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中华实验和临床感染病杂志(电子版) ›› 2021, Vol. 15 ›› Issue (06) : 402 -408. doi: 10.3877/cma.j.issn.1674-1358.2021.06.007

论著

非妊娠期肝硬化女性子宫异常出血临床特征及宫腔镜电切术疗效评价
周明书1, 郝一炜1, 伊诺1, 康晓迪1, 丛集美1, 宗艳丽2,†()   
  1. 1. 100015　北京，首都医科大学附属北京地坛医院妇产科
    2. 266000　青岛市，青岛市城阳区第一人民医院妇产科
  • 收稿日期:2021-04-27 出版日期:2021-12-15
  • 通信作者: 宗艳丽
  • 基金资助:
    教育部资助高等学校博士学科点专项科研基金(No. 20121107120011)

Clinical characteristics and the therapeutic effect evaluation of hysteroscopic electric resection of abnormal uterine bleeding in non-pregnant women with liver cirrhosis

Mingshu Zhou1, Yiwei Hao1, Nuo Yi1, Xiaodi Kang1, Jimei Cong1, Yanli Zong2,†()   

  1. 1. Department of Obstetrics and Gynecology, Beijing Ditan Hospital, Captial Medical University, Beijing 100015, China
    2. Department of Gynaecology and Obstetrics, The First People’s Hospital of Chengyang District, Qingdao, Qingdao 266000, China
  • Received:2021-04-27 Published:2021-12-15
  • Corresponding author: Yanli Zong
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引用本文：

周明书, 郝一炜, 伊诺, 康晓迪, 丛集美, 宗艳丽. 非妊娠期肝硬化女性子宫异常出血临床特征及宫腔镜电切术疗效评价[J]. 中华实验和临床感染病杂志(电子版), 2021, 15(06): 402-408.

Mingshu Zhou, Yiwei Hao, Nuo Yi, Xiaodi Kang, Jimei Cong, Yanli Zong. Clinical characteristics and the therapeutic effect evaluation of hysteroscopic electric resection of abnormal uterine bleeding in non-pregnant women with liver cirrhosis[J]. Chinese Journal of Experimental and Clinical Infectious Diseases(Electronic Edition), 2021, 15(06): 402-408.

目的

观察非妊娠期肝硬化女性子宫异常出血的临床特征以及探讨宫腔镜电切术的疗效。

方法

回顾性分析首都医科大学附属北京地坛医院妇产科2014年2月11日至2020年12月20日收治的152例子宫异常出血的非妊娠期患者，均行宫腔镜电切术。根据患者病史、症状、乙型肝炎病毒病原学、肝功能、凝血功能及超声诊断结果，将入组患者分为肝硬化组（22例）、慢性乙型肝炎组（67例）和对照组（63例）。分析3组患者的一般临床资料包括术前出血时长、术前出血量、住院时长、止血时长、输血以及急性出血患者比例、实验室检查结果[纤维蛋白原（FIB）、凝血酶原时间（PT）、凝血酶时间（TT）、活化的部分凝血活酶时间（APTT）、血红蛋白（Hb）、血小板（PLT）]，病理以及治疗总有效率。术前出血时长、术前出血量、住院时长、止血时长和实验室检查等计量资料两组间比较采用t检验或Mann-Whitney检验，多组间比较采用方差分析或KW检验；输血以及急性出血患者比例和病理以及治疗总有效率等计数资料采用Pearson卡方检验、连续校正卡方检验或Fisher’s确切概率法检验。

结果

肝硬化组、慢性乙型肝炎组和对照组患者术前出血时长、术前出血量、住院时长、止血时长、输血患者比例以及急性出血患者比例差异有统计学意义（F = 9.34、P < 0.001，F = 7.54、P < 0.001，F = 7.64、P = 0.01，F = 5.67、P = 0.02，χ2 = 8.64、P = 0.01，χ2 = 5.75、P = 0.02）；且肝硬化组患者上述指标显著高于慢性乙型肝炎组（t = 6.01、P = 0.02，t = 7.44、P = 0.01，t = 5.90、P = 0.02，t = 11.23、P < 0.001，χ2 = 10.45、P < 0.001，χ2 = 11.32、P < 0.001）。肝硬化组、慢性乙型肝炎组和对照组患者凝血功能指标（FIB、PT、TT、APTT、Hb和PLT）差异均有统计学意义（F = 11.36、P < 0.001，F = 8.35、P < 0.001，F = 8.33、P = 0.01，F = 15.64、P < 0.001，F = 7.34、P = 0.01，F = 10.36、P < 0.001）。肝硬化组（13.64%和9.09%）、慢性乙型肝炎组（2.99%和1.49%）和对照组（3.17%和0.00%）患者子宫内膜非典型增生和子宫内膜癌的发生率差异均有统计学意义（χ2 = 4.97、P = 0.02，χ2 = 8.61、P = 0.01）。三组患者宫腔镜电切术治疗后的总有效率（90.48%、89.55%和90.91%）差异无统计学意义（χ2 = 1.21、P = 0.32）；肝硬化组、慢性乙型肝炎组和对照组患者治疗后子宫异常出血的复发率（22.72%、20.89%和7.94%）差异有统计学意义（χ2 = 7.45、P = 0.01）。3组患者进行宫腔镜电切术术中和术后均未出现并发症。

