宫内外复合妊娠的诊断与治疗

doi:10.12280/gjszjk.20200687

摘要/Abstract

摘要：

宫内外复合妊娠（heterotopic pregnancy,HP）是一种病理性妊娠疾病,在自然妊娠中较为罕见,但随着辅助生殖技术的发展,其发病率逐渐增加。输卵管因素和辅助生殖技术的应用是HP发病的主要因素。经阴道超声和血人绒毛膜促性腺激素（human chorionic gonadotropin,hCG）值的联合应用可提高对其诊断的敏感度,但早期因同时合并宫内妊娠且症状和体征缺乏特异性,易出现漏诊或延迟诊断。因此,对有高危因素的患者应提高警惕性,及早诊断,降低不良产科结局的发生率。HP的治疗以腹腔镜手术为主,其他治疗包括保守治疗、药物治疗等。由于患者生育需求不同,应采用个体化治疗方案,尽量减少对宫内妊娠的影响,争取获得较好的妊娠结局。HP若能早期明确诊断,积极治疗异位妊娠后,预后一般较好。

关键词: 妊娠, 复合, 妊娠, 异位, 生殖技术, 辅助, 甲氨蝶呤, 腹腔镜检查

Abstract:

Heterotopic pregnancy (HP) is a complicated pathological pregnancy, which is rare in natural pregnancy. However, with the development of assisted reproductive technology (ART), the incidence is gradually increasing. Tubal factors and the application of ART are the main factors of HP pathogenesis. It is easy to miss diagnosis or delay diagnosis because of simultaneous intrauterine pregnancy and lack of specificity of symptoms and signs in early stage. The combined application of transvaginal ultrasound and blood hCG value can improve the sensitivity of diagnosis. Therefore, patients with high-risk factors should be in well vigilant, and be diagnosed early, so as to reduce the incidence of adverse obstetric outcomes. Laparoscopic surgery is the main treatment for HP, and other treatments include conservative treatment and drug treatment. Because of the different reproductive needs of patients, the individualized treatment should be adopted to minimize the impact on intrauterine pregnancy and strive for a better pregnancy outcome. If HP can be diagnosed early and treated actively, the prognosis is generally better.

Key words: Pregnancy, heterotopic, Pregnancy, ectopic, Reproductive techniques, assisted, Methotrexate, Laparoscopy

常晓英, 王丽艳, 沈豪飞, 宋霁, 许灵波, 张学红. 宫内外复合妊娠的诊断与治疗[J]. 国际生殖健康/计划生育, 2021, 40(4): 344-347.

CHANG Xiao-ying, WANG Li-yan, SHEN Hao-fei, SONG Ji, XU Ling-bo, ZHANG Xue-hong. Diagnosis and Treatment of Heterotopic Pregnancy[J]. Journal of International Reproductive Health/Family Planning, 2021, 40(4): 344-347.

