宫腔镜联合子宫动脉栓塞术终止剖宫产术后子宫瘢痕妊娠的疗效与安全性

Management of cesarean scar pregnancy by hysteroscopy combined with uterine artery embolism

目的探讨宫腔镜终止剖宫产术后子宫瘢痕妊娠（CSP）的疗效和安全性。方法回顾性分析2003年8月至2010年12月浙江大学医学院附属妇产科医院收治的、术中采用B超或腹腔镜监护的33例采用宫腔镜治疗的CSP病例资料，观察分析孕龄、术前血B—hCG水平、子宫峡部肌层厚度、病灶形态、手术成功率、治愈率、手术时间、术中出血量、CSP包块消失时间、血13-hCG恢复正常时间以及并发症等。结果33例患者中位孕龄为54d（37—140d），术前中位血13-hCG为15000U／L（3．3～151747U／L），子宫峡部肌层厚度平均为3．3mm。33例中29例术前联合子宫动脉栓塞术（UAE），官腔镜下见91％（30／33）的患者子宫峡部凹陷呈腔隙状，所有病例妊娠物均突向宫腔或峡部腔隙内，采用宫腔镜电切割环联合刮宫清除妊娠物。平均手术时间为（34±10）min，手术成功率、治愈率均为94％（31／33），其中1例术后追加单次甲氨蝶呤（MTX）治疗。血[3-hCG术后平均（22±10）d恢复正常，子宫峡部包块平均（21±12）d消失。并发症发生率为9％（3／33），其中1例下肢静脉血栓形成，2例大出血并行子宫切除术，无子宫穿孔发生。出血量≤100ml者31例。术后4例再次妊娠，其中1例足月妊娠，3例人工流产各1次，无CSP复发。结论官腔镜联合UAE终止CSP安全、有效。

Objective To investigate safety and efficacy of hysteroscopy in treatment of cesarean scar pregnancy（CSP）. Methods From Aug. 2003 to Dec. 2011, 33 cases with CSP treated by hysteroscopy guided by transabdominal ultrasound or laparoscopy were studied retrospectively in Women＇s Hospital, School of Medicine, Zhejiang University. The clinical characteristics including gestational age, myometrial thickness anterior to the CSP, β-hCG level before treatment, success rate, cure rate, operative time, blood loss, time of serum β-hCG resolution and CSP mass clearance, and complication were collected and analyzed. Results Median gestational age was 54 days （ range, 37 - 140 days）. Median level of β-hCG before treatment was 15 000 U/L（range,3.3 - 151 747 U/L）. Mean thickness of anterior myometrium was 3.3 mm. Twenty-nine cases underwent uterine artery embolism （UAE） before hysteroscopy. Pouch in the anterior uterine isthmus with gestation masses implanted were observed in 30 cases （91%, 30/33 ）. CSP masses progressed toward the pouch or uterine cavity in all cases was removed by cutting wire loop electrode combined with curettage. The mean operative time was （34 ± 10 ） minutes. Both success rate and cure rate were 94% （31/33）. Salvage methotrexate （MTX）therapy was administrated in one case. Complication occurred in three cases （9% , 3/33 ）. Both massive hemorrhage rate and hysterectomy rate were performed in two cases （6%, 2/33）. No uterine perforation occurred. The mean time of hCG resolution was （22±10） days. The mean time of CSP mass clearance was （21 ± 12 ） days. Four pregnancies were achieved in four cases： one term pregnancy and three abortions. No recurrent CSP occurred. Conclusion Management of CSP by hysteroscopy combined with UAE is safe and effective.