剖宫产术后瘢痕妊娠的个体化治疗方法探讨

Exploration of individualized therapy for cesarean scar pregnancy

目的分析剖宫产术后瘢痕妊娠的临床特点，探讨其早期诊断和个体化治疗方案。方法回顾性分析32例剖宫产瘢痕妊娠患者的临床资料及诊疗经过。结果患者均有停经史，23例发生停经后阴道点滴出血到中度流血。4例误诊为正常早孕或难免流产而行人流或药流，15例伴有轻微下腹痛。28例经阴道彩超确诊，4例行核磁共振成像确诊。6例（18．8％）因β-人绒毛膜促性腺激素较低行药物保守治疗；18例（56．3％）由于阴道流血较多行子宫动脉栓塞化疗＋清宫术；8例（25．0％）因包块较大植入较深，采用腹腔镜手术或开腹手术切除子宫病灶并修复瘢痕治疗。患者均痊愈出院，门诊随诊血13一人绒毛膜促性腺激素值至正常。药物保守治疗组、子宫动脉栓塞化疗＋清宫术组、手术治疗组的平均住院时间比较差异有统计学意义（F=25．96，P〈0．05）。结论阴道超声是诊断剖宫产瘢痕妊娠的有效方法，对患者应根据病情选择个体化的综合治疗方案。恰当应用甲氨蝶呤配伍米非司酮、子宫动脉栓塞＋清宫、子宫病灶切除及瘢痕修复均能取得良好的治疗效果。

Objective To analyze the clinical features of cesarean scar pregnancy（CSP） and explore the methods for early diagnosis and individualized treatment for it. Methods The clinical data and diagnosis and treatment of 32 cases with CSP were analyzed retrospectively. Results All cases had amenorrhoea and 23 cases had vaginal bleeding from spotting to moderate degree, Four cases were misdiagnosed as normal early intrauterine pregnancy or inevitable abortion and were treated with dilation and curettage or medical abortion. There were 15 cases with mild lower abdominal pain. There were 28 cases diagnosed by transvaginal B-ultrasound or color uhrasonography, and 4 cases diagnosed by MRI. Six cases （ 18.8% ） received drug conservative therapy because of low level of blood β-hCG, 18 cases （56.3%） were treated with uterine artery embolization plus curettage because of more vaginal bleeding, and 8 cases （25.0%） received laparoscope treatment or scar tissue excision and neoplasty by laparotomy because of large scar with deep implantation. All cases were cured and blood 13-hCG was followed up till it came to normal level. The difference in average stay among patients with conservative therapy, patients with uterine artery embolization plus curettage and patients with surgery was statistically significant （ F = 25.96, P 〈 0.05 ）. Conclusion Transvaginal sonography is an effective method to diagnose CSP, and individualized therapy should be selected according to situation of patients. Reasonable application of MTX and mifepristone, uterine artery embolization plus curettage, scar tissue excision and neoplasty can obtain good therapeutic efficacy.