Skip to main content
NCBI home page
Journal of Central South University Medical Sciences logoLink to Journal of Central South University Medical Sciences
. 2022 Nov 28;47(11):1568–1574. [Article in Chinese] doi: 10.11817/j.issn.1672-7347.2022.220248

宫腔粘连好发和相对严重部位的临床特征

Clinical features of the predilection and severer sites of intrauterine adhesions

YU Yang 1,1, ZOU Lingxiao 1, LI Waixing 1, ZHAO Xingping 1, SHU Changfa 1, CHENG Chunxia 1,✉, XU Dabao 1,✉
Editor: 傅 希文
PMCID: PMC10930625  PMID: 36481635

Abstract

Objective

Intrauterine adhesions (IUA) refers to the adhesions between the myometrium of the uterine cavity, which is secondary to damage to the basal layer of the endometrium due to trauma or infection. The occurrence of IUA is mainly related to intrauterine operations. Hysteroscopic adhesiolysis (HA) is the standard surgical treatment for IUA. But the recurrence rate of IUA after HA is still high. Importantly, endometrium recovery is difficult, resulting in unsatisfied prognosis for moderate to severer IUA patients. Therefore, it is important to take effective primary preventive measures against the etiology to avoid endometrium damage from medical surgery. In this paper, we discuss and analyze predilection and severer sites of intrauterine adhesions, aiming to provide a basis for how to avoid and reduce injuries during intrauterine operations, such as abortion, dilation and curettage.

Methods

In this study, we retrospectively analyzed the surgical videos of patients who underwent HA for the first time from January 2019 to December 2021 in the Third Xiangya Hospital of Central South University so as to assess the area of adhesions and predilection and severer sites of occurrence of adhesions, and we collected 657 patients who underwent HA for the first time, including 81 patients with total IUA and 576 patients with partial IUA. We counted and analyzed the number and composition ratio of partial IUA patients with severer sites of damage to the lateral wall of the uterine cavity and severerr sites of damage to each segment of the uterine cavity.

Results

Among 576 patients with partial IUA, there were 60 patients with no significant difference in the degree of adhesions between the right and left sides, 143 patients with severer adhesions on the left side of the uterine cavity, and 373 patients with severer adhesions on the right side of the uterine cavity. There was a difference in the severity of damage of left and right lateral wall. The proportion of patients with severer adhesions on the right side of the uterine cavity (64.8%) was higher than that of patients with adhesions on the left side of the uterine cavity (24.8%), and there was statistically difference (P<0.05). There was 93 patients with severer adhesions at the fundus or bilateral horn of the uterus, 190 patients with severer adhesions at the middle and upper part of the uterine cavity, 245 patients with severer adhesions at the middle and lower part of the uterine cavity and at the endocervix, and 48 patients with no significant difference in the degree of adhesions in each part. The proportion of patients with severer adhesions at the middle and lower part of the uterine cavity and at the endocervix was higher (42.5%) than those with adhesions in the fundus or bilateral horn of the uterus (16.1%) and in the middle and upper part of the uterine cavity (33.0%), and there were statistically differences (both P<0.05).

Conclusion

The predilection site of IUA is the lateral wall of the uterine cavity. The severer adhesions is in the right lateral wall of the uterine cavity, the middle and lower segments and the endocervix, which may be related to the operating habits of the surgeon. Therefore, gynecologists should minimize damage to the lateral wall of the uterine cavity, especially the right lateral wall in performing uterine operations (more attention should be paid by right-handed physicians). Besides, we should pay attention to protecting the middle and lower segments of the uterine cavity and the endocervix, avoiding maintaining negative pressure to withdraw the uterine tissue suction tube from the uterine cavity during abortion procedures to minimize damage.

Keywords: intrauterine adhesions, predilection of intrauterine adhesions, hysteroscopic surgery, induced abortion, complications

