發(fā)布時(shí)間：2018-06-10 19:01

  本文選題：妊娠滋養(yǎng)細(xì)胞腫瘤 + 動(dòng)靜脈瘺��； 參考：《山東大學(xué)》2017年碩士論文

【摘要】：研究目的總結(jié)分析妊娠滋養(yǎng)細(xì)胞腫瘤(Gestational Trophoblastic Neoplasms,GTN)患者化療后發(fā)生子宮動(dòng)靜脈瘺(Arteriovenousfistula,AVF)的臨床特點(diǎn)、診治方法及治療結(jié)局,為臨床治療決策提供更多的依據(jù)。研究方法收集2006年1月至2016年12月山東大學(xué)齊魯醫(yī)院婦科住院病例資料,診斷為GTN化療后子宮動(dòng)靜脈瘺共11例�？偨Y(jié)分析所有患者的臨床資料及診治情況,隨訪其月經(jīng)恢復(fù)、妊娠及分娩結(jié)局。研究結(jié)果1、臨床特點(diǎn):本組患者發(fā)病年齡在24-50歲,平均年齡為37.2歲,其中6例(55%)有生育要求。5例(45%)患者因化療后無(wú)明顯誘因的"開(kāi)關(guān)式"突發(fā)性陰道大出血就診;4例(36%)無(wú)明顯臨床癥狀;2例(19%)為化療后持續(xù)性陰道少量出血。本組患者從接受化療至診斷子宮動(dòng)靜脈瘺的間期時(shí)間范圍較大(2天-13年),其中8例(73%)在接受化療第一個(gè)療程即因突發(fā)性陰道大量出血或典型影像學(xué)表現(xiàn),診斷為子宮動(dòng)靜脈瘺。其中血hCG-β呈高水平的患者共9例(81.8%)。2、影像學(xué)特點(diǎn):本組患者中6例(55%)患者有典型超聲表現(xiàn):子宮壁回聲不均質(zhì),可見(jiàn)迂曲管狀暗區(qū),CDFI內(nèi)探及豐富血流信號(hào),呈五彩狀,可探及動(dòng)靜脈瘺樣頻譜;5例(45%)示探及子宮壁不均質(zhì)回聲,其內(nèi)探及豐富血流信號(hào),呈高速低阻型。2例患者的MRI檢查示子宮壁及周?chē)?jiàn)彌漫性條狀迂曲擴(kuò)張流空血管影,可見(jiàn)異常粗大血管影。3、治療方法:本組中4例患者因突發(fā)性陰道大出血行急癥子宮動(dòng)脈栓塞術(shù),術(shù)后陰道出血均有效控制,且無(wú)遠(yuǎn)期出血。6例行子宮切除術(shù)的患者,其中5例因無(wú)生育要求選擇手術(shù);1例因突發(fā)性陰道大出血,2次行子宮動(dòng)脈栓塞術(shù)仍無(wú)法控制出血,行急癥子宮切除術(shù)。1例因診斷子宮動(dòng)靜脈瘺時(shí)合并早孕,患者有生育要求,密切隨訪觀察至足月妊娠。4、治療結(jié)局:4例行子宮動(dòng)脈栓塞術(shù)成功的患者中,1例于術(shù)后2年余再次成功妊娠分娩;2例無(wú)生育要求;1例化療仍在進(jìn)行中。6例行子宮切除術(shù)的患者,術(shù)后陰道出血均得到有效控制,且無(wú)遠(yuǎn)期陰道出血。因合并早孕未處理的1例患者于妊娠39周+4天在我院行剖宮產(chǎn)順利分娩。結(jié)論1、GTN本身及化療后子宮動(dòng)靜脈瘺均可導(dǎo)致陰道大出血,臨床醫(yī)師應(yīng)提高對(duì)子宮動(dòng)靜脈瘺的認(rèn)識(shí)。對(duì)于急癥陰道大出血的患者可行急癥子宮動(dòng)脈造影術(shù),既可明確診斷,又能及時(shí)治療控制陰道大出血,為進(jìn)一步治療贏得時(shí)間。2、對(duì)于有生育要求的患者,首選治療方式為子宮動(dòng)脈栓塞術(shù)(uterine arterial embolization,UAE);但若栓塞后無(wú)法控制陰道流血,應(yīng)及時(shí)、果斷行子宮切除術(shù),以挽救患者的生命。3、GTN化療后子宮動(dòng)靜脈瘺的形成可能的高危因素為病灶位于子宮下段、高水平hCG-β及前次妊娠為葡萄胎。
[Abstract]:Objective to summarize and analyze the clinical characteristics, diagnosis and treatment methods and treatment outcome of Arteriovenous Fistula (AVFF) in patients with gestational trophoblastic Neoplasm tumor (GTNN) after chemotherapy. Methods from January 2006 to December 2016, 11 cases of uterine arteriovenous fistula diagnosed by GTN chemotherapy were collected from Qilu Hospital of Shandong University. The clinical data, diagnosis and treatment of all patients were analyzed, and their menstrual recovery, pregnancy and delivery outcomes were followed up. Results 1. Clinical features: the onset age of the patients was 24-50 years old with an average age of 37.2 years. Among them, 6 cases with reproductive requirement (5 cases with reproductive requirement, 45 cases) were treated with "switch" sudden vaginal hemorrhage without obvious inducement after chemotherapy. 