Effects of modified tubal conservative operation on subsequent fertility outcomes of ampullary pregnancy

doi:10.3877/cma.j.issn.1673-5250.2018.04.008

Objective

To evaluate the safety, efficacy and subsequent fertility outcomes of modified tubal conservative operation in treatment of ampullary pregnancy.

Methods

From January 1, 2015 to June 31, 2016, a total of 70 cases of patients who were diagnosed as ampullary pregnancy in Shanghai Putuo Maternity and Infant Health Hospital were chosen as study subjects, and those 70 patients had fertility requirements to retain the fallopian tubes. According to random number table method, they were divided into study group (n=36, treated by modified tubal conservative operation) and control group (n=34, treated by laparoscopic salpingostomy). A retrospective analysis method was used to collect general clinical data of two groups, including age, gravidity, menopause days, etc., and to collect treatment status of two groups, including operation duration, intraoperative blood loss, incidence rates of persistent ectopic pregnancy (PEP) and intrauterine pregnancy at the 6th and 12th months after operation, recurrent ectopic pregnancy (REP) rate, and cure rate, etc.. The age, menopause days, preoperative blood β-human chorionic gonadotropin (hCG) levels, operation duration, and intraoperative blood loss of two groups were statistically compared by independent-samples t test. The gravidity and postoperative pain duration of two groups were statistically compared by Wilcoxon rank sum test. The incidence rates of intrauterine pregnancy, PEP, REP and cure rates of two groups were statistically compared by chi-square test. The proportions of different pain levels at the 3rd and 7th days after operation of two groups were statistically compared by Mann-Whitney U test. The study protocol was approved by the Ethical Review Board of Investigation in Human Being of Shanghai Putuo Maternity and Infant Health Hospital (Approval No. 2014-18). Informed consent was obtained from each participant.

Results

① There were no significant differences between two groups in the age, gravidity, menopause days, and preoperative blood β-hCG levels (P>0.05). ② The operative duration of study group was (58.3±11.2) min, which was significantly longer than that of control group (30.1±10.7) min, and the difference was statistically significant (t=10.759, P<0.001). The intraoperative blood loss of study group was (35.2±6.3) mL, which was significantly higher than that of control group (20.4±5.6) mL, and the difference also was statistically significant (t=10.370, P<0.001). ③ There was no significant difference between two groups in the incidence rates of intrauterine pregnancy and REP at the 6th month after operation (P>0.05). Follow-up results at the 12th month after operation showed that the incidence rate of intrauterine pregnancy in study group was 25.0% (9/36), which was significantly higher than that of control group 5.9% (2/34), and the difference was statistically significant (χ²=4.825, P=0.028); however, there was no significant difference between two groups in the incidence rate of REP (χ²=2.802, P=0.094).

Conclusions

Modified tubal conservative operation for ampullary pregnancy has the advantage of higher intrauterine pregnancy rate than that of laparoscopic salpingostomy, but it has a longer operation duration and higher intraoperative blood loss.

Key words: Pregnancy, tubal, Reproduction, Salpingostomy, Hysteroscopes, Guide-wire, indwelling, Women

图1 输卵管壶腹部妊娠患者行手术治疗前照片图

图2 输卵管壶腹部妊娠患者行改良输卵管保守性手术置入支架后照片图

表1 2组输卵管壶腹部妊娠患者一般临床资料比较

组别	例数	年龄(岁，±s)	孕次[次，M(P₂₅～P₇₅)]	停经天数(d，±s)	术前血β-hCG水平(IU/L，±s)	附件区包块最大径线(cm，±s)
研究组	36	24.3±4.2	1(1～3)	48.6±12.6	4 206.3±818.6	3.2±1.8
对照组	34	26.2±3.8	1(1～3)	47.7±15.3	4 095.6±899.8	3.1±1.9
检验值	?	t＝1.981	Z＝—0.986	t＝0.269	t＝0.539	t＝0.226
P值	?	0.052	0.324	0.788	0.592	0.822

表1 2组输卵管壶腹部妊娠患者一般临床资料比较

组别	例数	年龄(岁，±s)	孕次[次，M(P₂₅～P₇₅)]	停经天数(d，±s)	术前血β-hCG水平(IU/L，±s)	附件区包块最大径线(cm，±s)
研究组	36	24.3±4.2	1(1～3)	48.6±12.6	4 206.3±818.6	3.2±1.8
对照组	34	26.2±3.8	1(1～3)	47.7±15.3	4 095.6±899.8	3.1±1.9
检验值	?	t＝1.981	Z＝—0.986	t＝0.269	t＝0.539	t＝0.226
P值	?	0.052	0.324	0.788	0.592	0.822