宫腔粘连(intrauterine adhesions，IUA)又称 Asherman 综合征，是指创伤或感染等病因造成子宫内膜基底层损伤后继发的宫腔肌壁间的粘连，可导致宫腔、宫颈管完全或部分闭塞，临床表现为月经量减少、闭经、不孕、反复流产等症状。IUA的发生与宫腔手术操作、宫腔感染、子宫内膜低灌注血流等多种因素有关[1]，研究[2-3]表明超过90%的IUA患者都有1次以上的宫腔手术史，其中最常见的是人工流产术和刮宫术。宫腔镜下宫腔粘连分离术(hysteroscopic adhesiolysis，HA)是治疗IUA的标准手术方式，在一定程度上可以改善IUA患者的宫腔内情况，但轻度至中度的IUA患者术后复发率达33.3%，重度IUA患者的术后复发率更是高达66.7%[4]，对于治疗效果满意的IUA患者，其术后妊娠率仅为40.4%~60.1%，活产率为64.0%~86.1%[3, 5]，且患者产后出血、胎盘残留、胎盘植入的发生率高达63.2%[3]。有些IUA患者术后虽然能够成功妊娠，但是孕早期可能由于稽留流产等原因再次行清宫术，从而进一步加重子宫内膜的损伤。因此，针对病因采取有效的一级预防措施，尽可能避免或减轻医源性子宫内膜损伤至关重要。本研究回顾性分析中南大学湘雅三医院(以下简称本院)657例首次进行HA患者的手术视频，了解并分析IUA及子宫内膜损伤的好发部位以及损伤相对严重部位的特点，希望能够为未来宫腔内操作(人工流产、清宫、宫内膜息肉切除术等)时如何避免和减少这些好发部位及相对严重部位的损伤提供研究基础。

1. 对象与方法

1.1. 对象

回顾性分析2019年1月至2021年12月在本院就诊的IUA患者的手术视频，共纳入657例首次进行HA的患者，年龄20~48岁，孕次0~10，产次0~4，流产0~10次，55.3%为中度粘连，44.7%为重度粘连(表1)，657例中全IUA患者81例，部分IUA患者576例，部分IUA患者的比例(87.7%)明显高于全IUA患者(12.3%)，差异有统计学意义(P<0.05)。576例部分IUA患者中，单纯周围型粘连381例，混合型粘连195例，无单纯中央型粘连和单纯周围型粘连患者所占的比例(66.1%)明显高于混合型粘连患者(33.9%)，差异有统计学意义(P<0.05)。657例患者中仅有1人无宫腔手术史，术后病理检查提示子宫内膜结核，其余患者均有宫腔手术史，病因由高到低依次为流产、引产、子宫内膜息肉切除、异常子宫出血清宫、残留妊娠组织清除、产后出血清宫、子宫畸形矫形、子宫内膜结核(表1)。

表1.

患者的一般资料

Table 1 General data of patients

观察指标 全部患者(n=657) 全宫腔粘连患者(n=81) 部分宫腔粘连患者(n=576)
年龄/岁 32.73±5.04 31.90±4.70 32.85±5.08
孕次 3.02±1.71 3.21±1.79 3.00±1.70
产次 0.55±0.61 0.54±0.50 0.55±0.62
流产次数 2.28±1.53 2.42±1.79 2.26±1.51
粘连程度/[例(%)]
中度 363(55.3) 0(0) 363(63.0)
重度 294(44.7) 81(100.0) 213(37.0)
粘连可能原因/[例(%)]
流产手术 622(94.70) 73(90.10) 549(95.30)
引产手术 18(2.70) 4(5.00) 14(2.40)
宫内膜息肉切除 6(0.90) 1(1.20) 5(0.90)
异常子宫出血清宫 4(0.60) 1(1.20) 3(0.50)
残留妊娠组织清除 3(0.50) 0 3(0.50)
产后出血清宫 2(0.30) 2(2.50) 0
子宫畸形矫形 1(0.15) 0 1(0.20)
子宫内膜结核 1(0.15) 0 1(0.20)
Open in a new tab

纳入标准：首次在本院进行HA的患者，手术视频清晰完整。排除标准：IUA合并子宫畸形(纵膈子宫、单角子宫等)、宫内膜息肉、黏膜下肌瘤、子宫内膜增殖症或妊娠物残留等。本研究经本院医学伦理委员会批准(审批号：快 22022)。

1.2. 方法

回顾符合纳入标准的患者的手术录像，评估患者的宫腔粘连面积及主要粘连部位和子宫内膜损伤相对严重的部位。在本研究中，将IUA面积≥90%、宫腔各部分损伤皆较重、较难分析损伤相对严重的部位的粘连判定为全IUA(图1)；将IUA面积<90%、易于分析损伤相对严重的部位的粘连判定为部分IUA。对于部分IUA，粘连位于宫底或宫腔侧壁者判定为单纯周围型粘连；粘连带仅于宫腔前后壁且与侧壁不相连者判定为单纯中央型粘连；中央型粘连合并周围型粘连则为混合型粘连。根据IUA和子宫内膜损伤的严重程度，分为宫腔左侧壁损伤相对严重、宫腔右侧壁损伤相对严重、左右侧壁损伤程度无明显差别(图2)；宫底或双侧宫角损伤相对严重(图3A、图3B、图3C)、宫腔中上段损伤相对严重(图3D)、宫腔中下段及宫颈内口损伤相对严重(图3E)及各部分损伤无明显差别(图3F)。

图1.