参考文献 22

[1]	胡晓吟, 张路, 林奕, 等. 胚胎移植后宫内外复合妊娠手术治疗264例分析[J]. 实用妇产科杂志, 2019, 35(9):710-713. doi: CNKI:SUN:SFCZ.0.2019-09-021. doi: CNKI:SUN:SFCZ.0.2019-09-021
[2]	Wang X, Ma D, Zhang Y, et al. Rare heterotopic pregnancy after frozen embryo transfer: a case report and literature review[J]. BMC Pregnancy Childbirth, 2020, 20(1):542. doi: 10.1186/s12884-020-03214-1. doi: 10.1186/s12884-020-03214-1 URL
[3]	Hewlett K, Howell CM. Heterotopic pregnancy: Simultaneous viable and nonviable pregnancies[J]. JAAPA, 2020, 33(3):35-38. doi: 10.1097/01.JAA.0000654012.56086.97. doi: 10.1097/01.JAA.0000654012.56086.97
[4]	Yu Y, Xu W, Xie Z, et al. Management and outcome of 25 heterotopic pregnancies in Zhejiang, China[J]. Eur J Obstet Gynecol Reprod Biol, 2014, 180:157-161. doi: 10.1016/j.ejogrb.2014.04.046. doi: 10.1016/j.ejogrb.2014.04.046 URL
[5]	刘风华, 李旎. 辅助生殖技术后发生宫内外同时妊娠的相关因素分析[J]. 中国优生与遗传杂志, 2010, 18(4):126-127,131. doi: CNKI:SUN:ZYYA.0.2010-04-063. doi: CNKI:SUN:ZYYA.0.2010-04-063
[6]	Xiao S, Mo M, Hu X, et al. Study on the incidence and influences on heterotopic pregnancy from embryo transfer of fresh cycles and frozen-thawed cycles[J]. J Assist Reprod Genet, 2018, 35(4):677-681. doi: 10.1007/s10815-017-1109-x. doi: 10.1007/s10815-017-1109-x URL
[7]	刘文霞, 刘曼曼, 管一春, 等. 经阴道超声引导下减胎术在输卵管间质部妊娠合并宫内孕中的应用——减胎成功2例报告[J]. 中华生殖与避孕杂志, 2017, 37(5):403-406. doi: 10.3760/cma.j.issn.2096-2916.2017.05.013. doi: 10.3760/cma.j.issn.2096-2916.2017.05.013
[8]	Lv S, Wang Z, Liu H, et al. Management strategies of heterotopic pregnancy following in vitro fertilization-embryo transfer[J]. Taiwan J Obstet Gynecol, 2020, 59(1):67-72. doi: 10.1016/j.tjog.2019. 11.010. doi: 10.1016/j.tjog.2019. 11.010 URL
[9]	Liu M, Zhang X, Geng L, et al. Risk Factors and Early Predictors for Heterotopic Pregnancy after In Vitro Fertilization[J]. PLoS One, 2015, 10(10):e0139146. doi: 10.1371/journal.pone.0139146. doi: 10.1371/journal.pone.0139146 URL
[10]	Nabi U, Yousaf A, Ghaffar F, et al. Heterotopic Pregnancy-A Diagnostic Challenge. Six Case Reports and Literature Review[J]. Cureus, 2019, 11(11):e6080. doi: 10.7759/cureus.6080. doi: 10.7759/cureus.6080
[11]	Hassani KI, Bouazzaoui AE, Khatouf M, et al. Heterotopic pregnancy: A diagnosis we should suspect more often[J]. J Emerg Trauma Shock, 2010, 3(3):304. doi: 10.4103/0974-2700.66563. doi: 10.4103/0974-2700.66563
[12]	吴丹, 张瑶, 张慧杰, 等. 复合妊娠的诊疗进展[J]. 国际生殖健康/计划生育杂志, 2021, 40(1):84-88. doi: 10.12280/gjszjk.20200139. doi: 10.12280/gjszjk.20200139
[13]	Stanic Z, Roje D, Matić D, et al. Spontaneous Heterotopic Pregnancy as an Uncommon Clinical Problem[J]. Z Geburtshilfe Neonatol, 2020, 224(4):223-226. doi: 10.1055/a-1079-6260. doi: 10.1055/a-1079-6260 URL
[14]	Yang X, Zhu L, Le F, et al. The effect of local aspiration and methotrexate injection on live interstitial pregnancy coexisting with live intrauterine pregnancy after assisted reproductive technology[J]. J Obstet Gynaecol Res, 2019, 45(7):1296-1302. doi: 10.1111/jog.13975. doi: 10.1111/jog.13975 URL
[15]	Kwon B, Kang S, Lee HJ, et al. Non-surgical management and obstetric outcomes of heterotopic interstitial pregnancies[J]. Minim Invasive Ther Allied Technol, 2020, 29(6):375-379. doi: 10.1080/13645706.2019.1653924. doi: 10.1080/13645706.2019.1653924 URL
[16]	Qiong Z, Yanping L, Deep JP, et al. Treatment of cornual heterotopic pregnancy via selective reduction without feticide drug[J]. J Minim Invasive Gynecol, 2011, 18(6):766-768. doi: 10.1016/j.jmig.2011.08.007. doi: 10.1016/j.jmig.2011.08.007 URL
[17]	徐俊翠, 刘明星, 龚景进, 等. 辅助生殖技术后复合妊娠49例的临床特点及治疗方式[J]. 实用医学杂志, 2018, 34(11):1843-1846. doi: 10.3969/j.issn.1006-5725.2018.11.022. doi: 10.3969/j.issn.1006-5725.2018.11.022
[18]	饶杰, 杨瑞敏, 苏高盛, 等. 连续硬膜外麻醉与气管插管静脉全麻下宫内外合并妊娠腹腔镜手术患者的妊娠结局分析[J]. 中华生殖与避孕杂志, 2018, 38(7):588-590. doi: 10.3760/cma.j.issn.2096-2916.2018.07.013. doi: 10.3760/cma.j.issn.2096-2916.2018.07.013
[19]	樊慧流, 应婷, 张佳. 单孔腹腔镜手术诊治输卵管妊娠在基层医院的应用价值[J]. 生殖医学杂志, 2019, 28(2):184-187. doi: 10.3969/j.issn.1004-3845.2019.02.016. doi: 10.3969/j.issn.1004-3845.2019.02.016
[20]	陈艳, 李怀芳. 单孔腹腔镜技术在妇科手术中的应用和进展[J]. 国际妇产科学杂志, 2013, 40(4):350-352,357. doi: CNKI:SUN:GWVC.0.2013-04-017. doi: CNKI:SUN:GWVC.0.2013-04-017
[21]	范晓东, 王怡, 朱颖军. 宫内外复合妊娠腹腔镜手术治疗34例分析[J]. 国际妇产科学杂志, 2019, 46(2):197-200. doi: 10.3969/j.issn.1674-1870.2019.02.020. doi: 10.3969/j.issn.1674-1870.2019.02.020
[22]	Guan Y, Ma C. Clinical Outcomes of Patients With Heterotopic Pregnancy After Surgical Treatment[J]. J Minim Invasive Gynecol, 2017, 24(7):1111-1115. doi: 10.1016/j.jmig.2017.03.003. doi: 10.1016/j.jmig.2017.03.003 URL