目的:保守治疗的急性腹膜积血是深部子宫内膜异位症的先兆吗?
结论:我们的研究提供的证据表明,在相当大比例的病例中,急性腹膜积血可能导致深部子宫内膜异位症的发展。
背景:最近的一项初步研究首次表明急性腹膜出血可能是深部子宫内膜异位症的前兆。然而,样本量很小,由于凝块吸收和子宫内膜异位症的发生率未知,随访没有标准化。
■这是一项31个月内在一个中心进行的前瞻性观察性队列研究。使用先前研究的结果计算所需的样本大小为30,在有和没有明显腹膜的组中,每组至少有15名妇女(研究组和对照组,分别)。共有59名女性被招募到这项研究中,8名女性失去了随访。最终样本包括51名女性,研究组为15,对照组为36。
方法:所有非孕妇,年龄在18~50岁之间的绝经前女性,因严重急性下腹痛连续就诊于我们的妇科诊断室,符合本研究的条件.我们仅包括临床稳定且适合保守治疗的女性。那些在最初的超声扫描中有子宫内膜异位症病史或证据的人,以前子宫切除术,或双侧卵巢切除术被排除.参与者进行了6个月的标准化随访,每次访视时完成盆腔超声扫描和英国妇科内窥镜学会盆腔疼痛问卷。主要结果是超声检查证实存在新形成的子宫内膜异位症。次要结果是盆腔疼痛症状的存在和变化以及与健康相关的生活质量(HR-QOL)。
结果:完成随访后,7/15(47%;95%CI21.3-71.4%)出现急性腹膜出血的女性(研究组)出现了深部子宫内膜异位症的超声检查证据,与对照组的0/36(0%;97.5%CI0.0-9.7%)女性相比。功能性出血性囊肿破裂是腹膜出血的最常见原因,13/15例(87%)。从最初事件到超声检查发现子宫内膜异位症的时间从2到6个月不等。在基线时,发生和未发生子宫内膜异位症的组之间,EuroQol视觉模拟评分没有显着差异[28(四分位距(IQR)15-40,n=6)vs56(IQR35-75,n=44),P=0.09],而子宫内膜异位症组的EuroQol-5D值较低[-0.01(IQR-0.07至0.19,n=6)vs0.62(IQR0.24-0.73,n=44),P=0.002]。6个月时,两组的EuroQol-5D评分均有所改善,但与非子宫内膜异位症组相比,子宫内膜异位症组[0.69(IQR0.66-0.80,n=6)vs0.85(IQR0.76-1.00,n=44),P=0.03]。在任一时间点的骨盆疼痛评分均无临床相关差异。
结论:尚不确定是否最小,浅表子宫内膜异位症在研究开始时就存在,并在深部子宫内膜异位症的发生发展中起作用.尽管超声检查结果与深子宫内膜异位症一致,这在组织学上没有得到证实.当患者因急性疼痛入院时,骨盆疼痛和HR-QOL的发现可能受到基线评分的影响。此外,样本量太小,无法得出关于新发生的子宫内膜异位症对QoL影响的可靠结论.
结论:我们的研究提供了进一步的证据,表明严重的腹膜可能是深部子宫内膜异位症的前兆。血液动力学稳定的女性出现急性盆腔疼痛和明显的腹膜积血,应咨询发生深部子宫内膜异位症的风险。将来应进行介入研究,以了解腹腔镜检查和盆腔冲洗是否可以预防深部子宫内膜异位症的发展。预防性策略,包括抑制排卵和功能性囊肿形成的治疗,应该进一步调查。这包括联合避孕药和仅孕激素的避孕药。未来还需要更大规模的研究来评估更长时期的女性,在对混杂因素进行调整的情况下,评估对HR-QOL和疼痛症状的可能影响。
背景:资金来自妇科超声中心,伦敦,英国。TT收到了GE的个人费用,三星,美敦力,和默克公司的超声波讲座。TT还获得了挪威东南部卫生局的博士后资助(资助号2020083)。
背景:研究注册6472。
OBJECTIVE: Is acute haemoperitoneum that is managed conservatively a precursor of deep endometriosis?
