【摘要】：目 的探討宮頸錐切術對患者生育能力的影響及其相關妊娠結(jié)局的影響。方 法對2008年1月1日-2013年5月31日收治的86例因?qū)m頸病變在我院實施宮頸錐切手術的患者進行隨訪,選取術前無原發(fā)性不孕癥、有生育要求的45例患者作為宮頸錐切組,隨機從同期婦產(chǎn)科門診患者中抽取無宮頸錐切術史、有生育要求的婦女50例作為對照組。宮頸錐切方法目前主要采用兩種,宮頸環(huán)形電切術(loop electrosurgical excision procedure,LEEP)和宮頸冷刀錐切術(cold knife conization,CKC)。通過查閱病案室相關病例資料,并對在我院和未在我院分娩的患者行電話隨訪：包括兩組患者的一般情況、年齡、身高、體重、孕史、產(chǎn)史、不良孕產(chǎn)史、宮頸錐切術后錐體大小、宮頸錐切術后至懷孕的時間長短、懷孕期間是否因保胎而住院治療、妊娠期間是否行宮頸環(huán)扎術、妊娠結(jié)局(流產(chǎn)、早產(chǎn)、足月產(chǎn)、胎膜早破)和終止妊娠方式(剖宮產(chǎn)、經(jīng)陰分娩)結(jié) 果1.患者一般情況比較 宮頸錐切組和對照組的患者一般情況進行比較,差異均無統(tǒng)計學意義(P0.05)2.妊娠情況比較 宮頸錐切組45例患者中,有40例患者獲得41次妊娠,妊娠率為88.8%(40/45)；對照組中46例患者獲得47次妊娠,妊娠率為92.0%(46/50),兩組妊娠率相比,差異無統(tǒng)計學意義(P0.05)3.妊娠結(jié)局比較(1)對流產(chǎn)、早產(chǎn)、胎膜早破的影響 宮頸錐切組36例已分娩患者中早產(chǎn)3例(8.3%)；對照組42例已分娩患者中早產(chǎn)2例,發(fā)生率4.8%(2/42)。宮頸錐切組胎膜早破3例,發(fā)生率為8.3%(3/36)；對照組中胎膜早破1例,發(fā)生率為2.3%(1/42)。宮頸錐切組40例已妊娠患者,5例流產(chǎn),流產(chǎn)率12.5(5/40)；對照組46例已妊娠患者,5例流產(chǎn),流產(chǎn)率10.9(5/46)。宮頸錐切組流產(chǎn)、早產(chǎn)、胎膜早破的發(fā)生率均高于對照組,但差異無統(tǒng)計學意義(P0.05)。(2)宮頸錐切高度與妊娠結(jié)局及宮頸環(huán)扎的關系 宮頸錐切組40例已妊娠婦女將宮頸錐切高度按照10mm,10-20mm,》10mm分3組,3組中患者流產(chǎn)率、早產(chǎn)率、胎膜早破發(fā)生率及剖宮產(chǎn)率隨宮頸錐切的高度增加而增加,但3組兩兩比較,差異無統(tǒng)計學意義(p0.05)；36例已分娩患者中2例行宮頸環(huán)扎術,這兩例患者的宮頸錐切高度均20mm,其中1例患者為冷刀錐切的宮頸錐體高度為30mm。宮頸錐切高度≥20mm是導致患者行宮頸環(huán)扎術的重要原因。(3)宮頸錐切手術至妊娠時間間隔與妊娠結(jié)局的關系 宮頸錐切組中宮頸錐切手術至妊娠時間間隔最短為4個月,最長為48個月,將患者按宮頸錐切手術距離妊娠時間間隔長短分3組,分別為6月組、6-12月組及≥12月組。將3組中的流產(chǎn)率、早產(chǎn)率、胎膜早破發(fā)生率及剖宮產(chǎn)率兩兩進行比較發(fā)現(xiàn),宮頸錐切手術至妊娠時間間隔短于6個月組中早產(chǎn)發(fā)生率明顯高于大于12月組,差異有統(tǒng)計學意義(P＝0.014)。比較三組中的流產(chǎn)率、胎膜早破發(fā)生率和剖宮產(chǎn)率,差異無統(tǒng)計學意義(P0.05)(4)宮頸錐切術與住院保胎治療的關系 宮頸錐切組已分娩的患者36例,其中有14例在懷孕期間因“保胎”而住院治療,保胎率為38.8(14/36)。2例患者因?qū)m頸機能不全行宮頸環(huán)扎術,并一直臥床到妊娠結(jié)束；其余12例患者實際上無保胎指征,但因害怕宮頸管縮短導致流產(chǎn)而強烈自動要求住院,其中1例2次住院。對照組中42例已分娩的患者中,有3例在不同妊娠時期住院保胎,保胎率為7.1%(3/42)。宮頸錐切組高于對照組,差異有統(tǒng)計學意義(P=0.001)。4.對圍生兒的影響 兩組均無新生兒死亡,宮頸錐切組新生兒出生體重與對照組比較,低于對照組,差異有統(tǒng)計學意義(P=0.027)。5.終止妊娠方式比較(1)宮頸錐切組40例患者41次妊娠中,36例已分娩,22例行擇期剖宮產(chǎn),14例經(jīng)陰道試產(chǎn)。陰道試產(chǎn)中共4例改行急癥剖宮產(chǎn),10例成功經(jīng)陰道分娩。剖宮產(chǎn)率為72.7%(26/36),社會心理因素作為剖宮產(chǎn)手術指征的患者16例,去除此手術指征,剖宮產(chǎn)人數(shù)為10例,剖宮產(chǎn)率為27.7%(10/36)；對照組46例患者47次妊娠,42例已分娩,16例擇期剖宮產(chǎn),26例經(jīng)陰道試產(chǎn)。陰道試產(chǎn)中共4例改行急癥剖宮產(chǎn),22例成功經(jīng)陰道分娩。剖宮產(chǎn)率為47.6%(20/42),因社會心理因素要求剖宮產(chǎn)的患者9例,去除此手術指征,剖宮產(chǎn)患者11例,剖宮產(chǎn)率為26.1%(11/42)。宮頸錐切組剖宮產(chǎn)率高于對照組,差異有統(tǒng)計學意義(P=0.028)；已分娩病例、陰道試產(chǎn)成功率低于對照組,但差異無統(tǒng)計學意義(P0.05)。宮頸錐切術增加了患者社會心理因素手術指征,兩組患者均去除社會心理因素手術指征,剖宮產(chǎn)率基本一致。(2)兩組剖宮產(chǎn)指征比較 宮頸錐切組40例妊娠患者剖宮產(chǎn)指征為社會心理因素的患者占16例,比例為40.0%(16/40);對照組46例妊娠患者剖宮產(chǎn)指征為社會心理因素的患者占9例,比例為19.6%(9/46)。宮頸錐切組社會心理因素手術指征明顯高于對照組,兩組比較差異有統(tǒng)計學意義(P=0.037)。比較兩組患者剖宮產(chǎn)指征的其他方面,差異均無統(tǒng)計學意義(P0.05)。結(jié) 論1.宮頸錐切術對宮頸病變患者的妊娠能力無明顯影響。2.宮頸錐切術對流產(chǎn)、早產(chǎn)、胎膜早破發(fā)生率沒有明顯影響。3.宮頸錐切高度與不良圍生結(jié)局無明顯關系,但宮頸錐切高度≥20mm是導致患者行宮頸環(huán)扎術的重要原因。4.宮頸錐切手術至妊娠時間間隔短于6個月的患者早產(chǎn)率明顯高于妊娠時間間隔大于12個月的患者。5.宮頸錐切術增加了妊娠期間保胎住院率6.宮頸錐切術沒有導致新生兒死亡率增加,但新生兒出生體重明顯降低。7.宮頸錐切術對陰道試產(chǎn)成功率沒有明顯影響,但明顯增加了剖宮產(chǎn)率、主要是增加了社會心理因素這個剖宮產(chǎn)指征,沒有增加其他方面剖宮產(chǎn)指征。