图1

Open in a new tab

宫腔镜检示全IUA

Figure 1 Total IUA by hysteroscopy

A: Adhesions of the middle and lower uterine cavity and the endocervix; B: Adhesions of the middle and upper uterine cavity after separating the IUA; C: Heavy damages in all parts of the uterine cavity, with more than >90% of IUA area, at the end of the operation. IUA: Intrauterine adhesions.

图2.

图2

Open in a new tab

宫腔镜检示部分IUA

Figure 2 Partial IUA in the uterine cavity by hysteroscopy

A and B: Right (A) and left (B) lateral wall in patient A, there is relative severer damage in 2B. C and D: Right (C) and left (D) lateral wall in patient B, there is relative severer damage in 2C. E and F: Right (E) and left (F) lateral wall in patient C, there is no significant difference between 2E and 2F. IUA: Intrauterine adhesions.

图3.

图3

Open in a new tab

宫腔镜检示部分IUA

Figure 3 Partial IUA in the uterine cavity by hysteroscopy

A: Right horn of the uterus adhesions; B: Fundus adhesions; C: Left horn of the uterus adhesions; D: Middle and upper part of the uterine cavity; E: Middle and lower part of the uterine cavity and the endocervix; F: Various parts of the uterine cavity. IUA: Intrauterine adhesions.

1.3. 统计学处理

采用SPSS 26.0软件进行统计学分析，计量资料以均数±标准差( x¯ ±s)表示。计数资料以频数和百分比(%)表示，采用单变量的χ 2检验，检验标准α=0.05，P<0.05为差异有统计学意义。

2. 结 果

2.1. 部分IUA患者宫腔侧壁损伤程度的比较

共纳入576例部分IUA患者，其中宫腔左侧壁和右侧壁损伤程度无明显差别60例，左侧壁损伤相对严重143例，右侧壁损伤相对严重373例，左右侧壁粘连严重程度存在差异，且右侧壁损伤相对严重的患者比例(64.8%)高于左侧壁损伤相对严重的患者(24.8%)，差异有统计学意义(P<0.05)。

2.2. 部分IUA患者宫腔各段损伤程度的比较

共纳入的576例部分IUA患者中，宫底或双侧宫角损伤相对严重者93例，宫腔中上段损伤相对严重者190例，宫腔中下段及宫颈内口损伤相对严重者245例，各部分损伤程度无明显差别者48例；宫腔中下段及宫颈内口损伤相对严重的患者比例(42.5%)高于宫底或双侧宫角损伤相对严重(16.1%)和宫腔中上段损伤相对严重的患者比例(33.0%)，差异均有统计学意义(均P<0.05)。

3. 讨 论

IUA是由于子宫内膜基底层损伤后继发的宫腔肌壁间的粘连，任何宫腔操作都有可能造成子宫内膜基底层的损伤，促使纤维结缔组织增生和子宫内膜再生障碍，进而导致IUA[6]。随着无痛人流术的推广以及宫腔镜在临床上的广泛应用，IUA的发生率和诊断率也大大提高[7]。一般来说，妊娠期子宫比非妊娠期的子宫有更大的粘连风险[4]，Gilman等[8]发现在经历扩宫和刮宫术处理的患者中，IUA的发生率为15%，另外一项研究[9]也报告了类似的发病率，人工流产术后的患者，1年内通过宫腔镜进行评估，19%的患者发现有IUA。还有研究[10]表明对于不全流产重复清宫的患者，其术后IUA的发生率更是高达40%。

HA是治疗IUA的标准手术方式，但是单纯的手术治疗后，IUA的术后复发率高[11]。近年来通过宫腔镜手术、物理屏障(宫内节育器、透明质酸、球囊等)和雌激素药物等多种治疗方式联合治疗IUA，在一定程度上降低了IUA的复发率，但是对于中度至重度IUA患者来说，子宫内膜损伤严重，尤其是术前超声检查提示子宫内膜薄的患者即使术后雌激素辅助治疗也较难恢复[12-13]。

