剖宫产瘢痕部位妊娠的超声分型及治疗效果的研究

The Analysis of Ultrasonic Classification and Treatment Effect for Cesarean Scared Pregnancy

目的:探讨剖宫产瘢痕部位妊娠(CSP)的超声分型及其对指导临床治疗的意义。方法:回顾性分析成都市第三人民医院2013年1月至2016年1月初诊收治的CSP 41例的临床资料,均根据Godin等提出的CSP B超影像诊断标准,结合剖宫产病史明确诊断。在Vial等的超声分型标准基础上超声测量孕囊处子宫肌层厚度,将其分为Ⅰ型组和Ⅱ型组。Ⅰ型组采用甲氨蝶呤(MTX)肌内注射治疗,3天后B超引导下清宫术;Ⅱ型组采用双侧子宫动脉化疗栓塞术(UACE)后B超引导下清宫术,或UACE后经腹或经腹腔镜或经阴式手术即病灶切除+子宫修补术。结果:Ⅱ型组与Ⅰ型组相比,孕囊处子宫肌层薄(Ⅰ型3.7±0.6 mm vsⅡ型2.1±1.1 mm),人工流产次数多(Ⅰ型1.5±0.6次vsⅡ型2.8±0.7次),差异均有统计学意义(P<0.05)。两组年龄、停经天数、剖宫产次数间的比较差异无统计学意义(P>0.05)。两组均治疗成功,术中出血、术前血β-HCG水平及术后恢复正常时间比较差异无统计学意义(P>0.05)。住院时间(Ⅰ型4.7±2.5天vsⅡ型8.6±2.7天)、费用(Ⅰ型5234.6±1688.8元vsⅡ型15668.4±4623.4元)Ⅱ型组均多于Ⅰ型组,差异均有统计学意义(P<0.05)。结论:根据CSP超声分型选择治疗方案针对性强,效果可靠,预后良好。术前应用UACE能有效控制术中出血,是CSP预处理治疗有效手段,因其费用较高,选择性使用于Ⅱ型CSP,性价比高。MTX肌内注射用于Ⅰ型CSP清宫术前,效果可靠,性价比高。

Objective： To explore the ultrasonic classification in cesarean scared pregnancy （CSP）and its effect on guiding the clinical treatment. Methods：The clinical data of 41 patients with CSP in the Third people＇s hospital of Chengdu from January 2013 to January 2016 were analyzed retrospectively. Diagnosis was confirmed according to the diagnostic criteria for ultrasound imaging by Godin etal and the history of cesarean section. Pa- tients were divided into type I group and type II group through measuring the outside uterine muscle layer thick- ness of pregnant bursa, based on the criteria by Vial et al. Type I ： MTX intramuscular injection followed by ultra- sound guided Dilation and Curettage（ D＆C）3 days later. Type ]] ：Uterine artery chemo-embolization（UACE） fol- lowed by ultrasound guided D＆C 2 days later,or lesion resection and repair of the uterus by trans-abdominal or laparoscopic or trans-vaginal operations 2 days later. Results：The outside uterine muscle layer of pregnant bursa in type II was more thinner than that in type I （2. 1 ±1.1 mm vs 3.7 ±0.6 mm,P〈0.05）.The number of abor- tion in type II was more than that in type I （2.8 ±0. 7 vs 1, 5 ±0.6,P〈0. 05）. There were no statistically signifi- cant differences in age,amenorrhea duration and the number of cesarean section （ P 〉 0.05）. Patients from two group were treated successfully,and there was no statistical significance about, intraoperative bleeding volume, preoperative serum levels of β-HCG and average recovery time of serum β-HCG （P 〉 0. 05）. The average hospi- tal stays and cost in type I were less than that in type II, with statistical significance （4.7 ± 2.5 vs 8.6 ± 2.7 clays,5234.6 ± 1688.8 vs 15668. 4 ±4623.4 RMB, P 〈0.05）. Conclusions ：The ultrasonic classification of CSP plays a directive role in making treatment option,with reliabe effect and the good prognosis. UACE as a pretreat- ment which can control intraoperative bleeding,is an effective method for CSP. For its higher cost, UACE should be selectively used in type II CSP, with cost-effective. MTX intramuscular injection used in type I CSP before D＆C is reliable and cost-effective.