腹腔镜下局部应用甲氨蝶呤治疗输卵管妊娠的临床观察

Clinical Observation on Local Methotrexate Injection under Laparoscopy for Tubal Pregnancy

【目的】探讨输卵管妊娠行腹腔镜保守手术时局部应用甲氨蝶呤的疗效。【方法1248例确诊为输卵管妊娠未破裂型的患者随机分成4组：A纽腹腔镜下清除病灶后局部注射生理盐水；B组腹腔镜下不行局部注射，而是立即行单次肌注甲氨蝶呤（MTX）50mg；C组腹腔镜下在病灶局部注射MTX20mg；D组腹腔镜下在病灶局部注射MTX50mg。观察术后持续性异位妊娠（PEP）发生率、血清β-绒毛膜促性腺激素（pHCG）水平变化、输卵管通畅情况及药物不良反应。【结果】A组PEP发生率为16．1％，B组为8．06％；C组和D组均为1．61％，A组明显高于其余组（P〈0．05），B组高于C组和D组（P〈0．05）；A组β-HCG水平在各个时点均高于其他各组（P〈0．05），C组和D组较B组下降更快，在术后3d、7d及12d均低于B组（P〈0．05）；A组手术侧通畅率59．7％，B组74．2％，C组91．9％，D组90．3％，A组通畅率低于其余组（P〈0．05），C组和D组通畅率高于B组（P〈0．05）；B组、C组和D组MTX不良反应无统计学差异（P〉0．05）。局部注射效果优于单次肌注，局部注射20mg与50mg无统计学差异。【结论】腹腔镜保守手术联合局部应用MTX20mg是要求保留生育功能的输卵管妊娠患者的适宜选择。

[Objective]To investigate the therapeutic effect of laparoscopic conservative surgery combined with local methotrexate（MTX） injection for the treatment of tubal pregnancy. [Methods] A total of 248 cases of tubal pregnancy without disrupture were chosen and randomly divided into 4 groups. Group A was given with normal saline, and group B was given with MTX 50mg i. m, and group C was locally injected with MTX 20mg and group D was locally injected with MTX 20mg. The incidence rate of PEP, changes of serum β-HCG, unobstructed conditions of fallopian tube and adverse effects of MTX were observed. [Results]The incidence rate of PEP of each group were 16.1%, 8.06%, 1.61% and 1.61%, respectively, and group A was the highest（ P〈0.05）, while group B was higher than group C and D（P〈0.05）. The level of serum β-HCG in group A was also the highest（ P 〈0.05）. The level of serum β-HCG in group C and D was decreasing faster than that in group B（ P G0.05）. The unobstructed rate of each group were 59.7%, 74.2%, 91.9% and 90.3%, respectively, and group A was the lowest, while group C and D were higher than group B. There was no difference about the adverse effects. The effect of local injection was better than that of intramuscular injection, and local use of 20mg was not different from that of 50mg. [Conclusion] Laparoscopic conservative surgery combined with 20mg methotrexate local injection for tubal pregnancy treatment is the proper choice.