宫内节育器异位至肠管内 1 例

2019-01-07 孙嘉敏 李改玲 刘丽雅 现代妇产科进展

患者, 女, 24岁, 因“间断性腹部隐痛10 天”就诊于当地医 院。行腹部DR示:距耻骨联合上约115mm 略左见丝状金属密 度影。行超声引导下取环失败,遂于2017 年3 月1 日转至郑州 大学第一附属医院。

1 病例简介

患者, 女, 24岁, 因“间断性腹部隐痛10 天”就诊于当地医 院。行腹部DR示:距耻骨联合上约115mm 略左见丝状金属密 度影。行超声引导下取环失败,遂于2017 年3 月1 日转至郑州 大学第一附属医院。患者平素月经规律,末次月经2017 年2 月 20日。患者既往体健, G2P2,分别于2013 年8 月及2015 年9 月 足月顺产。2016年6月哺乳期置入宫内节育器( IUD) 1枚,型号 不详。置环2日后自觉下腹部腹胀感,休息可缓解,未行特殊治 疗。置环1月后复查彩超示:宫内节育器位置异常,具体情况不 明,未处理。查体:腹软,脐周轻压痛,无反跳痛,肠鸣音 4 次/ min,妇科检查未及异常。超声示:子宫及双附件未及异常,子宫 直肠陷凹内可见12mm不规则液性暗区。中下腹部CT 示:腹腔 肠管无明显占位征象,子宫大小形态可,盆内子宫上方见高密度 节育环影。初步诊断:宫内节育器异位。2017 年 3 月 3 日全麻下行“宫腹腔镜联合探查术”。宫腔镜探查示:宫内未见节育器, 宫腔形态完好,无粘连或瘢痕,双侧输卵管口可明视。腹腔镜探 查示:子宫大小正常,表面光滑完整,无瘢痕组织,无粘连带;双 附件、子宫阔韧带及腹膜未见异常;两侧髂窝及腹腔内无粘连炎 症痕迹;肠管色粉质软,蠕动情况可;肠钳反复探查大网膜,未查 及异物。平卧位行床旁DR:距耻骨联合上缘约8cm处见金属密 度影。遂于腹腔内宫底上方约3cm 处肠管表面置一缝合针定 位,头低30°行床旁 DR 示( 图 1A、 B):距耻骨联合上缘约15cm 处见金属密度影,距定位针影约7cm。上移定位针,再次行床旁 DR示:金属影与定位影部分重合。于定位处再次仔细探查肠 管,探及小肠肠壁表面突起,突起旁约1cm处肠管表面有约2mm ×3mm大白色瘢痕。遂行肠管切开术,完整取出一 V 型节育器 (图1C),行肠吻合术。节育器为金属材质,双侧末端膨大,为爱 母节育器。手术过程顺利,术后患者恢复可。



2 讨 论

IUD异位与放置时间、环型选择及放环技术有关。IUD 异 位于子宫以外, 即IUD 进入盆腔、腹腔内为子宫外异位,是放置 IUD最严重的并发症之一,其发生率约 0.03%~0.28%。哺乳期 子宫壁薄、 软,宫腔较小,放置的 IUD 往往较大,不断刺激子宫, 并且哺乳引起了子宫收缩,从而造成 IUD 逐渐移位嵌入子宫肌 壁。研究表明,哺乳期6 个月以内放置 IUD 可明显增加异位的 风险。本例患者哺乳期放环,爱母环两脚跨度大,易刺激子宫收 缩导致穿孔,辅助检查宫内及肌壁均未见 IUD,应充分考虑子宫 外异位可能。异位的IUD在腹腔可能发生游走,增加取环难度, 且危及邻近脏器。由于IUD异位造成粘连,可引起腹痛、阴道不 规则出血、异位妊娠、慢性疼痛甚至不孕,或异位至邻近器官导 致肠梗阻、肠穿孔、膀胱损伤等严重并发症。因此,一旦发现 IUD异位,即使无症状也建议立即将异位的 IUD 取出。腹腔镜 手术具有微创、恢复快的优点,适用于超声发现宫内无IUD, 且X线或CT检查诊断IUD在盆腹腔内的进一步探查。腹腔镜手术 已成为IUD子宫外异位首选的治疗方法。当 IUD 异位至肠管、 盆腔内,同时粘连严重或 IUD 靠近大血管输尿管时腹腔镜诊治 有困难,可选择行开腹探查进一步治疗。本例患者无明显临床 症状及体征,且术中探查未见明显因避孕环异位造成的粘连或 肠梗阻痕迹,警示对无明显腹痛症状的置环患者应提高重视,不 能完全排除环异位可能,必要时需影响学相关检查,明确诊断。 本例患者术中使用腹腔镜探查结合床旁影像设备明确IUD异位 位置,提示此不失为一种 IUD 异位至肠管时可避免开腹探查的 有效方法。医护人员应加强对放置宫内节育器患者的宣教, 强 调定期检查,以便及时发现IUD的异常情况,早期发现问题并及 时处理,避免更为严重的并发症发生。针对考虑 IUD 子宫外异 位患者,应仔细询问病史,有无腹痛、腹痛发生时间及泌尿、消化 系统相关症状,可提供异位相关信息及诊疗思路。

参考文献略。

原始出处:

孙嘉敏,李改玲,刘丽雅,韩丽萍. 宫内节育器异位至肠管内1例[J]. 现代妇产科进展,2018,27(10):800.

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    2019-01-15 jyzxjiangqin

    宫内节育器异位。

    0

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    2019-01-10 尹乔

    有的孕妇要求剖宫产手术同时放置节育环,更是增加环移位的风险

    0

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    2019-01-07 jyzxjiangqin

    宫内节育器异位。

    0

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