清宫术前子宫动脉化疗栓塞术治疗瘢痕妊娠的疗效分析

Therapeutic analysis of bilateral uterine artery chemoembolization performed before uterine dilation and curettage for cesarean scar pregnancy

目的探讨清宫术前双侧子宫动脉化疗栓塞术(UACE)对瘢痕妊娠的治疗意义。方法回顾性分析2005年1月至2009年1月收治的瘢痕妊娠患者104例,分为A组49例,直接行清宫术;B组55例,清宫术前24～72 h行UACE治疗,比较两组术中出血量、β人绒毛膜促性脉激素(β-hCG)降至正常时间、手术成功率、住院时间、并发症和术后月经情况等。结果A组中,4例因无法控制的阴道出血或反复清宫无效而行予宫切除术,B组无一例行子宫切除术。清宫手术成功率在A组为91.84%(45/49),B组为100%(55/55);术中出血量在A组为(96.73±153.30)ml,显著多于B组的(54.36±38.09)ml,两组间差异有统计学意义(P<0.01);但两组中孕期≤10周者间差异无统计学意义[(36.67±15.72)ml比(36.75±16.85)ml,P>0.05],而两组孕期>10周者比较,术中出血量差异有统计学意义[(457.14±97.59)ml比(101.33±39.43)ml,P<0.01)]。A组β-hCG下降至正常时间为(25.32±6.21)d,B组为(26.21±7.32)d,两组间差异无统计学意义(P>0.05)。A组和B组中孕期≤10周者的住院时间分别为(11.21±3.24)d和(12.68±4.56)d,两组间差异无统计学意义(P>0.05),而在孕期>10周者则分别为(19.34±5.72)d和(13.46±4.87)d,组间差异有统计学意义(P<0.01)。除4例子宫切除患者外,其余均在术后半年内恢复正常月经周期。结论UACE可减少清宫术中的出血量,降低了宫切除风险,提高清宫术的成功率,为患者保留生育能力,同时也减少了住院时间,特别适用于孕中期和急性阴道大出血的患者。

Objective To evaluate the clinical outcomes of bilateral uterine artery chemoembolization （UACE） followed by uterine dilation and curettage in treating cesarean scar pregnancy. Methods A total of 104 patients with cesarean scar pregnancy, admitted to hospital during the period from Jan. 2005 to Jan. 2009, were enrolled in the study. The patients were divided into group A （control group, n = 49） and group B （study group, n = 55）. Patients in group A received uterine dilation and curettage only, and patients in group B received additional UACE, which was performed 24-72 hours before uterine dilation and curettage was carried out. The blood loss during the operation, the time for β-human chorionic gonadotrophin （β-hCG） level going down to normal, the success rate of operation, the hospitalization days, the occurrence of complications and the menstrual situation after operation were documented. The results were analyzed and compared between the two groups. Results In group A, 4 patients had to receive hysterectomy due to massive hemorrhage or inadequate curettage. None of the patients in group B needed to have a hysterectomy. The technical success rates of curettage for group A and group B were 91.84% and 100%, respectively. The mean blood loss in group B was （54.36± 38.09） ml, which was significantly lower than that of （54.36 ± 38.09） ml in group A （P 〈 0.01）. No statistically significant difference in the mean blood loss existedbetween the patients with pregnancy time ≤10 weeks of the two groups [（36.67 ± 15.72）ml vs. （36.75 ± 16.85）ml, P 〉 0.05], while between those patients who had pregnancy time 〉 10 weeks, the blood loss in group B was much less than that of group A[ （101.33 ± 39.43）ml vs.（457.14 ± 97.59）ml, P〈 0.01） ]. The average time for ^-hCG to decline to normal level in group A was not significantly different from that in group B [（25.32 ± 6.21）days vs.（26.21 ± 7.32）days, P 〉 0.05]. The difference in hospitalization days between the patients with pregnancy time ~ 10 weeks in two groups [ （11.21 ±3.24）days vs.（12.68 ± 4.56）days]was not significant （P 〉 0.05）. But for patients with pregnancy time〉10 weeks, the hospitalization days of group B was significantly shorter than that of group A （13.46 ± 4.87 days vs. 19.34 ± 5.72 days, P 〈 0.01）. Except for 4 patients who had received hysterectomy, all patients regained normal menstruation cycle within half a year after the treatment. Conclusion Preoperative bilateral UACE can significantly reduce the blood loss during the uterine dilation and curettage procedure, effectively lower the risk of hysterectomy and reliably increase the success rate of curettage, thus to preserve the fertility of patients with cesarean scar pregnancy to the greatest possible advantage. Besides, this treatment can shorten the hospitalization time, and is especially suitable for the patients with middle stage cesarean scar pregnancy or with acute massive vaginal bleeding.