宫腔镜下宫颈“图钉形”切除术对宫颈高级别鳞状上皮内病变患者妊娠结局的影响 (1).pdf

国际医药卫生导报 2023 年8 月第 29 卷第 16 期IMHGN,August 2023,Vol.29,No.16宫腔镜下宫颈“图钉形”切除术对宫颈高级别鳞状上皮内病变患者妊娠结局的影响刘锦1 王珍珍2 王卉1 徐晨1 岳庆玲11聊城市第三人民医院妇产科，聊城252000；2聊城市第三人民医院药剂科，聊城252000通信作者：刘锦，Email：【摘要】目的探讨宫腔镜下宫颈“图钉形”切除术对宫颈高级别鳞状上皮内病变患者妊娠结局的影响。方法选取2017年6月至2022年6月聊城市第三人民医院收治的宫颈高级别鳞状上皮内病变孕妇 160 例，按照手术方法分为观察组 88 例和常规组 72 例。观察组年龄（30.016.02）岁，孕周（36.110.93）周；常规组年龄（30.226.12）岁，孕周（36.250.96）周。观察组行宫腔镜下宫颈“图钉形”切除术，对照组行宫颈冷刀锥切术。分析两组围手术期苏醒指标；对比两组妊娠结局和新生儿结局。采用t检验和2检验。结果观察组术后苏醒时间、自主呼吸恢复时间均短于常规组（均P0.05）。观察组早产、羊水污染、产后出血、宫内感染、胎儿窘迫发生率均明显低于常规组（均P0.05）。观察组新生儿窒息、肺炎、病理性黄疸、感染的发生率均明显低于常规组 2.27%（2/88）比16.67%（12/72）、2.27%（2/88）比19.44%（14/72）、2.27%（2/88）比18.06%（13/72）、4.55%（4/88）比19.44%（14/72），均P0.05。结论宫腔镜下宫颈“图钉形”切除术治疗宫颈高级别鳞状上皮内病变患者可缩短患者术后苏醒时间、自主呼吸恢复时间，不会增加不良妊娠结局和新生儿不良结局的发生风险，值得推广。【关键词】孕妇；宫颈高级别鳞状上皮内病变；新生儿不良结局；宫颈冷刀锥切术；妊娠结局基金项目：山东省自然科学基金（ZR2020MH316）Effect of hysteroscopic cervical thumbtack resection on pregnancy outcomes in patients with high-grade cervical squamous intraepithelial lesions Liu Jin1,Wang Zhenzhen2,Wang Hui1,Xu Chen1,Yue Qingling11 Department of Gynecology and Obstetrics,Liaocheng Third Peoples Hospital,Liaocheng 252000,China;2 Department of Pharmacy,Liaocheng Third Peoples Hospital,Liaocheng 252000,ChinaCorresponding author:Liu Jin,Email:【Abstract】Objective To investigate the effect of hysteroscopic cervical thumbtack resection on pregnancy outcomes in patients with high-grade cervical squamous intraepithelial lesions.Methods One hundred and sixty pregnant women with high-grade cervical squamous intraepithelial lesions admitted to Liaocheng Third Peoples Hospital from June 2017 to June 2022 were selected.According to the surgical methods,they were divided into an observation group(88 cases)and a conventional group(72 cases).The observation group were(30.016.02)years old and(36.110.93)weeks pregnant.The conventional group were(30.226.12)years old and(36.250.96)weeks pregnant.The observation group took hysteroscopic cervical thumbtack resection.The conventional group took cervical cold-knife conical resection.The perioperative recovery indicators of the two groups were analyzed.The pregnancy and neonatal outcomes were compared DOI：10.3760/cma.j.issn.1007-1245.2023.16.012收稿日期 2023-02-09 本文编辑 成观星引用本文：刘锦,王珍珍,王卉,等.