子宫动脉栓塞联合腹腔镜治疗外生型剖宫产瘢痕妊娠临床分析

Clinical analysis of uterine artery embolization combined with laparoscopy in the treatment of exogenous cesarean scar pregnancy

目的探讨子宫动脉栓塞预处理后联合腹腔镜治疗外生型剖宫产瘢痕妊娠(CSP)的可行性和安全性。方法回顾性分析2012-01-01-2019-12-31中国人民解放军总医院第七医学中心子宫动脉栓塞术联合腹腔镜治疗的65例外生型CSP患者临床资料,根据腹腔镜手术方式分为病灶切除组38例及腹腔镜监视下刮宫组27例,比较2组患者手术出血量、治疗结局、并发症、术后恢复情况。结果所有患者双侧子宫动脉栓塞均一次成功,过程顺利。2组患者均无输血,病灶切除组手术出血量平均(103.521±30.814)mL,刮宫组手术出血量平均(87.424±58.525)mL,差异无统计学意义,t=1.056,P=0.302。病灶切除组治疗成功率为100.0%(38/38),高于刮宫组的59.3%(16/27),差异有统计学意义,χ^(2)=15.760,P=0.005。2组患者均未发生术中及术后并发症;术后2~6周血清β-人绒毛膜促性腺激素(β-hCG)下降正常,术后5~8周月经正常恢复,5年内术后再孕率为52.0%(13/25)。对腹腔镜监视下刮宫组患者进一步分层结果显示,孕<8周、瘢痕的肌层厚度≥2 mm治疗患者17例,14例刮宫术治疗成功,3例有残留再次手术,而孕≥8周、肌层厚度<2 mm治疗的患者10例,仅2例治疗成功,治疗成功率比较,差异有统计学意义,χ^(2)=10.145,P=0.023。结论子宫动脉栓塞预处理控制出血确切,联合腹腔镜可用于外生型CSP的治疗安全有效;建议早诊早治,对于孕8周以内肌层厚度≥2 mm外生型CSP可考虑腹腔镜严密监测下行刮宫术。

Objective To investigate the clinical feasibility and safety of laparoscopic management combined with uterine artery embolization(UAE)for the treatment of exogenous cesarean scar pregnancy(CSP).Methods A retrospective analysis was conducted on clinical data of 65 patients with exogenous CSP who underwent UAE combined with laparoscopic treatment at the Seventh Medical Center of PLA General Hospital from January 1,2012,to December 31,2019.Patients were divided into two groups based on the laparoscopic surgical approach:lesion excision group(n=38)and laparoscopic surveillance-guided curettage group(n=27),Surgical blood loss,treatment outcomes,complications,and postoperative recovery were compared between the two groups.Results All patients underwent bilateral uterine artery embolization successfully in one attempt,and the procedure proceeded smoothly.There was no need for blood transfusion in either group.The mean surgical blood loss was(103.521±30.814)ml in the lesion excision group and(87.424±58.525)ml in the curettage group,with no statistically significant difference(t=1.056,P=0.302).The effective rate of treatment was 100.0%(38/38)in the lesion excision group,higher than that 59.3%(16/27)in the curettage group,with a statistically significant difference(χ^(2)=15.760,P=0.005).No intraoperative or postoperative complications occurred in either group.Bloodβ-human chorionic gonadotropin(β-HCG)levels declined normally 2-6 weeks postoperatively,and menstruation resumed normally 5-8 weeks postoperatively.The rate of subsequent pregnancy within 5 years postoperatively was 52.0%(13/25).Further stratification of patients in the laparoscopic surveillance-guided curettage group showed that among patients treated within 8 weeks of gestation with scar thickness≥2 mm,14 out of 17 cases were successfully treated with curettage,while 3 cases required additional surgery due to residual tissue.Conversely,among patients treated after 8 weeks of gestation with scar thickness<2 mm,only 2 out of 10 cases were successfully treated,showing a statistically significant difference in treatment efficacy,χ^(2)=10.145,P=0.023.Conclusions UAE pretreatment can control bleeding accurately,and combined with laparoscopy can be used in the treatment of exogenous CSP safely and effectively.Early diagnosis and treatment are recommended.For exogenous CSP with muscular thickness≥2 mm within 8weeks of pregnancy,close monitoring curettage under laparoscopy can be considered.