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目的探讨子宫中隔影响妊娠的机理及宫腔镜子宫中隔切除术(TCRS)的生殖预后。方法对111例由于子宫中隔所致不孕或反复流产患者行TCRS,根据孕产史分为不孕组34例、不育组77例。随访TCRS的治疗效果,并与同期1548例正常结构子宫妊娠妇女(对照组)的妊娠经过和结局进行比较。同时对30例(不孕组8例,不育组22例)切除的中隔组织和子宫肌层进行了组织学超微结构观察,用真色彩病理图像分析系统对平滑肌纤维、胶原纤维含量和雌、孕激素受体阳性表达水平进行定量分析。结果(1)不孕组7例、不育组13例子宫中隔内膜腺体数目少于子宫内膜或与子宫内膜增殖不同步。中隔内膜雌、孕激素受体阳性表达水平低于子宫内膜;中隔基底部和中部平滑肌面密度高于子宫肌层(P<0.05),胶原纤维面密度低于子宫肌层(P<0.05);中隔尖部和中部小动脉分布少于子宫肌层(P<0.05)。不孕组患者中隔内膜腺上皮细胞排列紊乱、纤毛稀疏断离,无顶浆分泌。(2)TCRS后不孕组患者妊娠16例次(47.1%,16/34),明显高于术前(8.8%,3/34),TCRS前后比较,差异有统计学意义(P<0.01);不育组的自然流产率由84.1%(180/214)下降为29.0%(18/62),TCRS前后比较,差异也有统计学意义(P<0.01);足月儿及活婴率分别由3.3%(7/214)、0.9%(2/214)上升至56.4%(35/62)、64.5%(40/62),TCRS前后比较,差异也有统计学意义(P<0.01)。(3)TCRS后妊娠者,孕期并发症发生率及围产儿死亡率与对照组比较,差异无统计学意义(P>0.05),但TCRS后妊娠者剖宫产率显著高于对照组,差异有统计学意义(P<0.01)。结论中隔组织与子宫肌层的组织形态和超微结构异常,是导致流产或不孕的原因,TCRS可明显改善不孕、不育患者的生殖预后,不增加孕期并发症,不影响胎儿发育。
Objective To investigate the mechanism of uterine septum affecting pregnancy and reproductive prognosis of hysteroscopic resection of uterus (TCRS). Methods TCRS was performed on 111 cases of infertility caused by uterine septum or recurrent spontaneous abortion. According to the history of pregnancy, 34 cases were divided into infertility group and 77 cases of infertility group. The therapeutic effect of TCRS was followed up and compared with that of 1548 normal uterine pregnancy women (control group) during the same period. At the same time, the ultrastructure of the resected septum and myometrium of 30 cases (8 cases of infertility group and 22 cases of infertility group) were observed by histological ultrastructure. The contents of smooth muscle fiber, collagen fiber, The positive expression levels of estrogen and progesterone receptors were quantitatively analyzed. Results (1) Infertility group 7 cases, infertility group 13 cases of uterine septum endometrial glands less than the number of endometrial or endometrial proliferation is not synchronized. The positive expression of estrogen and progesterone receptor in endometrium was lower than that in endometrium, the density of basal and middle smooth muscle in septum was higher than that in myometrium (P <0.05), and the surface density of collagen fiber was lower than that in myometrium <0.05). The distribution of apex and middle artery was less than that of myometrium (P <0.05). Infertility patients with septal glandular epithelial cells in disorder, cilia sparse off, no apical secretion. (2) There were 16 cases of pregnancy (47.1%, 16/34) in TCRS infertility group after pregnancy, which was significantly higher than that before operation (8.8%, 3/34), there was significant difference between before and after TCRS (P <0.01) ; The rate of spontaneous abortion in infertile group decreased from 84.1% (180/214) to 29.0% (18/62), the difference was also statistically significant before and after TCRS (P <0.01) 3.3% (7/214), 0.9% (2/214) to 56.4% (35/62) and 64.5% (40/62) respectively. There was also a significant difference between before and after TCRS (P <0.01). (3) The post-TCRS pregnancy rate, the incidence of complications during pregnancy and perinatal mortality were not significantly different from those in the control group (P> 0.05). However, the rate of cesarean section in post-TCRS patients was significantly higher than that in the control group There was statistical significance (P <0.01). Conclusions Tissue morphology and ultrastructural abnormality of septum and myometrium are the causes of miscarriage or infertility. TCRS can significantly improve the reproductive prognosis of infertility and infertility patients without increasing complications during pregnancy and without affecting fetal development .