结论

肝硬化可加重非妊娠期子宫异常出血的症状，宫腔镜电切术治疗非妊娠期肝硬化女性子宫异常出血安全有效，但存在一定复发风险。

关键词: 肝硬化, 子宫异常出血, 非妊娠期, 宫腔镜
Objective

To investigate the clinical features of abnormal uterine bleeding of non-pregnancy women with liver cirrhosis and analyze the therapeutic effect of hysteroscopy.

Method

Data of 152 non-pregnant patients with abnormal uterine bleeding treated in the Department of Obstetrics and Gynecology of Beijing Ditan Hospital, Capital Medical University from February 11st, 2014 to December 20th, 2020 were analyzed, retrospectively. The 152 patients were divided into cirrhosis group (22 cases), chronic hepatitis B group (67 cases) and control group (63 cases) according to the patients’ medical history, symptoms, etiological examination of hepatitis B virus, liver function, coagulation function and ultrasonic diagnosis results. The general clinical data of the three groups (length of preoperative bleeding, preoperative bleeding volume, hospitalization duration, hemostasis duration, ratio of cases with blood transfusion and acute bleeding), laboratory examination results [fibrinogen (FIB), prothrombin time (PT), thrombin time (TT), activated partial thromboplastin time (APTT), hemoglobin (Hb) and platelets (PLT)], pathology analysis and treatment effective of the three groups were analyzed, respectively. Comparison of every two groups for length of preoperative bleeding, preoperative bleeding volume, hospitalization duration, hemostasis duration and results of laboratory test were performed by t-test or Mann-Whitney test, and comparison between multiple groups for the above indexes were performed by analysis of ANOVA or KW test; the ratio of patients with acute bleeding and total treatment efficiency were calculated by Pearson Chi-square test, continuous correction Chi-square test or Fisher’s exact probability test.

Results

The length of preoperative bleeding, hospitalization duration, hemostasis duration, ratio of cases with blood transfusion and acute bleeding of cirrhosis group, chronic hepatitis B group and control group were significantly different (F = 9.34, P < 0.001; F = 7.54, P < 0.001; F = 7.64, P = 0.01; F = 5.67, P = 0.02; χ2 = 8.64, P = 0.01; χ2 = 5.75, P = 0.02), and the above indicators of patients in cirrhosis group were significantly higher than those of chronic hepatitis B group (t = 6.01, P = 0.02; t = 7.44, P = 0.01; t = 5.90, P = 0.02; t = 11.23, P < 0.001; χ2 = 10.45、P < 0.001; χ2 = 11.32, P < 0.001). The levels of FIB, PT, TT, APTT, Hb and PLT of patients in cirrhosis group, chronic hepatitis B group and control group were significantly different (F = 11.36, P < 0.001; F = 8.35, P < 0.001; F = 8.33, P = 0.01; F = 15.64, P < 0.001; F = 7.34, P = 0.01; F = 10.36, P < 0.001). The incidence of endometrial atypical hyperplasia and endometrial cancer of patients in cirrhosis group (13.64% and 9.09%), chronic hepatitis B group (2.99% and 1.49%) and control group (3.17% and 0.00%) were significantly different (χ2 = 4.97, P = 0.02; χ2 = 8.61, P = 0.01). Total efficiency of the three groups were 90.48%, 89.55% and 90.91%, with no significant difference (χ2 = 1.21, P = 0.32); the recurrence rate of abnormal uterine bleeding were 22.72%, 20.89% and 7.94% of patients in cirrhosis group, chronic hepatitis B and control group, with significant difference (χ2 = 7.45, P = 0.01). There were no complications during or after hysteroscopic hysterotomy among the patients of the three group.

Conclusions

Liver cirrhosis could aggravate the symptoms of abnormal uterine bleeding during non-pregnancy. Hysteroscopic electrosurgical treatment of abnormal uterine bleeding for women with non-pregnancy cirrhosis is safe and effective, but with a certain risk of recurrence.