表2 2组输卵管壶腹部妊娠患者手术时间和术中出血量比较

组别	例数	手术时间(min，±s)	术中出血量(mL，±s)
研究组	36	58.3±11.2	35.2±6.3
对照组	34	30.1±10.7	20.4±5.6
t值	?	10.759	10.370
P值	?	<0.001	<0.001

表2 2组输卵管壶腹部妊娠患者手术时间和术中出血量比较

组别	例数	手术时间(min，±s)	术中出血量(mL，±s)
研究组	36	58.3±11.2	35.2±6.3
对照组	34	30.1±10.7	20.4±5.6
t值	?	10.759	10.370
P值	?	<0.001	<0.001

表3 2组输卵管壶腹部妊娠患者术后疼痛程度及持续时间比较

组别	例数	疼痛程度[例数(%)]								疼痛持续时间[d，M (P₂₅～P₇₅)]
		术后第3天				术后第7天
		0级	Ⅰ级	Ⅱ级	Ⅲ级	0级	Ⅰ级	Ⅱ级	Ⅲ级
研究组	36	34(94.4)	2(5.6)	0(0)	0(0)	36(100.0)	0(0)	0(0)	0(0)	1(0～3)
对照组	34	32(94.1)	2(5.9)	0(0)	0(0)	34(100.0)	0(0)	0(0)	0(0)	1(0～3)
Z值	?	—0.907				－0.217				－0.104
P值	?	0.364				0.828				0.917

表3 2组输卵管壶腹部妊娠患者术后疼痛程度及持续时间比较

组别	例数	疼痛程度[例数(%)]								疼痛持续时间[d，M (P₂₅～P₇₅)]
		术后第3天				术后第7天
		0级	Ⅰ级	Ⅱ级	Ⅲ级	0级	Ⅰ级	Ⅱ级	Ⅲ级
研究组	36	34(94.4)	2(5.6)	0(0)	0(0)	36(100.0)	0(0)	0(0)	0(0)	1(0～3)
对照组	34	32(94.1)	2(5.9)	0(0)	0(0)	34(100.0)	0(0)	0(0)	0(0)	1(0～3)
Z值	?	—0.907				－0.217				－0.104
P值	?	0.364				0.828				0.917

表4 2组输卵管壶腹部妊娠患者术后第4天血β-hCG水平及血β-hCG水平恢复正常时间比较

组别	例数	术后第4天血β-hCG水平(IU/L，±s)	术后血β-hCG水平恢复正常(<5 IU/L)时间(d，±s)
研究组	36	678.5±213.2	20.2±4.7
对照组	34	732.5±242.2	19.8±5.1
t值	?	0.992	0.325
P值	?	0.342	0.734

表4 2组输卵管壶腹部妊娠患者术后第4天血β-hCG水平及血β-hCG水平恢复正常时间比较

组别	例数	术后第4天血β-hCG水平(IU/L，±s)	术后血β-hCG水平恢复正常(<5 IU/L)时间(d，±s)
研究组	36	678.5±213.2	20.2±4.7
对照组	34	732.5±242.2	19.8±5.1
t值	?	0.992	0.325
P值	?	0.342	0.734

表5 2组输卵管壶腹部妊娠患者术后PEP发生率及治愈率比较[例数(%)]

组别	例数	术后PEP	治愈
研究组	36	1(2.8)	35(97.2)
对照组	34	1(2.9)	33(97.1)
χ²值	?	—	—
P值	?	1.000	1.000

表5 2组输卵管壶腹部妊娠患者术后PEP发生率及治愈率比较[例数(%)]

组别	例数	术后PEP	治愈
研究组	36	1(2.8)	35(97.2)
对照组	34	1(2.9)	33(97.1)
χ²值	?	—	—
P值	?	1.000	1.000

表6 2组输卵管壶腹部妊娠患者术后宫内妊娠率及REP发生率比较[例数(%)]

组别	例数	宫内妊娠		REP
组别	例数	术后第6个月	术后第12个月	术后第6个月	术后第12个月
研究组	36	1(2.8)	9(25.0)	1(2.8)	1(2.8)
对照组	34	0(0)	2(5.9)	1(2.9)	6(17.6)
χ²值	?	—	4.825	—	2.802 ^a
P值	?	0.986	0.028	1.000	0.094

表6 2组输卵管壶腹部妊娠患者术后宫内妊娠率及REP发生率比较[例数(%)]

组别	例数	宫内妊娠		REP
组别	例数	术后第6个月	术后第12个月	术后第6个月	术后第12个月
研究组	36	1(2.8)	9(25.0)	1(2.8)	1(2.8)
对照组	34	0(0)	2(5.9)	1(2.9)	6(17.6)
χ²值	?	—	4.825	—	2.802 ^a
P值	?	0.986	0.028	1.000	0.094

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