Intrauterine embryo residue is a common clinical complication. Abnormal position of embryo residue can lead to re-residue after blind curettage, and possible intrauterine abnormality is the root cause of blind curettage. Using hysteroscopy to locate curettage can reduce blindness and unnecessary damage, find abnormal pregnancy, and find out whether there are uterine lesions or uterine malformations, which is more intuitive, accurate and reliable.
1 data and methods
1. 1 General information: From June 2008 to February 2008, 44 cases of intrauterine embryo residues were diagnosed and treated by hysteroscopy. The youngest patient was (li _huan zhe zui xiao) 18 years old, and the oldest patient was (sui _zui) 63 years old with an average age of 27 years old. Among them, there were 16 cases after drug abortion, 16 cases after induced abortion (including curettage after drug abortion), 7 cases after spontaneous abortion, 3 cases after induced labor and 2 cases after vaginal delivery. 36 cases showed irregular or persistent vaginal bleeding, 7 cases were amenorrhea, 1 case was only diagnosed as "suspected endometrial cancer" by B-ultrasound in physical examination. (ai2 _shou 1 zhi4 _) has the shortest course 10d, and the longest is more than 30 years. The instrument adopts Japanese Olympus hysteroscopy diagnosis system, circulating uterine dilation machine and monitoring system, German wolf company lighting and other supporting equipment, the uterine dilation pressure is set to 13- 15 kPa, and 5% glucose solution is used as uterine dilation medium.
1.2 diagnosis and treatment methods: routine gynecological examination and color Doppler ultrasound examination before operation to screen contraindications. Naproxen suppository was placed in anus 65438 05 minutes before operation. The patient empties the bladder (if B-ultrasound monitoring is needed during the operation, water should be injected into the bladder (Chao 1 Jian 1 Shizhe 3 Bang 3 Guang 1 Zhu 4) until the bladder is clearly developed by ultrasound), and the improved lithotomy position of the bladder is taken, put in a speculum, and clamp the cervix for exploration.
1.2.65438+
1.2.2 Hysteroscopic treatment: Observe the relationship and position between the obvious occupying tissue in the uterine cavity and the tube wall, then quit hysteroscopy, use oval forceps to directly enter the residual focus to clip out a large piece of tissue, and then scrape the focus area with a curette until there is no residue under the microscope. For those who are close to the uterine wall, the electrode ring is used for local lesion resection, and the depth of electrotomy is appropriate to see the normal muscle layer. For patients with active bleeding, spherical electrodes can be used to stop bleeding. Under the condition of emergency operation, patients with suspected scar pregnancy or cornual pregnancy after cesarean section were sucked out or curetted under the supervision of B-ultrasound, and those with less bleeding were treated with drugs after operation. Those who are found to have fertility requirements due to uterine malformation during the operation can be treated with hysteroscopic electrotomy on another day. All patients were given antibiotics orally or intravenously for 3-5 days to prevent infection according to the operation time and intrauterine conditions, and sexual intercourse and sitz bath (yu4fang2gan3ran3 _ jinzhi3xing4jiao1_ zuo4) were forbidden for 2 weeks.
Two results
2. 1 hysteroscopy diagnosis: All 44 patients were diagnosed as residual embryos under hysteroscopy, including scar pregnancy after cesarean section 1 case, mediastinum with uterine incompleteness 1 case, endometrial polyps in 2 cases, submucosal myoma of type II in 3 cases, (li _) endometrial hyperplasia 1 case, and periuterine. In addition, 1 elderly women suspected of endometrial cancer saw the long limbs of old fetal bones during the operation.
2.2 Pathological diagnosis: 22 cases of placenta and villi degeneration, 6 cases of proliferative endometrium with decidual tissue, 5 cases of degenerated villi or villi shadow with trophoblast 1 case, and only1case of bone fragments; Cellulose exudation and inflammatory cell infiltration were found in 4 cases. 1 Cases of endometrial hyperplasia were pathologically confirmed as "mild atypical hyperplasia".