本文回顾本院近3年IUA患者的手术录像，评估IUA的面积和内膜损伤相对严重的部位，发现IUA最好发于宫腔侧壁，且宫腔右侧壁比左侧壁损伤更加严重。目前没有证据[14-17]证明宫腔左右侧壁胚胎着床率有差异，造成IUA右侧比左侧更加严重的差异不大可能与胚胎着床部位有关，因此猜测宫腔右侧壁损伤相对严重的患者比例高于左侧壁损伤相对严重者的比例的原因可能与施行宫腔手术医生的优势手有关。在普通人群中，大多数医生优势手为右手，进行人工流产或清宫等宫腔操作时，术者很容易不知不觉中对宫腔右侧壁的操作力量较宫腔左侧壁大，导致宫腔右侧壁损伤较宫腔左侧壁严重。这一现象是首次发现并提出，提示妇科医生日后进行宫腔操作时，应注意控制优势手的操作力度，尽量避免或减轻对宫腔侧壁尤其是宫腔右侧壁的损伤(优势手为左手的术者则注意避免或减轻对患者宫腔左侧壁的损伤)。

有研究[17]提示宫腔上段的胚胎着床率明显高于宫腔中下段，但本研究通过回顾性分析发现宫腔中下段及宫颈内口损伤相对严重的患者比例高于宫底部及双侧宫角和宫腔中上段的患者比例，也说明这个现象不是由于胚胎着床部位的差异所致，而可能与人工流产术中宫腔内的负压吸引管对相对狭窄的宫腔中下段更加容易损伤或者吸引管带有负压经过了宫腔中下段及宫颈内口有关[18-19]。因此建议妇科医生日后进行宫腔操作时，需结合患者术前四维彩色B超或者宫腔镜检的结果，尽量对胚胎着床部位进行吸引，避免对宫腔其余部位过度和反复吸引，同时也要避免在维持负压的情况下从宫腔中撤出宫腔组织吸引管，这有可能会减少宫腔中下段和宫颈内口的损伤。

本研究是单中心回顾性研究，存在一定的局限性，且无法验证入组患者既往妊娠时具体的胚胎着床部位，也无法追溯既往为入组患者施行宫腔操作的医生的优势手是右手还是左手，故未来需要进行大样本前瞻性的研究，以便进一步验证本研究的结果与猜想。

综上所述，基于本研究的结果，作者建议妇科医生进行宫腔操作时，要尽量减少对宫腔侧壁(特别是右侧壁)的损伤，右势手医生更加要注意对手部力量的控制，特别是要防止对患者宫腔的右侧壁造成损伤(左势手术者则反之)。同时也要注意在人工流产手术中，避免和减少对相对狭小的宫腔中段和下段及宫颈内口的损伤并避免吸引管带负压经过宫腔下段和宫颈内口，以减少损伤宫腔下段和宫颈内口。

基金资助

国家重点研发项目(2018YFC1004800)。

This work is supported by National Key Research and Development Program, China (2018YFC1004800).

利益冲突声明

作者声称无任何利益冲突。

作者贡献

于洋 研究设计，论文撰写和修改；邹凌霄、李外星 收集数据和统计分析；赵行平、舒常发 论文修改和指导；程春霞、徐大宝 实验构思和设计，论文修改和指导，研究经费支持等。所有作者阅读并同意最终的文本。