宫腔镜下宫颈“图钉形”切除术对宫颈高级别鳞状上皮内病变患者妊娠结局的影响J.国际医药卫生导报,2023,29(16):2273-2276.DOI:10.3760/cma.j.issn.1007-1245.2023.16.012.2273国际医药卫生导报 2023 年8 月第 29 卷第 16 期IMHGN,August 2023,Vol.29,No.16between the two groups.t and 2 tests were applied.ResultsThe postoperative recovery time and spontaneous breathing recovery time of the observation group were shorter than those of the conventional group(both P0.05).The incidences of preterm delivery,amniotic fluid contamination,postpartum hemorrhage,intrauterine infection,and fetal distress in the observation group were significantly lower than those in the conventional group(all P0.05).The incidences of asphyxia,pneumonia,pathological jaundice,and infection in the neonates of the observation group were significantly lower than those in the conventional group 2.27%(2/88)vs.16.67%(12/72),2.27%(2/88)vs.19.44%(14/72),2.27%vs.(2/88)18.06%(13/72),and 4.55%(4/88)vs.19.44%(14/72);all P0.05）。本研究经聊城市第三人民医院医学伦理委员审批通过（2022038）。纳入标准：均为宫颈高级别鳞状上皮内病变9；年龄20岁；选择于聊城市第三人民医院分娩；无剖宫产指征；孕妇及其家属均知情同意。排除标准：伴有严重心、肺、肝、肾功能障碍；伴有免疫系统障碍疾病；伴有血液系统疾病；伴有精神障碍或认知障碍；合并感染、恶性肿瘤；1个月内有抗生素应用史；营养不良者；对研究药物过敏者；取材前2周内有性生活史；临床资料不全者。2.方法常规组行宫颈冷刀锥切术，采用静脉全身麻醉。手术范围：冷刀切除原始鳞柱交界或碘试验宫颈不着色边缘0.5 cm，锥高2.02.5 cm，12点钟处带线标记，全部送病理检查，手术创面电凝止血，宫颈6点钟和12点钟位置进行“W形缝合，于3点钟和9点钟位置进行“U形缝合。检查创面无渗血，术毕碘伏纱布消毒宫颈管内及阴道。观察组行宫腔镜下宫颈“图钉形”切除术，采用静脉全身麻醉，使用日本Olympus-40型高频电源发生器及同型的宫腔镜、电切镜，等渗电切液作为膨宫液。常规消毒铺巾后，扩张宫颈至8.5号，置入宫腔电切镜，全面检查宫腔及宫颈管内形态，用双极电切环自宫颈组织学内口处6点钟方向开始顺时针切除宫颈管内膜，切除深度2.03.0 mm，上切缘超过移行带内侧缘0.5 cm，顺时针绕宫颈管1周切除病变组织，保留宫颈深部的间质及肌层组织，滚球电凝止血。缝线标记标本，送病理检查。所有孕妇均随访至分娩后3个月。3.观察指标围手术期苏醒指标（术后苏醒时间、自主呼吸恢复时间）。妊娠结局：早产、羊水污染、产后出血、宫内感染、胎儿窘迫等。新生儿结局：窒息、肺炎、病理性黄疸、感染等。4.统计学分析将SPSS 25.0软件作为统计学工具，符合正态分布的计量资料以（x s)描述，采用独立样本 t 检验；计数资料以“%”描述，采用2检验；P0.05为差异有统计学意义。2274国际医药卫生导报 2023 年8 月第 29 卷第 16 期IMHGN,August 2023,Vol.29,No.16结果1.围手术期苏醒指标观察组术后苏醒时间、自主呼吸恢复时间均短于常规组（均P0.05）。见表1。2.妊娠结局观察组早产、羊水污染、产后出血、宫内感染、胎儿窘迫的发生率均明显低于常规组（均P0.05），见表2。3.新生儿结局观察组窒息、肺炎、病理性黄疸、感染的发生率均明显低于常规组（均P0.05）。