考：《山東大學(xué)》2017年碩士論文

【摘要】：背景和目的復(fù)發(fā)性流產(chǎn)(recurrent spontaneous abortion,RSA)的定義目前在國際上存在諸多爭議,現(xiàn)行較為常用的定義之一是:接連發(fā)生兩次及以上的流產(chǎn),與不同性伴侶發(fā)生的流產(chǎn)不計數(shù)在內(nèi),且胎兒丟失(體重≤500g)發(fā)生于妊娠20周之前,其中流產(chǎn)必須是經(jīng)過超聲學(xué)或組織學(xué)證實的宮內(nèi)妊娠(intrauterine pregnancy),生化妊娠(biochemical pregnancy)和輸卵管妊娠流產(chǎn)(fallopian pregnancy abortion)不列入計算。由于RSA的診斷標(biāo)準(zhǔn)在不同國家和地區(qū)存在.較大差異,也給其流行病學(xué)調(diào)查工作帶來了困難;目前國際上較為公認(rèn)的結(jié)果是:在全體婦女中,RSA的發(fā)生比率大致為5%,其中存在三次及以上流產(chǎn)史患者的比率在1%左右。關(guān)于RSA的定義,各國不盡相同。美國生殖醫(yī)學(xué)學(xué)會(American Society for Reproductive Medicine)的標(biāo)準(zhǔn)是2次或2次以上妊娠失敗;2016年我國中華醫(yī)學(xué)會婦產(chǎn)科分會產(chǎn)科學(xué)組(Department of Obstetrics and gynecology of Chinese Medical Association)通過討論決定將RSA的診斷標(biāo)準(zhǔn)定為發(fā)生三次及以上的流產(chǎn),其中流產(chǎn)是指在妊娠28周之前的胎兒丟失。近年來,國內(nèi)外眾多學(xué)者對連續(xù)發(fā)生兩次流產(chǎn)的人群進(jìn)行宮腔鏡檢查后即可查見多種類型的宮腔異常;同時結(jié)合國內(nèi)外關(guān)于RSA的定義及流行病學(xué)研究情況,本研究設(shè)定的RSA的篩查標(biāo)準(zhǔn)為:與同一個性伴侶連續(xù)發(fā)生的兩次及以上妊娠20周以內(nèi)的自然流產(chǎn)。RSA的病因復(fù)雜多樣,除遺傳、免疫、感染及內(nèi)分泌等因素外,子宮作為提供胚胎和胎兒生存發(fā)育環(huán)境的場所,子宮的結(jié)構(gòu)與功能正常與否對于妊娠的結(jié)局意義尤為重大。據(jù)流行病學(xué)資料統(tǒng)計,子宮因素占復(fù)發(fā)性流產(chǎn)因素中的比例為16.4%,并隨不良孕產(chǎn)發(fā)病率地增加,子宮因素所占比例也逐漸增加。本研究所采用的方法為回顧性病例對照分析,設(shè)定存在RSA的女性為病例組,共488例。統(tǒng)計其經(jīng)宮腔鏡檢查后明確診斷的子宮解剖異常的類型與數(shù)量;設(shè)定同時期對照組,統(tǒng)計分析兩組患者的宮腔異常情況,觀察是否存在統(tǒng)計學(xué)差異,探索研究子宮解剖結(jié)構(gòu)異常與復(fù)發(fā)性流產(chǎn)的關(guān)系。研究方法本項研究隨機(jī)選擇488例于2011年1月至2015年6月期間至山東大學(xué)附屬生殖醫(yī)院就診的RSA患者,將其設(shè)定為病例組。病例組納入標(biāo)準(zhǔn):連續(xù)發(fā)生2次或2次以上的流產(chǎn),以上流產(chǎn)必須與同一性伴侶發(fā)生,且胎兒丟失(體重≤500g)發(fā)生于妊娠20周之前,生化妊娠和輸卵管妊娠流產(chǎn)均不計入本研究范圍,只有經(jīng)過超聲學(xué)或組織學(xué)證實的宮內(nèi)妊娠才被認(rèn)定為流產(chǎn)。通過查詢電子病歷系統(tǒng)及相關(guān)紙質(zhì)文檔,調(diào)閱病例組患者的詳細(xì)病史及各相關(guān)輔助檢查結(jié)果(包括經(jīng)過宮腔鏡檢查所明確診斷的宮腔情況)。本研究將病例組分為兩組,分類標(biāo)準(zhǔn)為患者病史中所述流產(chǎn)次數(shù),發(fā)生2次流產(chǎn)的患者被設(shè)定為A組;而若病史中所記述的流產(chǎn)次數(shù)為3次或3次以上,則被設(shè)定為B組。同時選取同期于我院因男性因素或輸卵管因素就診的無復(fù)發(fā)性流產(chǎn)病史(包括自然流產(chǎn)、胚胎停育及生化妊娠)的508例低風(fēng)險人群,將其設(shè)定為對照組。統(tǒng)計收集對照組人群的病史、宮腔鏡檢查結(jié)果及其他相關(guān)檢查結(jié)果。對照組排除標(biāo)準(zhǔn):夫妻雙方明確的染色體異常;全身代謝異常相關(guān)疾病,包括糖尿病、甲狀腺功能異常、多囊卵巢綜合征(polycystic ovary syndrome,PC0S)等;抗磷脂抗體綜合征(antiphospholipid syndrome,APS)、系統(tǒng)性紅斑狼瘡(systemic lupus erythematosus,SLE)等自身免疫性疾病。病例組及對照組患者的病史及各項輔助檢查結(jié)果被收集整理后列表整理,包括夫妻雙方染色體結(jié)果、甲狀腺功能、自身抗體、TORCH(Toxoplasma,others,Rubella.Virus,Cytomegalo.Virus,Herpes.Virus)、女性激素六項等。本研究中所有行宮腔鏡檢查術(shù)的患者均在排除相關(guān)禁忌癥后于月經(jīng)干凈后3-7天內(nèi)進(jìn)行;宮腔鏡檢查術(shù)過程中記錄先天性宮腔異常(congenital anomalies),包括完全性縱隔子宮/部分性縱隔子宮(uterine septum/subseptate uterus)、弓狀子宮(arcuate uterus)、單角子宮(uterus unicornis)等;獲得性宮腔異常(acquired anomalies),包括宮腔粘連(intrauterine adhesions)、子宮內(nèi)膜息肉(endometrial polyp)、黏膜下子宮肌瘤(submucous myoma)等。檢查中所取得的相關(guān)病理標(biāo)本均進(jìn)行常規(guī)病理檢查,如有必要,部分患者擇期住院行矯正手術(shù)治療。在本研究中,病例組及對照組中均存在某一患者同時合并多種宮腔異常的情況(詳見附表注釋),由于各項宮腔異常的發(fā)生之間并無明顯關(guān)聯(lián)及相互作用,結(jié)合本研究的目的及統(tǒng)計學(xué)原理,在尊重事實及臨床實際工作的基礎(chǔ)上采用如下方法計數(shù):以上同時存在多種異常的病例每一異常類型均計數(shù)一次。