4 cases (36 cases) had no obvious clinical symptoms and 2 cases (19 cases) were sustained vaginal bleeding after chemotherapy. The interval between chemotherapy and diagnosis of arteriovenous fistula in this group was from 2 days to 13 years. In the first course of chemotherapy, 8 patients were diagnosed as uterine arteriovenous fistula due to sudden massive vaginal bleeding or typical imaging manifestations. Among them, there were 9 cases with high level of hCG- 尾. Imaging features: 6 cases had typical ultrasonographic features: uterine wall echo was uneven, and CDFI in tubular dark area was found to be rich in blood flow signal, which was colorful, and the results were as follows: (1) among them, there were 9 cases with high blood level of hCG- 尾. The imaging features were as follows: the uterine wall echo was uneven, and the blood flow signal was abundant in the tubular dark area (CDFI). 5 cases of arteriovenous fistula like spectrum can be detected. It shows uneven echo of uterine wall and abundant blood flow signal. MRI of 2 cases with high speed and low resistance type shows diffuse strip dilatation vascular shadow in uterine wall and surrounding. In this group, 4 patients underwent emergency uterine artery embolization because of sudden massive vaginal hemorrhage. The bleeding was effectively controlled after operation, and there was no long-term bleeding in 6 patients undergoing hysterectomy. Among them, 5 cases were selected because of no fertility requirement, 1 case was treated with uterine artery embolization because of sudden vaginal hemorrhage, and 1 case underwent emergency hysterectomy with early pregnancy because of diagnosis of arteriovenous fistula, and the patient had fertility requirement. Closely followed up until term pregnancy .4, one of the 4 successful uterine artery embolization patients who had been treated with the outcome of the treatment, one of them was pregnant and delivered again more than 2 years after operation, 2 cases had no fertility requirement and 1 case was still undergoing a hysterectomy under chemotherapy, and 1 case was still undergoing hysterectomy. Postoperative vaginal bleeding was effectively controlled and there was no long-term vaginal bleeding. A patient with untreated early pregnancy underwent caesarean section at 39 weeks and 4 days of gestation. Conclusion 1 GTN itself and the uterine arteriovenous fistula after chemotherapy can lead to massive vaginal hemorrhage. Clinicians should improve the understanding of uterine arteriovenous fistula. For patients with acute vaginal hemorrhage, emergency uterine arteriography is feasible. It can be clearly diagnosed and can be treated in time to control vaginal hemorrhage. It can win time for further treatment. The first choice of treatment was uterine artery embolization arterial embolization, but if vaginal bleeding could not be controlled after embolization, hysterectomy should be carried out promptly and decisively. The high risk factors for the formation of arteriovenous fistula after GTN chemotherapy were located in the lower uterine segment, and the high level of hCG- 尾 and the previous pregnancy were hydatidiform mole.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R737.33

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