重新评估诊断性刮宫在异位妊娠诊断中的作用

Reevaluating the Role of Dilation and Curettage in the Diagnosis of Ectopic Pregnancy

目的重新评估诊断性刮宫(D&C)在诊断异位妊娠(EP)中的临床作用。方法回顾性分析血β-人绒毛膜促性腺激素(HCG)异常增高但阴道超声未见到明确宫内妊娠囊且行D&C的不明部位妊娠患者118例和β-HCG>5 000 IU/L但未行D&C的患者24例,最终诊断来自诊刮后血β-HCG的变化、病理和腹腔镜检查结果。结果所有行D&C患者中,65.3%诊断为EP,34.7%诊断为宫内妊娠(IUP)。诊断为EP的患者诊刮前血β-HCG水平明显高于诊断为IUP的患者(P=0.005),而IUP组的平均产次明显高于EP组(P=0.001)。当β-HCG<2 000 IU/L时,EP组子宫内膜厚度≤5 mm的患者为8例(40.0%),IUP组为3例(11.0%)(P=0.035)。EP的诊断率在β-HCG<2 000 IU/L和2 000 IU/L<β-HCG<5 000 IU/L时分别为42.6%和68.3%(P=0.012)。在β-HCG>5 000 IU/L的患者中,诊刮组和未诊刮组EP的诊断率差异无统计学意义(96.7%比96%,P=0.915)。结论虽然子宫内膜薄、存在盆腔包块与EP相关,但是不能作为诊断EP的独立因素。为了避免误诊和不必要的甲氨蝶呤的治疗,在2 000 IU/L<β-HCG<5 000 IU/L可疑EP的患者中,D&C仍有重要的作用;当患者血β-HCG>5 000 IU/L、宫内无妊娠囊且存在盆腔包块时,EP的可能性极大,D&C的意义减少,可直接行腹腔镜检查。

Objective To evaluate the clinical role of dilation and curettage （D＆C） in the diagnosis of ectopic pregnancy （EP） . Methods We retrospectively reviewed the clinical data of 108 patients with pregnancy of unknown location who underwent a D＆C with an abnormal rise in β-human chorionic gonadotropin （β-HCG） level and without visible intrauterine pregnancy （IUP） on transvaginal ultrasound and 24 patients who did not receive D＆C with β-HCG 〉 5 000 IU/L. The final diagnosis depended on β-HCG trend review after D＆C and the pathologic and laparoscopic findings. Results Overall, 65.3% of the patients were finally diagnosed with EP and 34. 7% were found to have a nonviable IUP. Those with EP had significantly higher initial 15-HCG than those with nonviable IUP. IUP patients were more likely to have had a history of delivery. Among the patients with β-HCG 〈 2 000 IU/L, 40. 0% of EP and 11.0% of IUP had endometrial echo complex no more than 5 mm （P =0. 035）.In β-HCG 〈 2 000 IU/L and 2 000 IU/L 〈 β-HCG 〈 5 000 IU/L groups, the diagnostic rate of EP was 42. 6% and 68. 3% respectively （P =0. 012） . Among the patients with [5-HCG 〉5 000 IU/L, there was no significant difference between those with D＆C and those without D＆C （96. 7% vs. 96%, P =0, 915）. Conclusions Ultrasound findings such as a thin endometrial echo complex and the presence of pelvic mass are associated with but are not diagnostic of an ectopic pregnancy. The patients with the suspected diagnosis of EP are 2 000 IU/L 〈 β-HCG 〈 5 000 IU/L, whereas D＆C remains important valuable to differentiate EP from nonviable IUP and to avoid misdiagnosis and unnecessary exposure to methotrexate. Because EP is the common final diagnosis in most of the patients with β-HCG 〉 5 000 IU/L and pelvic mass and without intrauterine gestational sac, the value of D＆C decreases and laparoscopy can be considered directly.