[Abstract]:Objective To investigate the effect of cervical conization on fertility and pregnancy outcome. Methods 86 patients with cervical lesions who underwent conization in our hospital from January 1, 2008 to May 31, 2013 were followed up. Forty-five patients without primary infertility and with fertility requirements were selected as cervical conization. Group A: 50 women without history of cervical conization and with fertility requirements were randomly selected from gynecology and obstetrics clinics at the same time as control group. Currently, there are mainly two methods of cervical conization: loop electrosurgical excision procedure (LEEP) and cold knife conization (CKC). Relevant case data and telephone follow-up of patients in our hospital and those who did not give birth in our hospital: including the general situation of the two groups of patients, age, height, weight, pregnancy history, childbirth history, adverse pregnancy and childbirth history, the size of the cone after cervical conization, the length of conization to pregnancy, whether pregnancy due to fetal care and hospitalization, pregnancy period is The results of cervical cerclage, pregnancy outcomes (abortion, premature delivery, full-term delivery, premature rupture of membranes) and termination of pregnancy (cesarean section, vaginal delivery) 1. The general situation of patients compared with cervical conization group and control group of patients in general, the difference was not statistically significant (P 0.05). 2. Pregnancy compared with cervical conization group of 45 patients, There were 41 pregnancies in 40 patients (88.8% (40/45); 47 pregnancies in 46 patients in the control group (92.0% (46/50). There was no significant difference in pregnancy rate between the two groups (P 0.05). 3. Pregnancy outcomes (1) Premature labor, premature rupture of membranes, abortion in 36 patients in the cervical conization group (8.3%); Premature rupture of membranes in cervical conization group was 8.3% (3/36), and that in control group was 2.3% (1/42). 6) The incidence of abortion, premature delivery and premature rupture of membranes in the conization group were higher than those in the control group, but there was no significant difference (P 0.05). (2) The relationship between the height of conization and pregnancy outcome and cervical cerclage. 40 pregnant women in the conization group were divided into three groups according to the height of 10 mm, 10-20 mm, > 10 mm. The incidence of premature rupture and the rate of cesarean section increased with the height of cervical conization, but there was no significant difference between the three groups (p0.05). Cervical cerclage was performed in 2 of 36 patients who had given birth. The height of cervical conization was 20 mm in both of the 36 patients. The height of cervical conization was 30 mm in one of them. (3) The shortest interval between conization and pregnancy was 4 months and the longest was 48 months. Patients were divided into 3 groups according to the interval between conization and pregnancy: 6 months, 6-12 months. The rates of abortion, premature delivery, premature rupture of membranes and cesarean section were compared between the three groups. The incidence of premature delivery in the group with the interval between conization and pregnancy less than 6 months was significantly higher than that in the group with 12 months (P = 0.014). There was no significant