子宫肌瘤与妊娠相关问题.ppt

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1、子 宫 肌瘤与妊娠相关问题,子宫肌瘤引起的症状,大部分无症状20%-50%有症状：AUB，贫血，压迫症状，生殖问题。绝经后大部分肌瘤可以萎缩，症状消失。Myers ER,Barber MD,Gustilo-Ashby T,Couchman G,Matchar DB,McCrory DC.Management of uterine leiomyomata:what do we really know?Obstet Gynecol 2002;100:817.,月经量过多,0型或1型首选宫腔镜手术其它类型,压迫症状，伴或不伴月经量多,关于手术指征,月经量过多继发贫血，药物治疗无效体积大或引起膀胱、直

2、肠等压迫症状严重腹痛、性交痛或慢性腹痛、有蒂肌瘤扭转引起的急腹痛能确定肌瘤是不孕或反复流产的唯一原因者可疑有肉瘤变者,子宫大于10周妊娠大小月经过多继发贫血有膀胱、直肠压迫症状或肌瘤生长较快保守治疗失败不孕或反复流产排除其它原因,八年制教材,人卫第八版教材,关于手术指征,无症状的子宫肌瘤不需要治疗子宫肌瘤的快速增长不作为手术指征 绝经前子宫肌瘤增长快慢的恶性率分别为0.26%，0.27%，差异无统计学意义。绝经后肌瘤增长或出现症状需要考虑恶性的可能，但发生率极低。有症状，无生育要求，一线治疗失败Parker WH,Fu YS,Berek JS.Uterine sarcoma in patien

3、ts operated on for presumed leiomyoma and rapidly growing leiomyoma.Obstet Gynecol.1994;83:4148.Weber AM,Mitchinson AR,Gidwani GP,Mascha E,Walters MD.Uterine myomas and factors associated with hysterectomy in premenopausal women.Am J Obstet Gynecol 1997;176:12137.Friedman AJ,Haas ST.Should uterine s

4、ize be an indication for surgical intervention in women with myomas?Am J Obstet Gynecol 1993;168(3 Pt 10):7515.,无症状子宫肌瘤行子宫切除术的唯一指征：绝经后未使用HRT，但肌瘤增大，考虑有恶性可能，尽管恶性可能很小。,子宫肌瘤切除手术指征,严重的经量过多（粘膜下肌瘤首选宫腔镜手术治疗）盆腔痛压迫症状一些存在生育问题的患者Garcia CR.Management of symptomatic fibroid older than 40 years of age:hysterectomy

5、 or myomectomy?Obstet Gynecol Clin。North Am 1993;20:33748.,需告知患者手术出血可能较多，手术时间长，复发率15%10%的患者在5-10年内可能仍然需要切除子宫。,宫腔镜下子宫肌瘤切除,0，I，II型直径4-5厘米以内,其它类型子宫肌瘤切除手术方式选择,腹腔镜子宫肌瘤切除或开腹子宫肌瘤切除术后受孕率，并发症，复发率相似。不孕人群中，腹腔镜手术和小切口开腹手术的受孕率相似，但是腹腔镜手术恢复快，术后疼痛轻，发热少。（II-3）Jin C,Hu Y,Chen XC,Zheng FY,Lin F,Zhou K,et al.Laparoscopi

6、c versus open myomectomy a meta-analysis of randomized controlled trials.Eur J Obstet Gynecol Reprod Biol 2009;145:1421.Palomba S,Zupi E,Falbo A,Russo T,Marconi D,Tolino A,et al.A multicenter randomized,controlled study comparing laparoscopic versus minilaparotomic myomectomy:reproductive outcomes.F

7、ertil Steril 2007;88:93341.,孕前发现子宫肌瘤需要手术吗？,子宫肌瘤增加了难产率（OR 2.9),剖宫产率（OR 3.7），早产率（OR 1.5）多数超声方面研究发现：孕期肌瘤大小保持不变或缩小。只有少数研究发现肌瘤增大。Klatsky PC,Tran ND,Caughey AB,Fujimoto VY.Fibroids and reproductive outcomes:a systematic literature review from conception to delivery.Am J Obstet Gynecol2008;198:35766.Neiger

8、 R,Sonek JD,Croom CS,Ventolini G.Pregnancy-related changes in the size of uterine leiomyomas.J Reprod Med 2006;51:6714.Hammoud AO,Asaad R,Berman J,Treadwell MC,Blackwell S,Diamond MP.Volume change of uterine myomas during pregnancy:do myomas really grow?J Minim Invasive Gynecol 2006;13:386-90.De Viv

9、o A,Mancuso A,Giacobbe A,Savasta LM,De Dominici R,Dugo N,et al.Uterine myomas during pregnancy:a longitudinal sonographic study.Ultrasound Obstet Gynecol 2011;37:3615.,肌壁间肌瘤本身虽然增加了不孕以及妊娠并发症的风险，但是肌瘤切除术不会降低这些风险，因此无症状的子宫肌瘤不推荐切除。担心孕期子宫肌瘤可能引起的并发症并不是子宫肌瘤切除术的指征，除非前次妊娠发生了肌瘤相关的并发症。(III)Marret H,Fritel X,Ould