见表3。讨论宫颈癌是妇科常见恶性肿瘤，因HPV感染导致。HPV感染后存在癌前病变过程，宫颈正常上皮在HPV持续感染后可缓慢发展为宫颈上皮内瘤变（CIN）级、CIN 级、CIN 级。如果未及时阻断，宫颈癌细胞可突破基底膜，属于最早期的宫颈癌。CIN 级与CIN 级称为高级别鳞状上皮内瘤变。宫颈CIN 级约20%可演变为宫颈浸润癌。40%70%CIN 级患者可演变为宫颈癌。因此，宫颈高级别上皮内瘤变可行宫颈锥切治疗10-11。宫颈高级别鳞状上皮内病变威胁孕妇的身体健康和新生儿的生命安全，并给家庭带来较大的经济压力12。因此，在宫颈高级别鳞状上皮内病变孕妇产前行手术治疗对改善妊娠结局和新生儿结局具有重要意义。本研究结果显示，观察组术后苏醒时间、自主呼吸恢复时间均短于常规组，提示宫腔镜下宫颈“图钉形”切除术治疗宫颈高级别鳞状上皮内病变患者可缩短患者术后苏醒时间、自主呼吸恢复时间。相关研究显示，将宫颈“图钉形”切除术与宫腔镜结合起来，开展宫腔镜下宫颈“图钉形”切除术，既能在直视下观察宫颈管情况，又能切除病变组织，同时保护正常组织，减少宫颈功能的损伤，降低术后不良妊娠结局的发生率，对有生育要求的女性来说尤为适合13。此外，本研究还显示，观察组早产、羊水污染、产后出血、宫内感染、胎儿窘迫、窒息、肺炎、病理性黄疸、感染的发生率均明显低于常规组，提示宫颈高级别鳞状上皮内病变患者感染B族链球菌会增加不良妊娠结局和新生儿不良结局的发生风险。相关研究显示，宫颈高级别鳞状上皮内病变患者感染B族链球菌会导致体内释放前列腺素和蛋白水解酶，易导致孕妇出现子宫收缩等情况，进而导致早产，且感染B族链球菌的孕妇会导致病菌上行，造成胎膜、胎盘及羊水感染14-16。B族链球菌具有较强的绒毛穿透能力，可能会导致孕妇胎盘绒毛感染，进而增加胎盘的血阻力，宫腔镜下宫颈“图钉形”切除术不仅能改变孕妇宫内子宫内环境，降低孕妇出现宫内感染、胎儿窘迫等不良妊娠结局17-18。宫颈高级别鳞状上皮内病变患者宫腔镜下宫颈“图钉形”切除术能够降低胎儿储备能力，不利于胎儿供氧，且当B族链球菌进入宫腔后会造成羊水感染，严重影响胎儿呼吸道功能，升高新生儿不良结局的发生风险19。宫腔镜下宫颈“图钉形”切除术定位准确，且“图钉形”切除可以完全切除病灶和保护周围正常组织免受损伤，有利于宫颈功能的保全；其术中止血彻底，避免发生术后出血、宫颈粘连狭窄等，通过宫腔镜放大作用改善了肉眼对病变组织观察的局限性，能清楚观察到宫颈管内口，改善妊娠结局和新生儿结局。表3 两组宫颈高级别鳞状上皮内病变孕妇新生儿结局比较例（%）组别常规组观察组2值P值例数7288窒息12（16.67）2（2.27）10.2760.001肺炎14（19.44）2（2.27）12.9740.001病理性黄疸13（18.06）2（2.27）11.6100.001感染14（19.44）4（4.55）8.8040.001注：观察组行宫腔镜下宫颈“图钉形”切除术，对照组行宫颈冷刀锥切术表2 两组宫颈高级别鳞状上皮内病变孕妇妊娠结局比较例（%）组别常规组观察组2值P值例数7288早产17（23.61）4（4.55）12.6240.001羊水污染14（19.44）4（4.55）8.8040.001产后出血13（18.06）2（2.27）11.6100.001宫内感染17（23.61）4（4.55）12.6470.001胎儿窘迫22（30.56）4（4.55）16.8180.001注：观察组行宫腔镜下宫颈“图钉形”切除术，对照组行宫颈冷刀锥切术表1 两组宫颈高级别鳞状上皮内病变孕妇围手术期苏醒指标比较（min，x s）组别常规组观察组t值P值例数7288术后苏醒时间11.841.9110.572.013.9590.001自主呼吸恢复时间18.933.5117.243.233.0430.003注：观察组行宫腔镜下宫颈“图钉形”切除术，对照组行宫颈冷刀锥切术 2275国际医药卫生导报 2023 年8 月第 29 卷第 16 期IMHGN,August 2023,Vol.29,No.16综上所述，宫腔镜下宫颈“图钉形”切除术治疗宫颈高级别鳞状上皮内病变患者可缩短患者术后苏醒时间、自主呼吸恢复时间，不会增加不良妊娠结局和新生儿不良结局的发生风险，值得推广。利益冲突 所有作者均声明不存在利益冲突参考文献1Lamagni T,Wloch C,Broughton K,et al.Assessing the added value of group B Streptococcus maternal immunisation in preventing maternal infection and fetal harm:population surveillance study 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