difference between the rate of cervical conization and the rate of cesarean section (P 0.05) (4) The relationship between conization and hospitalization for fetal preservation was not significant (P 0.05). The other 12 patients had no indication of fetal preservation, but they had to be hospitalized for fear of cervical tube shortening, one of them had to be hospitalized twice. Compared with the control group, the birth weight of newborns in the conization group was lower than that in the control group (P = 0.027). 5. Comparison of termination methods of pregnancy (1) Of the 41 pregnancies in the conization group, 36 had given birth, 22 had elective cesarean section and 14 had a vaginal trial. The cesarean section rate was 72.7% (26/36), and 16 patients with psychosocial factors as the indication of cesarean section were removed. The number of cesarean section was 10, and the cesarean section rate was 27.7% (10/36); 46 patients in the control group had 47 pregnancies, 42 had given birth, 16 had elective cesarean section, and 26.7% (10/36). The cesarean section rate was 47.6% (20/42). 9 patients were required to undergo cesarean section because of social and psychological factors. The cesarean section rate was 26.1% (11/42). The cesarean section rate in the conization group was higher than that in the control group. The difference was statistically significant. There was no significant difference between the two groups (P = 0.028). (2) The cesarean section rate was basically the same between the two groups. (2) Comparing the cesarean section indications between the two groups, the cervical conization group had 40 cases. 16 pregnant women with cesarean section indications for social and psychological factors accounted for 40.0% (16/40); the control group of 46 pregnant women with cesarean section indications for social and psychological factors accounted for 9 cases, the proportion was 19.6% (9/46). Cervical conization group of social and psychological factors of surgical indications were significantly higher than the control group, the difference was statistically significant (P = 0.037). Conclusion 1. Conization of cervix has no significant effect on the pregnant ability of patients with cervical lesions. 2. Conization of cervix has no significant effect on the incidence of abortion, premature delivery and premature rupture of membranes. The cervical conization height (> 20 mm) is an important reason for cervical cerclage. 4. The premature delivery rate of patients whose interval between conization and pregnancy is shorter than 6 months is significantly higher than that of patients whose interval between pregnancy is longer than 12 months. 5. The cervical conization increases the hospitalization rate of pregnancy. 6. Cervical conization does not lead to neonatal mortality. Cervical conization did not significantly affect the success rate of vaginal delivery, but significantly increased the rate of cesarean section, mainly increased the social and psychological factors of cesarean section indications, did not increase other aspects of cesarean section indications.
【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2016
【分類號】：R714.2

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