2.3 postoperative follow-up: 1 case of scar pregnancy after cesarean section was successfully cleared by B-ultrasound combined with hysteroscopy, and MTX was used intravenously after operation. 1 week later, the blood HCG turned negative and was discharged, and the menstruation returned to normal 1.5 months after operation; The remaining 43 cases were all resected or resected once in the uterine cavity. Follow-up for 2-6 months showed that all patients recovered to normal menstruation without dysmenorrhea, and 3 cases were pregnant. No 1 patient had water poisoning (Shui Sheng Du Zhong by Li Huanzhe), uterine perforation, severe cardiocerebral syndrome and postoperative infection.
3 discussion
3. 1 Application of Gong Qiangjing in the diagnosis of intrauterine embryo residue: Hysteroscopy is the only instrument that can directly and accurately observe intrauterine diseases and is the gold standard for diagnosis of intrauterine diseases, so it is necessary to replace the blind diagnosis of curettage [1]. Some data show that the sensitivity of hysteroscopy in diagnosing intrauterine diseases is 93% [2]. The nature, size, shape and position of residual tissue can be observed under hysteroscopy. Early placental villi are flocculent tissues under hysteroscopy, which is somewhat similar to the phenomenon that villi are washed with water after abortion. When organized, irregular tissues in yellow-brown or yellow-white are attached to the wall, mostly loosely adhered. If there is fetal bone embedded in some muscle layers, the needle electrode can cut some muscle layers to observe the appearance of the bone, and its complete shape is an important basis for distinguishing it from endocardial ossification.
3.2 The value of hysteroscopy in the treatment of intrauterine embryo residues: It has been reported that even if experienced doctors perform blind curettage, there is still a missed diagnosis rate of intrauterine lesions as high as 35% [3]. Cohen et al. [4] retrospectively analyzed 70 patients who were clinically or ultrasonically suspected to have pregnancy residues, and 20.8% of the patients who were diagnosed and curetted by traditional methods underwent hysteroscopy because of the persistence of pregnancy residues. Hysteroscopic surgery is accurate and intuitive, which can solve this contradiction in clinic. Avoiding or reducing the secondary intrauterine adhesion and infertility caused by repeated curettage of normal endometrium has played a unique role in improving reproductive prognosis [5]. For the diagnosis and treatment of uterine cavity residues in special parts, such as uterine horn or scar after cesarean section, and patients with missed abortion and close relationship between residues and uterine wall, the correct removal method can be selected after accurate positioning, which eliminates the blind area of uterine curettage, reduces the risk of uterine wall injury and perforation, and is conducive to guiding treatment and discovering the causes of incomplete abortion, and can be used as the ideal first choice for diagnosis and treatment of pregnancy residues.
3.3 Hysteroscopy and scar pregnancy after cesarean section: Scar pregnancy after cesarean section is extremely rare in clinic, but with the increase of cesarean section rate in recent years, the incidence of this disease is on the rise. Seow et al. summarized the cases of 6 years, and the incidence rate was 1: 22 16, accounting for 6.1%of ectopic pregnancy [6]. At present, its formation mechanism is not clear, which may be related to the implantation of fertilized eggs in the tiny gap of cesarean scar. Due to the lack or defect of endometrial stromal decidua (Mian 4 Jian 1 Zhi 4 tui 4 Mo 2 Deficiency 1 Fa 2 Huo 4 You 3 Deficiency 1 Sun 3), chorionic cells directly invade the myometrium of uterus, forming intramuscular pregnancy and even penetrating the myometrium of uterus. The purpose of treatment is to kill the embryo, eliminate pregnancy products and preserve the patient's reproductive function. Among them, MTX and cesarean section are considered to be the best choices, but the operation has some shortcomings, such as big trauma, long hospitalization time and slow recovery. In the past, fatal vaginal bleeding often occurred in curettage, so most scholars listed curettage as a contraindication [6]. However, in recent years, with the wide application of hysteroscopy, especially hysteroscopic electrotomy, some scholars tried to perform curettage under the supervision of B-ultrasound, and combined with hysteroscopy and laparoscopy to make early diagnosis of cases without emergency surgical symptoms [7]. There are 1 case of early pregnancy residues in this group. Under the condition of (li4zao3qi1ren4shen1can2liu2huan4zhe3 _ zai4), hysteroscopy combined with B-ultrasound successfully performed uterine curettage, and the treatment was satisfactory.