CONCLUSIONS: Our study provides evidence to suggest that acute haemoperitoneum may lead to the development of deep endometriosis in a significant proportion of cases.
BACKGROUND: A recent pilot study was the first to suggest that acute haemoperitoneum could be a precursor of deep endometriosis. However, the sample size was small, and the follow-up was not standardized owing to unknown rates of clot absorption and development of endometriosis.
UNASSIGNED: This was a prospective observational cohort study conducted at a single centre over a 31-month period. A required sample size of 30 was calculated using results from a previous study, with a minimum of 15 women each in the groups with and without significant haemoperitoneum (study and control groups, respectively). A total of 59 women were recruited to the study and eight were lost to follow-up. The final sample comprised 51 women, 15 in the study group and 36 in the control group.
METHODS: All non-pregnant, premenopausal women aged 18-50 years who consecutively presented to our dedicated gynaecological diagnostic unit with severe acute lower abdominal pain were eligible for this study. We only included women who were clinically stable and were suitable for conservative management. Those with prior history or evidence of endometriosis on their initial ultrasound scan, previous hysterectomy, or bilateral oophorectomy were excluded. Participants had standardized follow-up visits for 6 months, with pelvic ultrasound scans and the British Society of Gynaecological Endoscopy pelvic pain questionnaires completed at each visit. The primary outcome was the sonographically confirmed presence of newly formed endometriosis. Secondary outcomes were the presence and change of pelvic pain symptoms and health-related quality of life (HR-QOL).
RESULTS: After completion of follow-up, 7/15 (47%; 95% CI 21.3-71.4%) women presenting with acute haemoperitoneum (study group) developed sonographic evidence of deep endometriosis, compared to 0/36 (0%; 97.5% CI 0.0-9.7%) women in the control group. A ruptured functional haemorrhagic cyst was the most common cause of haemoperitoneum, occurring in 13/15 cases (87%). The time from the initial event to sonographic evidence of endometriosis varied from 2 to 6 months. The EuroQol visual analogue scores were not significantly different at baseline between the groups that developed and did not develop endometriosis [28 (interquartile range (IQR) 15-40, n = 6) vs 56 (IQR 35-75, n = 44), P = 0.09], while the EuroQol-5D values were lower in the endometriosis group [-0.01 (IQR -0.07 to 0.19, n = 6) vs 0.62 (IQR 0.24-0.73, n = 44), P = 0.002]. At 6 months, the EuroQol-5D scores were improved in both groups, but remained significantly lower in the endometriosis group compared to the no endometriosis group [0.69 (IQR 0.66-0.80, n = 6) vs 0.85 (IQR 0.76-1.00, n = 44), P = 0.03]. There was no clinically relevant difference in the pelvic pain scores at either time point.
CONCLUSIONS: It remains uncertain whether minimal, superficial endometriosis existed at commencement of the study and had a role in the development of deep endometriosis. Although the ultrasound findings were in keeping with deep endometriosis, this was not confirmed histologically. The pelvic pain and HR-QOL findings could have been influenced by the baseline scores being taken when the patient was admitted with acute pain. Also, the sample size was too small to draw reliable conclusions regarding the impact of newly developed endometriosis on QoL.
CONCLUSIONS: Our study provides further evidence showing that significant haemoperitoneum may be a precursor of deep endometriosis. Haemodynamically stable women presenting with acute pelvic pain and significant haemoperitoneum should be counselled about the risk of developing deep endometriosis. Interventional studies should be carried out in the future to see whether laparoscopy and pelvic washout could prevent development of deep endometriosis. Preventative strategies, including treatment to suppress ovulation and formation of functional cysts, should be further investigated. This includes the combined and progesterone-only contraceptive pills. Larger future studies are also required to assess women over a longer period of time, with adjustment for confounding factors, to evaluate a possible effect on HR-QOL and pain symptoms.
BACKGROUND: Funding was obtained from The Gynaecology Ultrasound Centre, London, UK. TT received personal fees from GE, Samsung, Medtronic, and Merck for lectures on ultrasound. TT also received a postdoctoral grant from the South-Eastern Norwegian Health Authority (grant number 2020083).
BACKGROUND: researchregistry6472.