Key words: Cirrhosis, Abnormal uterine bleeding, Non-pregnancy, Hysteroscopy
表1 三组患者临床资料
指标 对照组（63例） 慢性乙型肝炎组（67例） 肝硬化组（22例） 统计量 P值
平均年龄（ ± s） 46.63 ± 10.08 44.84 ± 11.77 47.77 ± 10.32 t = 2.67 0.894
生产史[例（%）] 29（46.03） 30（44.78） 10（45.46） χ2 = 2.55a 0.914
流产史[例（%）] 12（19.05） 13（19.40） 4（18.18） χ2 = 4.02b 0.075
未孕史[例（%）] 22（34.92） 24（35.82） 8（36.36） χ2 = 3.52a 0.241
术前出血时长（ ± s，d） 103.41 ± 8.97 122.33 ± 12.67 146.32 ± 16.14 t = 9.34 < 0.001
术前出血量（ ± s，ml/d） 4.56 ± 1.35 7.54 ± 1.44 10.35 ± 2.44 t = 7.54 0.010
住院时长（ ± s，d） 9.44 ± 3.64 14.37 ± 3.64 17.88 ± 2.36 t = 7.64 0.010
止血时长（ ± s，d） 2.67 ± 0.34 3.74 ± 0.56 4.31 ± 1.34 t = 5.67 0.020
输血[例（%）] 13（20.63） 22（32.84） 14（63.64） χ2 = 8.64a 0.010
急出血[例（%）] 5（7.93） 9（13.43） 10（45.45） χ2 = 5.75b 0.020
表2 三组患者的实验室指标（ ± s）
指标 对照组（63例） 慢性乙型肝炎组（67例） 肝硬化组（22例） F值 P值
FIB（g/L） 3.64 ± 1.01 1.34 ± 0.24 0.85 ± 0.14 11.36 < 0.001
PT（s） 11.10 ± 0.77 13.21 ± 5.24 14.85 ± 3.22 8.35 < 0.001
TT（s） 20.01 ± 3.11 24.62 ± 4.12 30.14 ± 3.71 8.33 0.010
APTT（s） 38.34 ± 5.34 43.61 ± 4.01 49.33 ± 3.09 15.64 < 0.001
Hb（g/L） 120.35 ± 18.64 104.59 ± 17.51 95.31 ± 19.18 7.34 0.010
PLT（× 109/L） 263.35 ± 54.17 113.64 ± 36.34 62.34 ± 18.66 10.36 < 0.001
图1 三组患者子宫内膜组织病理图（HE染色，× 100） 注：A：不伴非典型增生（对照组）；B：伴非典型增生（慢性乙型肝炎组）；C：子宫内膜癌（肝硬化组）
表3 三组患者子宫内膜组织病理学特征[例（%）]
组别 例数 正常组织 伴非典型增生 子宫内膜癌
对照组 63 61（96.83） 2（3.17） 0（0.00）
慢性乙型肝炎组 67 64（95.52） 2（2.99） 1（1.49）
肝硬化组 22 17（77.27） 3（13.64） 2（9.09）
χ2值   5.31a 4.97b 8.61c
P值   0.02 0.02 0.01
表4 三组患者的疗效[例（%）]
疗效 对照组（63例） 慢性乙型肝炎组（67例） 肝硬化组（22例） χ2值 P值
显效 45（71.43） 49（73.13） 16（72.72） 1.23a 0.30
有效 12（19.05） 11（16.42） 4（18.18） 0.83b 0.41
无效 6（9.52） 7（10.45） 2（9.09） 1.54b 0.21
总有效 57（90.48） 60（89.55） 20（90.91） 1.21a 0.32
复发 5（7.94） 14（20.89） 5（22.72） 7.45b 0.01
[1]
Khafaga A, Goldstein SR. Abnormal uterine bleeding[J]. Obstet Gynecol Clin North Am,2019,46(4):595-605.
[2]
Kaunitz AM. Abnormal uterine bleeding in reproductive-age women[J]. JAMA,2019,321(21):2126-2127.
[3]
Schaffrath SFG, Dreessen JRJ, Bongers MY, et al. Recurrence and prediction of abnormal uterine bleeding and re-intervention after initial hysteroscopic treatment: a retrospective cohort study[J]. Arch Gynecol Obstet,2019,300(6):1651-1657.
[4]
Goldstein SR, Lumsden MA. Abnormal uterine bleeding in perimenopause[J]. Climacteric,2017,20(5):414-420.
[5]
Chen L, Li S, Nie J, et al. Bmal1 regulates coagulation factor biosynthesis in mouse liver in Streptococcus oralis infection[J]. Front Cell Infect Microbiol,2020,10:530190.
[6]
Islam MS, Ciavattini A, Petraglia F, et al. Extracellular matrix in uterine leiomyoma pathogenesis: a potential target for future therapeutics[J]. Hum Reprod Update,2018,24(1):59-85.
[7]
中华医学会感染病学分会、中华医学会肝病学分会. 慢性乙型肝炎防治指南(2019年版)[J/CD]. 中华实验和临床感染病杂志(电子版),2019,13(6):441-466
[8]
Lee SA, Martina C, Bush EL, et al. Distant organ dysfunction in acute kidney injury: A review[J]. AM J Kidney Dis,2018,72(6):846-856.
[9]
朱玉莲, 陈霞, 包理丽, 等. 称重法和目测法在计算产后出血量的差异[J]. 江苏医药,2013,39(4):479-480.
[10]
Marnach ML, Laughlin-Tommaso SK. Evaluation and management of abnormal uterine bleeding[J]. Mayo Clin Proc,2019,94(2):326-335.
[11]
Santiago WS, Silva JBD, Pereira RM, et al. Abnormal uterine bleeding: hysterectomy versus resection [J]. Rev Assoc Med Bras,2020,66(12):1731-1735.
[12]