原文网址

http://xbyxb.csu.edu.cn/xbwk/fileup/PDF/2022111568.pdf

参考文献

  • 1. Christina AS, Keith I, Stephanie M, et al. A comprehensive review of Asherman’s syndrome: causes, symptoms and treatment options[J]. Curr Opin Obstet Gynecol, 2017, 29(4): 249-256. 10.1097/GCO.0000000000000378. [DOI] [PubMed] [Google Scholar]
  • 2. Amer MI, Abd-El-Maeboud K. Amnion graft following hysteroscopic lysis of intrauterine adhesions[J]. J Obstet Gynecol Res, 2006, 32(6): 559-566. 10.1111/j.1447-0756.2006.00454.x. [DOI] [PubMed] [Google Scholar]
  • 3. Xiao SS, Wan YJ, Xue M, et al. Etiology, treatment, and reproductive prognosis of women with moderate-to-severe intrauterine adhesions[J]. Int J Gynecol Obstet, 2014, 125(2): 121-124. 10.1016/j.ijgo.2013.10.026. [DOI] [PubMed] [Google Scholar]
  • 4. Anon . AAGL practice report: practice guidelines for management of intrauterine synechiae[J]. J Minim Invasive Gynecol, 2010, 17(1): 1-7. 10.1016/j.jmig.2009.10.009. [DOI] [PubMed] [Google Scholar]
  • 5. Diamond MP. Reduction of postoperative adhesion development[J]. Fertil Steril, 2016, 106(5): 994-997. 10.1016/j.fertnstert.2016.08.029. [DOI] [PubMed] [Google Scholar]
  • 6. Evans-Hoeker EA, Young SL. Endometrial receptivity and intrauterine adhesive disease[J]. Semin Reprod Med, 2014, 32(5): 392-401. 10.1055/s-0034-1376358. [DOI] [PubMed] [Google Scholar]
  • 7. 刘欣燕, 黄薇，郁琦, 等. 人工流产术后促进子宫内膜修复专家共识[J]. 中国实用妇科与产科杂志, 2021, 37(3): 322-326. 10.19538/j.fk2021030114. [DOI] [Google Scholar]; LIU Xinyan, HUANG Wei, YU Qi, et al. Expert consensus on promoting endometrial repair after induced abortion[J]. Chinese Journal of Practical Gynecology and Obstetrics, 2021, 37(3): 322-326. 10.19538/j.fk2021030114. [DOI] [Google Scholar]
  • 8. Gilman AR, Dewar KM, Rhone SA, et al. Intrauterine Adhesions Following Miscarriage: Look and Learn[J]. J Obstet Gynecol Can, 2016, 38(5): 453-457. 10.1016/j.jogc.2016.03.003. [DOI] [PubMed] [Google Scholar]
  • 9. Hooker AB, Lemmers M, Thurkow AL, et al. Systematic review and meta-analysis of intrauterine adhesions after miscarriage: prevalence, risk factors and long-term reproductive outcome[J]. Hum Reprod Update, 2014, 20(2): 262-278. 10.1093/humupd/dmt045. [DOI] [PubMed] [Google Scholar]
  • 10. Westendorp IC, Ankum WM, Ben WJ, et al. Prevalence of Asherman’s syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion[J]. Hum Reprod, 1998, 13(12): 3347-3350. 10.1093/humrep/13.12.3347. [DOI] [PubMed] [Google Scholar]
  • 11. Kou LF, Jiang X, Xiao SY, et al. Therapeutic options and drug delivery strategies for the prevention of intrauterine adhesions[J]. J Control Release, 2020, 318: 25-37. 10.1016/j.jconrel.2019.12.007. [DOI] [PubMed] [Google Scholar]
  • 12. Myers EM, Hurst BS. Comprehensive management of severe Asherman syndrome and amenorrhea[J]. Fertil Steril, 2012, 97(1): 160-164. 10.1016/j.fertnstert.2011.10.036. [DOI] [PubMed] [Google Scholar]
  • 13. Dreisler E, Kjer JJ. Asherman’s syndrome: current perspectives on diagnosis and management[J]. Int J Womens Health, 2019, 11: 191-198. 10.2147/IJWH.S165474. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14. 贺玉珍. 100例定位吸胚人工流产术的探讨[J]. 空军总医院学报, 1985, 1(3): 35-37. [Google Scholar]; HE Yuzhen. Discussion of 100 cases of positional aspiration abortion[J]. Journal of General Hospital of Air Force, 1985, 1(3): 35-37. [Google Scholar]
  • 15. 向志奎, 曾良驹, 濮德敏, 等. 胚囊定位吸刮宫术[J]. 武汉医学院学报, 1981, 25(3): 23-26 [Google Scholar]; XIANG Zhikui, ZENG Liangju, PU Demin, et al. Embryo sac localization aspiration and curettage[J]. Journal of Wuhan Medical College, 1981, 25(3): 23-26. [Google Scholar]
  • 16. Kawakami Y, Yamada K, Andoh K, et al. Assessment of the implantation site by transvaginal ultrasonography[J]. Fertil Steril, 1993, 59(5): 1003-1006. 10.1016/s0015-0282(16)55918-4. [DOI] [PubMed] [Google Scholar]
  • 17. Minami S, Ishihara K, Araki T. Determination of blastocyst implantation site in spontaneous pregnancies using three-dimensional transvaginal ultrasound[J]. J Nippon Med Sch, 2003, 70(3): 250-254. 10.1272/jnms.70.250. [DOI] [PubMed] [Google Scholar]
  • 18. Mo XL, Qin GR, Zhou ZL, et al. Assessment of risk factors of intrauterine adhesions in patients with induced abortion and the curative effect of hysteroscopic surgery[J]. J Invest Surg, 2019, 32(1): 85-89. 10.1080/08941939.2017.1376130. [DOI] [PubMed] [Google Scholar]
  • 19. Sun LN, Yu Y, Qi XX. Short-term effects of catheter pressure and time control in vacuum aspiration abortion for early high-risk pregnancies[J]. Iran J Public Health, 2017, 46(5): 634-639. [PMC free article] [PubMed] [Google Scholar]

Articles from Journal of Central South University Medical Sciences are provided here courtesy of Central South University

RESOURCES