剖宫产术后子宫瘢痕妊娠的诊断及急诊处理

Diagnosis and treatment of uterine scar pregnancy after cesarean section

目的:探讨剖宫产术后子宫瘢痕妊娠的诊断治疗方法及急诊处理措施。方法:回顾性分析2007-09-2011-09我科住院治疗的剖宫产术后子宫瘢痕妊娠患者临床资料25例。结果:25例患者均有剖宫产史,停经史,血HCG升高。其中10例患者在人流术前阴道超声诊断瘢痕妊娠;13例在人流时出血100～300ml,再经阴道超声诊断;2例人流术中出血800～1000ml休克,急行剖腹探查术中发现。术前明确诊断10例,用米非司酮+MTX+B超宫腔镜下清宫,效果满意;15例人流中出血较多者,其中5例经宫颈注射缩宫素,双合诊按压子宫下段30min后宫腔填塞纱布;另8例用22号Foleys尿管注液20～30ml压迫,术后24～48h取出,行双侧子宫动脉栓塞术,2d后行B超下清宫;2例出血过多伴休克剖腹探查时行子宫下段瘢痕处妊娠组织切除及子宫修补。25例患者均保全了子宫,保留了生育功能。结论:HCG、阴道超声在子宫瘢痕妊娠的诊断中的重要价值。应用米非司酮,MTX或子宫动脉栓塞,用B超或宫腔镜下清宫是治疗子宫瘢痕妊娠的有效方法。宫腔填塞纱布及Fo-leys尿管球囊注液局部压迫,对人流大出血时能取得很好的急诊止血作用,适合基层医院的紧急止血,为进一步及后续保留子宫治疗提供机会。

Objective：To investigate the diagnosis and emergency treatment of secondary pregnancy with cica- tricial uterus after cesarean section. Method：The clinical of 25 cases of uterine scar pregnancy after cesarean section in our hospital from September 2007 to September 2011 was retrospectively analyzed. Result： All the patients had the history of cesarean section, menopause and increase of serum HCG. 10 cases were diagnosed by transvaginal sonography before artificial abortion. 13 cases were diagnosed by transvaginal sonography after artificial abortion with 100--300ml of hemorrhage. 2 cases were found by urgent laparotomy during the surgery of artificial abortion with shock and 800--1000 ml of hemorrhage. 10 patients who were diagnosed before surgery, received the treat- ment of mifepristoneq-MTX＋B ultrasound hysteroscopy curettage, the result was satisfactory. Among the 15 ca- ses of abortion with bleeding,5 were treated with cervical injection of oxytocin,bimanual compression of lower u- terine segment and intrauterine with packing gauze for 30 minutes. Another 8 cases were treated with 22 Foleys catheter compression with infusion of 20--30ml liquid which was removed after 24--48 hours,then the patients re ceived the treatment of bilateral uterine artery embolization. B ultrasound hysteroscopy curettage was performed af- ter two days. 2 cases with excessive bleeding and shock were treated with lower segment scar tissue excision and repair of the uterus. The uterus and fertility of the 25 patients were preserved. Conclusion： HCG and transvaginal ultrasound play significant role in diagonosis of uterine scar pregnancy. The mifepristone, MTX or uterine artery embolization and B ultrasound hysteroscopy curettage are effective methods for treatment of uterine scar pregnan- cy. Uterine packing gauze and Foleys catheter balloon compression can achieve effective hemostasis, which is suit- able for emergency hemostasis in primary hospitals and can provide opportunities for preservation of uterus and fertility.