经阴道彩色多普勒超声引导应用水囊压迫后行刮宫术治疗剖宫产术后瘢痕妊娠的效果

Effect of transvaginal color Doppler ultrasound guidance in application of water sac compression for curettage of cesarean scar pregnancy

目的探讨经阴道彩色多普勒超声引导下应用水囊压迫后行刮宫术治疗剖宫产术后瘢痕妊娠（CSP）的效果。方法选择2013年1月-2016年1月上海市第一人民医院宝山分院收治的CSP患者40例，将其随机分入水囊压迫组和药物组，每组20例，分别在刮宫术前应用Foley导尿管球囊内注入40～60mL常温0．9％氯化钠溶液压迫CSP孕囊处24h或给予药物（甲氨蝶呤和米非司酮）治疗后，在超声引导下行刮宫术。观察患者治疗前，以及分别接受水囊压迫或药物治疗后的超声声像图特征；于刮宫术后1--2d和术后随访1～8周定期行超声检查的超声声像图特征，以及宫腔刮出物组织病理学检查结果；比较两组患者术中和术后24h的出血量，以及定期复查β-人绒毛膜促性腺激素（HCG）降至正常水平的时间。结果两组患者超声声像图均表现为孕囊型，部分患者见胚芽和心管搏动，切口处子宫肌层变薄，孕囊周围肌层彩色血流丰富。两组患者分别行水囊压迫或药物治疗后孕囊均明显缩小，孕囊周围血流信号减弱，血流阻力指数（RI）值增高。两组RI增高值的差异无统计学意义（P〉O．05）。行刮宫术后1～2d复查，两组超声声像图均表现为前壁切口处肌层回声增高，部分患者在切口处见混合性回声包块。水囊压迫组宫腔刮出物组织为蜕膜组织和胎盘组织蜕变，伴胚囊绒毛水肿；药物组宫腔刮出物组织为妊娠期子宫内膜伴绒毛。术后随访1～8周定期行超声检查，发现部分在切口处见混合性回声包块逐渐缩小直至恢复正常。水囊压迫组患者的术中和术后24h的出血量均显著少于药物组（P值均〈0．05）。术后定期复查血β—HCG结果显示，水囊压迫组患者的β-HCG降至正常水平的时间显著短于药物组（P〈0．05）。结论经阴道彩色多普勒超声检查能较准确地早期诊断CSP，并对其治疗和随访起到重要的监测作用。在治疗CSP的过程中，刮宫术前应用Foley导尿管球囊注水压迫治疗是一种简单易行、疗效显著的方法。

Objective To investigate the effect of transvaginal color Doppler ultrasound guidance in water sac compression for curettage of cesarean scar pregnancy （CSP）. Methods Forty CSP patients undergoing curettage from January 2013 to January 2016 admitted to Shanghai First People＇ s Hospital Baoshan Branch were enrolled in this study. The patients were randomly divided into water sac compression group and drug treatment group （n = 20）. Before curettage, 40- 60 mL normal saline was injected through Foley catheter balloon to compress the gestational sac （GS） for 24 h in water sac compression group, and methotrexate and mifepristone were used in drug treatment group. Ultrasound imaging features and pathological results of specimens from intrauterine curettage after treatment were analyzed. The amount of bleeding during operation and 24 h after operation and the time of beta-human.chorionic gonadotrophin （HOG） decreasing to normal level were compared between two groups. Results The ultrasound showed GS type imaging in all patients, embryo and fetal heart beat in some patients, thin uterine muscular layer at the incision, and rich blood flow in the muscular layer around the GS. In the two groups, the GS became smaller after treatment, and blood flow around the GS decreased and resistance index （RI） value increased. There was no significant difference in increased RI value between the two groups （P〉0.05）. All images showed higher echo at the anterior muscular layer of incision within 1 -- 2 days after curettage, and part of them showed mixed echo masses. In water sac compression group, specimens from the intrauterine curettage were decidual and placental tissues and embryo chorionic edema. In drug treatment group, specimens from the intrauterine curettage were gestational uterine endometrium and chorion. Regular ultrasound examination was done during follow-up （1 --8 weeks after surgery）, and postoperative mixed echo masses gradually became smaller and normal. The amounts of bleeding during operation and 24 h after operation in the water sac compression group were significantly less than those in the drug treatment group （both P〈0. 05）. The time of serum beta-HOG level decreasing to normal in the water sac compression group was significantly shorter than that in the drug treatment group （P〈0.05）. Conclusion Transvaginal color Doppler ultrasound can provide relatively accurate early diagnosis of CSP~ and has important monitoring effect on the treatment and follow-up. During the treatment of CSP, application of Foley balloon compression before curettage is an easy and feasible method. （Shanghai Med J, 2016, 39： 656-659）