謝明聰，連興剛

(上虞區(qū)第二人民醫(yī)院，浙江上虞 312365)

不同LEEP術(shù)治療CINⅡ患者與妊娠結(jié)局相關(guān)性研究

謝明聰，連興剛

(上虞區(qū)第二人民醫(yī)院，浙江上虞 312365)

目的 探討宮頸電環(huán)切除術(shù)(LEEP)對(duì)宮頸上皮內(nèi)瘤變(CIN)Ⅱ患者術(shù)后妊娠結(jié)局的影響。方法 收集2004至2011年因?qū)m頸高度病變行LEEP術(shù)、術(shù)后成功受孕并已終止妊娠的婦女100例作為研究組，根據(jù)接受的不同LEEP術(shù)式將其分為“一刀法”和“兩刀法”組，比較兩組的錐切范圍及預(yù)后。選擇同期門(mén)診無(wú)宮頸治療史的健康孕產(chǎn)婦102例為對(duì)照組，追蹤并比較各組早產(chǎn)率、胎膜早破率、低出生體重率。結(jié)果 研究組行LEEP術(shù)后，妊娠婦女的早產(chǎn)率(2.00%)、胎膜早破率(3.00%)與對(duì)照組比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(均P>0.05)，兩組新生兒出生體重比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)?！耙坏斗ā钡腻F切深度小于“兩刀法”，且前者的術(shù)后殘留/復(fù)發(fā)率明顯高于后者，經(jīng)比較差異有統(tǒng)計(jì)學(xué)意義(t=0.034，P<0.05)；“一刀法”和“兩刀法”的錐切寬度、術(shù)后自然受孕率及不良妊娠事件發(fā)生率比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(均P>0.05)；而殘留/復(fù)發(fā)發(fā)生率比較差異有統(tǒng)計(jì)學(xué)意義(χ2=0.401，P<0.05)。結(jié)論 LEEP對(duì)術(shù)后懷孕婦女的妊娠結(jié)局無(wú)明顯影響?！皟傻斗ā盠EEP術(shù)作用明顯，而且對(duì)術(shù)后病變殘留/復(fù)發(fā)率具有明顯降低作用，并且未增加不良妊娠結(jié)局的發(fā)生。

宮頸上皮內(nèi)瘤樣病變；宮頸電環(huán)切除術(shù)；妊娠結(jié)局；一刀法；二刀法

隨著宮頸癌篩查方案的廣泛推廣，近年來(lái)宮頸上皮內(nèi)瘤變(cervical intraepithelial neoplasias，CIN)的發(fā)病率有漸漸升高的趨勢(shì)，且趨于年輕化[1-2]。目前，宮頸電環(huán)切除術(shù)(loop electrosurgical excisional procedure，LEEP)是臨床上治療CIN的常用有效方法之一[3-5]。本文就收治的100例CINⅡ患者行LEEP術(shù)后，對(duì)其術(shù)后妊娠結(jié)局進(jìn)行臨床研究。

1 資料與方法

1.1 一般資料

選擇2004年6月至2011年6月在上虞區(qū)第二人民醫(yī)院婦產(chǎn)科因CINⅡ行LEEP術(shù)后妊娠的產(chǎn)婦100例作為研究組，年齡為21～36歲，平均(29.9±3.8)歲；選擇同期住院產(chǎn)檢并分娩的產(chǎn)婦102例作為對(duì)照組，年齡為22～36歲，平均(30.1±2.5)歲，對(duì)照組均身體健康，無(wú)產(chǎn)科相關(guān)合并癥，妊娠前未進(jìn)行任何宮頸術(shù)。對(duì)研究組電話隨訪至2013年9月，了解其生育能力。兩組產(chǎn)婦在孕次(研究組：3.1±1.5，對(duì)照組：3.2±1.1)、產(chǎn)次(研究組：0.8±0.5，對(duì)照組：0.7±0.9)和年齡方面比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(均P>0.05)，具有可比性。

1.2 宮頸電環(huán)切除術(shù)法

“一刀法”：根據(jù)病灶大小，使用適宜的電環(huán)以50w功率切除宮頸陰道部病變區(qū)域?！皟傻斗ā保涸凇耙坏斗ā钡幕A(chǔ)上，常規(guī)以50w功率及較小電環(huán)切除部分頸管組織。

1.3 調(diào)查方法

觀察研究組受孕情況、隨訪兩組患者至妊娠結(jié)束，比較兩組產(chǎn)婦的胎膜早破率和早產(chǎn)率等病理妊娠情況，評(píng)估妊娠結(jié)局，以及殘留/復(fù)發(fā)率和自然受孕率。

1.4 統(tǒng)計(jì)學(xué)方法

2 結(jié)果

2.1 兩組妊娠結(jié)局情況

研究組與對(duì)照組的早產(chǎn)率、胎膜早破率和新生兒出生體重比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(均P>0.05)，見(jiàn)表1。

2.2 不同手術(shù)方法錐切深度與寬度對(duì)妊娠結(jié)局的影響情況

“一刀法”與“兩刀法”錐切寬度比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，而錐切深度比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)，見(jiàn)表2。

兩種不同LEEP術(shù)后總自然受孕率為97.00%?！耙坏斗ā焙汀皟傻斗ā苯M的自然受孕率及不良妊娠事件發(fā)生率比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(均P>0.05)，而殘留/復(fù)發(fā)發(fā)生率比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)，見(jiàn)表3。

