剖宫产瘢痕妊娠早期诊断与治疗方法的选择

Study on early diagnosis and treatment choice of cesarean scar pregnancy

目的:探讨剖宫产瘢痕妊娠的早期诊断与治疗方法的选择。方法:回顾性分析剖宫产瘢痕妊娠66例临床资料,所有病例均行阴道联合腹部彩超检查。其中47例行子宫动脉栓塞术(UAE)联合B超引导下清宫术(A组),9例行甲氨蝶呤(MTX)联合B超引导下清宫术(B组),10例行开腹子宫病灶切除术(C组)。结果:阴道联合腹部彩超的诊断准确率为92.4%。术中出血量A组少于B组和C组,B组少于C组(均P<0.05);术后阴道流血时间、住院时间及血β-hCG下降时间A组少于B组,C组少于B组(均P<0.05),A与C组比较差异无统计学意义(P>0.05);所有患者成功保留子宫并恢复正常月经,无严重并发症发生。结论:阴道联合腹部彩超是剖宫产瘢痕妊娠早期诊断的主要手段。剖宫产瘢痕妊娠的治疗应个体化,MTX可用于UAE或子宫病灶切除术的辅助治疗;开腹手术适用于病灶大,孕囊植入于子宫肌层深部,靠近浆膜层甚至侵犯膀胱的病例;UAE联合B超引导下清宫术的创伤小,安全有效。适用于剖宫产瘢痕妊娠发生急性大量出血或孕囊向子宫颈、峡部或宫腔生长的病例。

Objective： To explore early diagnosis and treatment choice of cesarean scar pregnancy （CSP）. Methods： The clinical data of 66 cases of CSP were analysed retrospectively. Patients underwent transvaginal in combination with transabdominal color Doppler ultrasonography. Forty-seven women were treated with uterine arterial embolization （UAE） in combination with ultrasonography-guided suction curettage （group A）, 9 women received methotrexate in combination with ultrasonography-guided suction curettage （group B）, and laparotomy lesion excision was conducted in 10 women （group C）. Results： The accuracy of transvaginal in combination with transabdominal color Doppler ultrasonography in the diagnosis of CSP was 92.4%. The intraoperative blood loss in group A was significantly less than those of the other groups, and that in Group B was significantly less when compared with group C （P〈0.05）. The durations of postoperative vaginal bleeding, hospitalization and serum β-hCG declining to normal in group A and group C were significantly less than those of group B （P〈0.05）, while no statistical difference was found between group A and group C. Women were healed without hysterectomy and severe complications. Resumption of normal menstrual cycles occurred in all women afterwards. Conclusions： Transvaginal in combination with transabdominal color Doppler ultrasonography is proved to be valuable in early diagnosis of CSP. The treatment choice of CSP should be individualized. Methotrexate could be used for assistant treatment of UAE or laparotomy lesion excision in the treatment of CSP. While laparotomy lesion excision is recommended for those with big focus, a gestational sac embedded into the deep myometrium, even into the bladder. UAE in combination with ultrasonography-guided suction curettage could be a safe and effective method, and be suggested for those with acute hemorrhea or a gestational sac growing towards cervical canal, uterine isthmus and uterine cavity.