复发性妊娠丢失中的诊断不一致：宫腔镜解决超声-MRI对纵隔子宫的分歧，但同期促排卵阻碍了生殖结局的因果归因。

文献信息

中文摘要

背景： 先天性子宫异常是复发性妊娠丢失（RPL）的重要且可能可治疗的病因。纵隔子宫是与早孕期丢失相关的最常见苗勒管异常，其与良性弓形子宫的鉴别对治疗至关重要，但影像学方法可能不一致。方法：我们报告一例23岁女性（G2P0A2），表现为月经稀发和连续两次自然早孕期流产。初始经阴道超声提示纵隔子宫，而盆腔磁共振成像提示弓形子宫，导致诊断困惑。诊断性宫腔镜显示厚纤维性部分纵隔，并同时进行了宫腔镜子宫纵隔切除术。结果：无法完成全面的RPL评估：抗磷脂抗体检测、父母核型分析和流产物的遗传分析均不可用，因此无法排除其他病因，也不能确定纵隔是流产的唯一原因。全面的内分泌评估同样不可用，排卵功能障碍未能完全表征；不能排除瘦型多囊卵巢综合征表型。结论：在子宫纵隔切除术后及随后使用来曲唑促排卵，她受孕并通过剖宫产足月分娩一健康男婴。由于受孕仅发生在来曲唑之后，这两种序贯干预的相对贡献无法区分。未进行二次宫腔镜检查，因此从未客观确认宫腔恢复正常，受孕前不能排除残留纵隔或宫腔粘连。本病例展示了宫腔镜在解决不一致影像学中的诊断价值，同时强调不能将结局单独归因于子宫纵隔切除术。

英文摘要

Congenital uterine anomalies are an important and potentially treatable contributor to recurrent pregnancy loss (RPL). The septate uterus is the commonest Müllerian anomaly linked to first-trimester loss, and its differentiation from the benign arcuate uterus is essential for management, yet imaging modalities may disagree. We report the case of a 23-year-old woman (G2P0A2) who presented with oligomenorrhea and two consecutive spontaneous first-trimester miscarriages. Initial transvaginal ultrasound suggested a septate uterus, whereas pelvic magnetic resonance imaging indicated an arcuate uterus, resulting in diagnostic confusion. Diagnostic hysteroscopy revealed a thick, fibrous partial septum, and simultaneous hysteroscopic septoplasty was performed. A complete RPL evaluation was not possible: antiphospholipid antibody testing, parental karyotyping, and genetic analysis of products of conception were unavailable, so alternative etiologies could not be excluded and the septum cannot be established as the sole cause of the miscarriages. Comprehensive endocrine assessment was likewise unavailable, leaving ovulatory dysfunction incompletely characterized; a lean polycystic ovary syndrome phenotype could not be excluded. Following septoplasty and subsequent ovulation induction with letrozole, she conceived and delivered a healthy male infant at term by cesarean section. Because conception occurred only after letrozole, the relative contributions of these two sequential interventions cannot be distinguished. Second-look hysteroscopy was not performed, so restoration of a normal cavity was never objectively confirmed and residual septum or intrauterine adhesions could not be excluded before conception. This case demonstrates the diagnostic value of hysteroscopy in resolving discordant imaging while emphasizing that the outcome must not be attributed to septoplasty alone.