Elmaoğullar S, Aycan Z. Abnormal Uterine Bleeding in Adolescents [J]. J Clin Res Pediatr Endocrinol,2018,10(3):191-197.
[13]
Sun Y, Wang Y, Mao L, et al. Prevalence of abnormal uterine bleeding according to new international federation of gynecology and obstetrics classification in Chinese women of reproductive age: A cross-sectional study[J]. Medicine (Baltimore),2018,97(31):e11457.
[14]
Munro MG. Abnormal uterine bleeding: A well-travelled path to iron deficiency and anemia[J]. Int J Gynaecol Obstet,2020,150(3):275-277.
[15]
Zhang T, Guo J, Gu J, et al. Identifying the key genes and microRNAs in colorectal cancer liver metastasis by bioinformatics analysis and in vitro experiments[J]. Oncol Rep,2019,41(1):279-291.
[16]
Kur P, Kolasa-Wołosiuk A, Misiakiewicz-Has K, et al. Sex hormone-dependent physiology and diseases of liver[J]. Int J Environ Res Public Health,2020,17(8):2620.
[17]
Shapiro JP, Guzeloglu-Kayisli O, Kayisli UA, et al. Thrombin impairs human endometrial endothelial angiogenesis; implications for progestin-only contraceptive-induced abnormal uterine bleeding[J]. Contraception,2017,95(6):592-601.
[18]
He Y, Zhong J, Zhou W, et al. Four surgical strategies for the treatment of cesarean scar defect: A systematic review and network Meta-analysis[J]. J Minim Invasive Gynecol,2020,27(3):593-602.
[19]
Lee D, Park S, Ang MJC, et al. Evaluation of liver lesions by use of shear wave elastography and computed tomography perfusion imaging after radiofrequency ablation in clinically normal dogs[J]. Am J Vet Res,2018,79(11):1140-1149.
[20]
石艳, 肖绍树. 肝炎肝硬化门脉高压合并食管胃静脉曲张破裂出血与再出血危险性的预测[J/CD]. 中华实验和临床感染病杂志(电子版),2012,6(4):351-352.
[21]
Pennant ME, Mehta R, Moody P, et al. Premenopausal abnormal uterine bleeding and risk of endometrial cancer[J]. BJOG,2017,124(3):404-411.
[22]
Clarke MA, Long BJ, Del Mar Morillo A, et al. Association of endometrial cancer risk with postmenopausal bleeding in women: A systematic review and Meta-analysis[J]. JAMA Intern Med,2018,178(9):1210-1222.
[23]
Vitale SG, Ferrero S, Ciebiera M, et al. Hysteroscopic endometrial resection vs. hysterectomy for abnormal uterine bleeding: impact on quality of life and sexuality. Evidence from a systematic review of randomized controlled trials[J]. Curr Opin Obstet Gynecol,2020,32(2):159-165.
[24]
Friedman JA, Wong JMK, Chaudhari A, et al. Hysteroscopic myomectomy: a comparison of techniques and review of current evidence in the management of abnormal uterine bleeding[J]. Curr Opin Obstet Gynecol,2018,30(4):243-251.
[25]
高俊. 宫腔镜电切术治疗异常子宫出血的临床疗效观察[J]. 医学食疗与健康,2020,18(16):45-47.
[26]
Maheux-Lacroix S, Mennen J, Arnold A, et al. The need for further surgical intervention following primary hysteroscopic morcellation of submucosal leiomyomas in women with abnormal uterine bleeding[J]. Aust N Z J Obstet Gynaecol,2018,58(5):570-575.
[27]
Bradley LD. Diagnosis of abnormal uterine bleeding with biopsy or hysteroscopy[J]. Menopause,2011,18(4):425-433.
[28]
Levy-Zauberman Y, Pourcelot AG, Capmas P, et al. Update on the management of abnormal uterine bleeding[J]. J Gynecol Obstet Hum Reprod,2017,46(8):613-622.
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[15] 孔凡彪, 杨建荣. 肝脏基础疾病与结直肠癌肝转移之间关系的研究进展[J]. 中华临床医师杂志(电子版), 2023, 17(07): 818-822.
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