本研究所有統(tǒng)計分析均采用SPSS 20.0統(tǒng)計學(xué)軟件完成,在理論頻數(shù)足夠的情況下,采用卡方分析,若較少時則行校正卡方或Fisher確切概率法。設(shè)定P0.05為差異有統(tǒng)計學(xué)意義。分析病例組、對照組之間及病例組中A、B兩組之間宮腔異常發(fā)生率是否存在統(tǒng)計學(xué)差異。研究結(jié)果1.在488例復(fù)發(fā)性流產(chǎn)患者中,經(jīng)宮腔鏡檢查未發(fā)現(xiàn)明顯宮腔異常的有371例,占病例組總?cè)藬?shù)的76.02%;先天性異常38例,占7.87%;獲得性異常98例,占20.08%。在508例對照組人群中,有406例未見明顯宮腔異常,占對照組總?cè)藬?shù)的79.92%;先天性異常17例,占3.35%;獲得性異常96例,占18.90%。以對照組宮腔鏡檢查結(jié)果為例:對照組中有2名患者同時存在子宮內(nèi)膜息肉及子宮縱隔,3名合并子宮內(nèi)膜增生及子宮內(nèi)膜息肉,1名合并子宮內(nèi)膜息肉及單角子宮,1名合并子宮內(nèi)膜息肉及粘膜下肌瘤,1名合并宮腔粘連及弓形子宮,1名合并子宮內(nèi)膜炎及單角子宮,1名合并雙子宮及子宮內(nèi)膜息肉,1名合并子宮內(nèi)膜息肉及子宮內(nèi)膜炎。如前所述,如某患者同時存在兩種及以上宮腔異常,則每種宮腔異常均計數(shù)一次,由于使用該計數(shù)方法,所有宮腔異常的例數(shù)之和大于病例組總?cè)藬?shù),各項異常比例相加亦大于百分之百,但不會影響進(jìn)行相關(guān)統(tǒng)計學(xué)檢驗;為防止引起誤解,特此說明。兩組之間先天性異常發(fā)生地比率被認(rèn)定有統(tǒng)計學(xué)差異(P=0.005)。在各類獲得性宮腔異常中,病例組與對照組發(fā)生率最高的依次是宮腔粘連和子宮內(nèi)膜息肉,且兩組之間兩種異常均存在統(tǒng)計學(xué)差異(P0.001)。2.根據(jù)病史中流產(chǎn)次數(shù)將病例組分為A、B兩組,其中A組(2次流產(chǎn))患者中宮腔鏡檢查未見異常患者228例,占A組總?cè)藬?shù)的78.62%;先天性異常21例,占7.24%;獲得性異常52例,占17.93%;B組(3次或3次以上)患者中經(jīng)過宮腔鏡檢查未發(fā)現(xiàn)明顯宮腔異常的病例有143例,占B組總?cè)藬?shù)的72.22%;先天性異常17例,占8.59%;獲得性異常46例,占23.23%。A、B兩組中也存在類似對照組中一名患者合并兩種及以上宮腔異常的情況,相關(guān)結(jié)果說明同前。在A、B兩組中,正常宮腔、先天性宮腔異常及獲得性宮腔異常例數(shù)均未見統(tǒng)計學(xué)差異。研究結(jié)論1、先天性子宮解剖結(jié)構(gòu)異常(包括完全性縱隔子宮/部分性縱隔子宮等)與RSA之間存在明顯的統(tǒng)計學(xué)相關(guān)性;獲得性宮腔異常中,發(fā)生率最高的是宮腔粘連,該種類型的宮腔異常與復(fù)發(fā)性流產(chǎn)存在明顯的統(tǒng)計學(xué)關(guān)聯(lián)。2、宮腔鏡檢查在診斷宮腔異常方面具有獨特優(yōu)勢,且能進(jìn)行相應(yīng)矯正手術(shù)。連續(xù)2次流產(chǎn)后,再次計劃妊娠前,有必要進(jìn)行宮腔鏡檢查以發(fā)現(xiàn)異常,減少流產(chǎn)的發(fā)生,提高妊娠成功率。
[Abstract]:The definition of background and objective recurrent spontaneous abortion (RSA) is currently controversial in the world. One of the most commonly used definitions is that two and more abortions occur in succession, the abortion is not counted with the same sex partner, and the loss of fetus (weight < 500g) occurs before 20 weeks of pregnancy. Abortion must be intrauterine pregnancy (intrauterine pregnancy) confirmed by ultrasound or histology, biochemical pregnancy (biochemical pregnancy) and fallopian pregnancy abortion (fallopian pregnancy abortion) are not included in the calculation. Since the diagnostic criteria for RSA exist in different countries and regions. Major differences are also given to its epidemiological survey. It is difficult to do so; the internationally recognized result is that among all women, the incidence of RSA is approximately 5%, of which three and more abortion patients have a ratio of about 1%. The definition of RSA is not the same. The standard of the American Institute of reproductive medicine (American Society for Reproductive Medicine) is 2 or 2 times. In 2016, Department of Obstetrics and Gynecology of Chinese Medical Association, China's Chinese Medical Association of Chinese Medical Association, decided to determine the diagnostic criteria of RSA as three or more abortions, of which abortion was lost before 28 weeks of pregnancy. In recent