3 討論

3.1 宮頸電環(huán)切除術(shù)后對(duì)妊娠的影響

宮頸疾病是生育期婦女常見(jiàn)疾病，發(fā)病率高。宮頸機(jī)能不全可引起晚期流產(chǎn)、早產(chǎn)，且近年有上升趨勢(shì)[6-7]。LEEP術(shù)是目前臨床上治療宮頸病變的主要手段，但LEEP術(shù)用于CIN的治療，有無(wú)不利影響尚在探索階段[8-9]。

LEEP術(shù)切除部分宮頸組織是否可引起宮頸口松弛或?qū)m頸機(jī)能不全而影響患者生育？李喜萍等[10]研究提示，LEEP術(shù)后妊娠，與對(duì)照組相比，平均新生兒出生體重、早產(chǎn)等發(fā)生率均無(wú)明顯差異。還有研究顯示，大多患者在LEEP術(shù)后妊娠分娩的早產(chǎn)率與正常人群相比無(wú)差異[11]。本研究中LEEP術(shù)后妊娠者的早產(chǎn)率為2.00%、胎膜早破率為3.00%，與文獻(xiàn)報(bào)道[10]基本相似。研究組新生兒平均出生體重為(3.25±0.29)kg，對(duì)照組為(3.44±0.26)kg，兩組新生兒體重比較差異無(wú)統(tǒng)計(jì)學(xué)意義。

3.2 “一刀法”與“兩刀法”宮頸電環(huán)切除術(shù)術(shù)的比較

目前大部分醫(yī)生依舊運(yùn)用傳統(tǒng)的“一刀法”LEEP術(shù)式。陽(yáng)霞等[12]運(yùn)用“一刀法”LEEP術(shù)式對(duì)92例CINⅡ患者進(jìn)行治療，患者發(fā)生病變復(fù)發(fā)/殘留率是22.2%；而Park等[13]用“兩刀法”LEEP術(shù)式治療236例CINⅡ患者，發(fā)生病變復(fù)發(fā)/殘留率只有4.2%。本資料中顯示，“一刀法”LEEP術(shù)后有3例(10.00%)患者發(fā)生復(fù)發(fā)/殘留，“兩刀法”LEEP術(shù)后有1例(1.43%)患者發(fā)生復(fù)發(fā)/殘留，兩者差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)，提示使用“兩刀法”LEEP治療CINⅡ患者可以降低術(shù)后病變殘留/復(fù)發(fā)率。本資料還顯示，進(jìn)行LEEP術(shù)后總自然受孕率為97.00%，“一刀法”與“兩刀法”治療的自然受孕率比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。本研究還發(fā)現(xiàn)，LEEP術(shù)后并未增加早產(chǎn)、胎膜早破等不良妊娠結(jié)局的反應(yīng)，并且“一刀法”與“兩刀法”LEEP術(shù)后不良妊娠結(jié)局發(fā)生率無(wú)明顯差異(P>0.05)。由此可以看出，“兩刀法”術(shù)式并未增加不良妊娠事件的發(fā)生率。

總之，宮頸環(huán)切術(shù)是治療CIN安全有效的方法，與“一刀法”LEEP術(shù)相比，“兩刀法”LEEP術(shù)不僅有效，而且對(duì)術(shù)后病變殘留/復(fù)發(fā)率有明顯降低作用，并未增加不良妊娠結(jié)局的發(fā)生，是一種臨床上常用的LEEP術(shù)式。

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[專業(yè)責(zé)任編輯：韓 蓁]

Correlation between different LEEP on patients with CINⅡand their pregnancy outcomes

XIE Ming-cong, LIAN Xing-gang

(TheSecondPeople’sHospitalofShangyuDistrict,ZhejiangShangyu312365,China)

Objective To discuss the influence of loop electrosurgical excisional procedure (LEEP) on pregnancy outcomes of women with CINⅡ. Methods In this case-control study women treated with LEEP during the period of 2004 to 2011 and had conceived after the procedure were selected as study group (n=100), and they were divided into one incision method group and two incision method group. The conization depth and prognosis were compared between two groups. Healthy gravidas without cervical treatment history were chosen as control group (102 cases). The rates of preterm birth，premature rupture of membranes and low birth weight of different groups were compared. Results After LEEP the preterm birth rate (2.00%) and the rate of premature rupture of membranes (3.00%) of the study group were not significantly different from those of the control group (bothP>0.05), and the birth weight of neonates of two groups was not significantly different (P>0.05). The conization depth of one incision was less than that of two incisions, and the postoperative residual/recurrent rate of the former was significantly higher than the latter with significance difference (t=0.034,P<0.05). There were no significant differences in conization width, natural conception rate after surgery and incidence of adverse pregnancy events between one incision method and two incision method (allP>0.05), but the difference in residual/recurrent rate was significant (χ2=0.401，P<0.05).Conclusion LEEP has no remarkable influence on pregnancy outcomes of pregnancy women. Two incision method LEEP surgery has obvious effect and can effectively reduce the postoperative residual/recurrence rate without enhancing the adverse pregnancy events.

cervical intraepithelial neoplasia (CIN)；loop electrosurgical excision procedure (LEEP)；pregnancy outcomes；one incision method；two incision method

2014-10-10

謝明聰(1975-)，女，主治醫(yī)師，主要從事婦產(chǎn)科的臨床工作。

連興剛，副主任醫(yī)師。

10.3969/j.issn.1673-5293.2015.01.031

R713

A

1673-5293(2015)01-0081-03