10、amer L,et al.Therapeutic management of uterine fibroid tumors:updated French guidelines.Eur J Obstet Gynecol Reprod Biol 2012;165:156-64.Pritts EA,Parker WH,Olive DL.Fibroids and infertility:an updated systmatic review of the evidence.Fertil Steril 2009;91:1215-23.,子宫肌瘤对生育力的影响,文献报道，不孕患者子宫肌瘤发生率5%-10%

11、，但是除外其它不孕因素后子宫肌瘤发生率仅为1%-2%目前没有好的研究说明肌瘤与不孕的关系。浆膜下肌瘤似乎不影响生育力。粘膜下肌瘤影响种植率、受孕率、流产率以及顺产率。肌壁间肌瘤也影响种植率与受孕率，但是影响力不如粘膜下肌瘤大。宫腔镜下粘膜下子宫肌瘤切除是有益的。Pritts EA,Parker WH,Olive DL.Fibroids and infertility:an updated systematic review of the evidence.Fertil Steril 2009;91:121523.,子宫肌瘤切除术对生育力影响,不孕患者粘膜下肌瘤切除术后临床受孕率增加，但是肌壁间

12、肌瘤及浆膜下肌瘤切除术后，受孕率无改变。Bozdag G,Esinler I,Boynukalin K,Aksu T,Gunalp S,Gurgan T.Single intramural leiomyoma with normal hysteroscopic findings does not affect ICSI-embryo transfer outcome.Reproductive Biomedicine Online 2009;19:27680.,孕前子宫肌瘤的评估,需要详细评估评估子宫肌瘤大小及位置：MRI敏感性100%，特异性91%，优于超声，但价格昂贵。评估子宫内膜：宫腔造影

13、 优于超声，但是有感染风险（1%），且患者有不适感。但是不孕患者子宫肌瘤的评估，尚无最好的方式。Dueholm M,Lundorf E,Hansen ES,Ledertoug S,Olesen F.Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis,mapping,and measurement of uterine myomas.Am J Obstet Gynecol 2002;186:40915.Dueholm M,Forman A,Jensen ML,Laurse

14、n H,Kracht P.Transvaginal sonography combined with saline contrast sonohysterography in evaluating the uterine cavity in premenopausal patients with abnormal uterine bleeding.Ultrasound Obstet Gynecol 2001;18:5461.,宫腔镜子宫肌瘤切除术并发症,宫腔镜下子宫肌瘤切除术后宫腔粘连率7.5%。但是没有证据表面利用Foley球囊、雌激素或者宫内避孕装置可以预防宫腔粘连。Touboul C,F

15、ernandez H,Deffieux X,Berry R,Frydman R,Gervaise A.Uternine syndechiae after bipolar hysteroscopic resection of submucosal myomas in patients with infertility.Fertil Steril 2009;92:16903.Kodaman PH,Arici A.Intrauterine adhesions and fertility outcome:how to optimize success?Curr Opin Obstet Gynecol

16、2007;19:20714.,子宫动脉栓塞术后受孕率低，流产率高，不良妊娠结局多，而且可能会影响卵巢功能。（III）Mara M,Maskova J,Fucikova Z,Kuzel D,Belsan T,Sosna O.Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy.Cardiovasc Intervent Radiol 2008;31:7385.Goodwin SC,Mc

17、Lucas B,Lee M,Chen G,Perrella R,Vedantham S,et al.Uterine artery embolization for the treatment of uterine leiomyomata midterm results.J Vasc Intervent Radiol 1999;10:115965.,子宫肌瘤切除术后必须剖宫产吗？,有文献随访了523例腹腔镜肌瘤切除术后病人，400例足月分娩，其中100例阴道分娩，子宫破裂率0.6%。孕期子宫瘢痕破裂仅见于肌壁间肌瘤切除未多层缝合或者术中过度使用电刀。Pregnancy Outcomes and

18、Risk Factors for Uterine Rupture After Laparoscopic Myomectomy:A Single-Center Experience and Literature Review.Seinera P,Arisio R,Decko A,Farina C,Crana F.Laparoscopic myomectomy:indications,surgical technique and complications.HumReprod 1997;12:192730.Parker WH,Einarsson J,Istre O,Dubuisson JB.Ris

19、k factors for uterine rupture after laparoscopic myomectomy.J Minim Invasive Gynecol 2010;17:5514.,参考文献,妇产科学Elizabeth A，Stewart，MD.Uterine Fibroids.N Engl J Med.2015;372(17):1646-1655.The Management of Uterine Leiomyomas.SOGC Clinical Practice Guidelines.J Obstet Gynaecol Can 2015;37(2):157178.Carranza-Mamane B,Havelock J,Hemmings R;Society of Obstetrics and Gynaecology Canada Reproductive Endocrinology and Infertility Committee.The Management of Uterine fibroids in women with otherwise unexplained infertility.SOGC Clinical Practice Guidelines.J Obstet Gynaecol Can 2015.,