years, many domestic and foreign countries A variety of uterine cavity abnormalities can be found after hysteroscopy for two consecutive abortions. At the same time, combined with the domestic and international definition of RSA and epidemiological studies, the screening criteria for RSA in this study are: spontaneous abortion within 20 weeks of pregnancy and more than 20 weeks of pregnancy with the same sexual partner. The cause of A is complex and varied. Besides heredity, immunity, infection and endocrinology, the uterus is the place to provide the survival and development environment of embryo and fetus. The structure and function of the uterus are of particular significance to the outcome of pregnancy. According to the epidemiological data, the proportion of uterine factors in recurrent abortion is 16.4%. The incidence of bad pregnancy increased and the proportion of uterine factors increased gradually. The method used in this study was a retrospective case control analysis, a case group of women with RSA was set as a case group. A total of 488 cases were diagnosed by hysteroscopy, and the types and numbers of abnormal uterine anatomic abnormalities diagnosed by hysteroscopy were statistically analyzed, and the same period control group was set, the statistical analysis was two. The abnormal uterine cavity situation in the group of patients, observed whether there is statistical difference, explore the relationship between abnormal uterine anatomy and recurrent abortion. This study randomly selected 488 cases of RSA patients who visited the affiliated reproductive Hospital of Shandong University from January 2011 to June 2015, and set it as a case group. Standard: 2 or more than 2 times of abortion, the above abortion must occur with the same sexual partner, and the fetal loss (weight < 500g) occurs before 20 weeks of pregnancy, biochemical pregnancy and tubal pregnancy abortion are not included in the scope of this study, only through ultrasound or histology confirmed intrauterine pregnancy can be identified as abortion. Through inquiries through inquiry. The electronic medical record system and related paper documents were used to read the detailed medical history of the case group and the results of the related auxiliary examination (including the uterine cavity clearly diagnosed by hysteroscopy). The case group was divided into two groups. The classification standard was the number of abortions in the patient's history, and the patients who had 2 abortions were set as group A; The number of miscarriages described in the medical history was 3 or more than 3 times, and it was set as group B. At the same time, 508 cases of low risk of recurrent abortion (including natural abortion, embryo arrest and biochemical pregnancy) in our hospital were selected as control group. History, hysteroscopy results and other related examination results. Control group exclusion criteria: chromosomal abnormalities of both husband and wife; systemic