子宫动脉灌注栓塞联合清宫术治疗子宫剖宫产瘢痕妊娠的效果评价

Curettage after uterine artery embolization combined with methotrexate treatment for caesarean scar pregnancy

为了探讨经子宫动脉甲氨蝶呤灌注＋子宫动脉栓塞联合清宫术对剖宫产瘢痕妊娠（CSP）的治疗价值,本文回顾性地分析了2003年2月至2013年4月首都医科大学附属北京妇产医院收治的140例CSP患者的临床资料。2003年2月至2010年3月35例CSP患者采用甲氨蝶呤全身及局部注射（简称MTX组）联合清宫术治疗。2010年4月至2013年4月105例CSP患者采用子宫动脉甲氨蝶呤灌注＋子宫动脉栓塞（简称子宫动脉灌注栓塞,UACE组）,栓塞术24～72 h内在超声引导下行超声/宫腔镜/腹腔镜监测下清宫术,分析其临床疗效。比较两组的手术时间、术中出血、血清人绒毛膜促性腺激素（HCG）转阴时间、住院时间和住院费用,并观察远近期副反应。结果表明,140例CSP的病例中,阴道超声和腹部超声联合检查确诊140例,北京妇产医院首诊108例病人,误诊3例。外院转诊32例中,均被误诊为宫内早孕而行流产术,术中发生大出血,来北京妇产医院确诊为CSP。采用甲氨蝶呤全身及局部注射联合清宫术,33例患者治疗成功,2例因过程中出现大出血而行全子宫切除术。105例患者采用子宫动脉甲氨蝶呤灌注＋子宫动脉栓塞联合清宫术治疗,100例患者治疗顺利,余下3例患者因清宫过程中再次大出血而行二次介入术,2例患者因介入术后血清HCG下降不满意,病理回报考虑滋养细胞疾病转至肿瘤科全身化疗。MTX保守治疗组和UACE治疗组的患者年龄、剖宫产次、妊娠时间、孕囊直径及血清β人绒毛膜促性腺激素（β—HCG）之间,差异无统计学意义,但UACE治疗组在清宫术中出血量,血清β—HCG恢复正常的时间及住院时间上,要明显少于MTX保守治疗组,两组差异有统计学意义。综上,早期诊断是成功治疗CSP的关键,阴道超声是CSP的首选确诊方法,经子宫动脉化疗栓塞联合清宫术治疗瘢痕妊娠是目前安全、快速、防止大出血的有效方法。

To evaluate the effect of curettage after uterine artery embolization and methotrexate（UACE）treatment for caesarean scar pregnancy（CSP）. A retrospective study on 140 patients diagnosed with CSP between February 2003 to April 2013 at Beijing Obstetrics and Gynaecology Hospital was carried out. 35 patients between February 2003 to March 2010 were offered systemic chemotherapy and local injection with methotrexate（MTX）prior to uterine suction curettage. 105 patients between April 2010 to April 2013 were offered prophylactic UACE prior to uterine suction curettage with using ultrasound/hysteroscopy/laparoscopy-guided uterine curettage. The operation time,blood loss,uterine retention rate,hospitalization days serum beta-HCG,menstrual recover,serious adverse effect and medical expense of two groups were recorded and compared. The results show that among 140 cases of CSP,108 cases were diagnosed in our hospital by transabdominal ultrasound and transvaginal ultrasound exactly. 3 cases were misdiagnosed in our hospital. 32 cases were referred from other hospitals where the initial management with uterine suction curettage had resulted in uncontrollable massive haemorrhage. In MTX group,33 patients with CSP recovered without complications and 2 patients underwent emergency hysterectomy for massive haemorrhage. In UACE group,100 patients were treated successfully with UACE. Three patients were received second UACE as uncontrolled massive vaginal hemorrhage. No significant difference in preoperative indicators was found between two groups including average age,menopause time,gestational sac diameter and β—HCG levels. But after the operation,we found significant difference between MTX group and UACE group in uterine retention rates. The significant differences were also observed in the amount of vaginal bleeding during uterine suction curettage：average hospitalization days,average resume time in β—HCG levels and medical expense between MTX group and UACE group. No treatmentrelated complications occurred in long-term observation in neither of the groups. Based observing our patients,it appears that ultrasound-guided curettage after uterine artery embolization combined with methotrexate may be an effective means of treatment for caesarean scar pregnancy.