metabolic disorders related to diabetes, thyroid dysfunction, polycystic ovary syndrome (polycystic ovary syndrome, PC0S); anti phospholipid antibody syndrome (antiphospholipid syndrome, APS). The history of systemic lupus erythematosus (SLE) and other autoimmune diseases. The history of the case group and the control group were collected and collated, including the chromosomal results of both husband and wife, thyroid function, autoantibody, TORCH (Toxoplasma, others, Rubella.Virus, Cytomegalo.Virus, Herpes.Vir). Us), female hormone six. All patients undergoing hysteroscopy in this study were performed within 3-7 days after the exclusion of contraindications and after menstruation. During hysteroscopy, the congenital uterine cavity abnormalities (congenital anomalies), including the complete mediastinal uterus / partial mediastinal uterus (uterine septum/subseptate uterus), were recorded. Arcuate uterus (arcuate uterus), single horned uterus (uterus unicornis), acquired uterine cavity abnormalities (acquired anomalies), including intrauterine adhesion (intrauterine adhesions), endometrial polyps (endometrial polyp), submucosal hysteromyoma (submucous myoma), etc.. The pathological specimens obtained in the examination were all routine pathological examination, such as It is necessary for some patients to be hospitalized for corrective surgery. In this study, the case group and the control group have a case of a patient with a variety of uterine abnormalities (detailed in the annotation of the appendix). There is no obvious association and interaction between the occurrence of various uterine cavity abnormalities, and the purpose and statistical principle of this study are combined with the principle of statistics. On the basis of heavy facts and clinical practice, the following methods are counted as follows: all the abnormal cases are counted at the same time. All the statistical analysis of this study is completed by SPSS 20 statistics software. In the case of sufficient frequency of the theory, the chi square analysis is adopted, and the correction card or Fisher is performed if it is less. The exact probability method. The difference was statistically significant in setting the P0.05. Whether there was a statistical difference in the incidence of abnormal uterine cavity between A and B two groups between the control group and the case group. 1. in 488 cases of recurrent abortion, there were 371 cases of no obvious uterine cavity abnormalities by hysteroscopy, accounting for 76 of the total number of cases in the case group. 2%, 38 cases of congenital abnormalities, accounting for 7.87%, 98 cases of acquired abnormalities, accounting for 20.08%. in 508 cases of control group, 406 cases had no obvious uterine cavity abnormalities, accounting for 79.92% of the total number of the control group, 17 cases of congenital abnormalities, 3.35%, and 96 cases of acquired abnormalities, accounting for the results of hysteroscopy in the control group, for example, there were 2 patients in the control group at the same time. Endometrial polyps and uterine mediastinum, 3 with endometrial hyperplasia and endometrium polyps, 1 with endometrial polyps and single angle uterus, 1 with endometrial polyps and submucous myoma, 1 with intrauterine adhesions and arcuate uterus, 1 with endometritis and single angle uterus, 1 with double uterus and endometrium polyps, 1 with 1 endometrium polyps. Endometrial polyps and endometritis. As mentioned earlier, if there are two or more abnormalities of the uterine cavity in a certain patient, the abnormalities of each uterine cavity are counted once, because the number of cases of all uterine abnormalities is greater than the total number of cases, and the addition of each anomaly is more than one hundred percent, but does not affect the phase. In order to prevent misunderstandings, the rate of congenital anomaly between the two groups was found to be statistically different (P=0.005). In all kinds of acquired uterine abnormalities, the highest incidence of the case group and the control group was the intrauterine adhesions and the endometrium, and the two abnormalities between the two groups were statistically poor. P0.001.2. was divided into A and B two groups according to the number of miscarriages in the medical history. Among them, 228 cases of hysteroscopy were found in group A (2 abortions), accounting for 78.62% of the total number of A, 21 cases of congenital abnormalities, 7.24%, 52 of acquired abnormalities, and 17.93%, and in the B group (3 or more than 3 times), hysteroscopy did not find obvious palace in hysteroscopy. There were 143 cases of abnormal cavity, which accounted for 72.22% of the total number of B group, 17 cases of congenital abnormalities, 8.59%, 46 cases of acquired abnormalities, and 23.23%.A. There were also two or more cases of abnormal uterine cavity in the group B two, which were similar to those in the control group. In the group of A, B two, normal uterine cavity, congenital uterine cavity abnormality and acquired palace. There was no statistical difference in the number of abnormal cases. Conclusion 1, there is a significant statistical correlation between congenital uterine anatomic abnormalities (including complete mediastinal uterus / partial mediastinal uterus) and RSA; the highest incidence of acquired uterine cavity abnormalities is uterine cavity adhesion, the type of uterine cavity abnormality and recurrent abortion exist. Significant statistical correlation.2, hysteroscopy in the diagnosis of abnormal uterine cavity has a unique advantage, and can carry out corresponding corrective surgery. After 2 consecutive abortions, again before pregnancy, it is necessary to carry out hysteroscopy to find abnormality, reduce the occurrence of abortion, and improve the success rate of pregnancy.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R714.21

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