剖宫产术后子宫瘢痕妊娠清宫治疗的可行性分析

Feasibility of treatment of cesarean scar pregnancy with dilatation and curettage under ultrasound guidance

目的 通过分析剖宫产术后子宫瘢痕妊娠（CSP）患者B超指引下行清宫术治疗的不同结局,探讨该方法治疗CSP所具备的条件和不良结局的相关因素,使CSP治疗方法简单、安全而有效.方法 回顾性分析2013年1月至2014年12月于天津市中心妇产科医院计划生育科行B超指引下清宫治疗的84例CSP患者.清宫术中发生子宫大量出血经宫腔填塞压迫止血无效而行子宫动脉栓塞术为清宫失败组.清宫成功组根据清宫术后瘢痕部位有无组织残留定义为无病灶残留和病灶残留组.使用单变量回归分析清宫失败和病灶残留的危险因素,使用相关分析和线性回归比较各危险因素对预后的影响大小,使用ROC曲线预测危险因素的切点.结果 清宫成功组75例（89.3％）,其中瘢痕部位有组织残留36例（48％）,失败组9例（10.7％）.清宫失败和病灶残留与血人绒毛膜促性腺激素（hCG）,胎囊大小（GS）,胎囊着床部位的瘢痕肌层厚度（CSM）和血流RI值有关（P＜0.01）.清宫术中无法控制的子宫出血与血hCG值最具相关性,血hCG＞ 97 006 U/L的患者清宫术失败可能性大（预测价值100％,95％ CI 94.9％～100％）.血hCG＜ 58 076 U/L、GS≤19 mm、CSM＞2.7 mm、RI＞0.25的病例清宫成功率高,其中停经时间≤41 d、GS≤15 mm、CSM＞ 3.7 mm、RI ＞0.4、血hCG＜3 935 U/L的CSP患者通过B超引导下清宫能达到无病灶残留的最佳治疗效果.病灶残留者月经恢复延迟,但不发生闭经,残留病灶在清宫术后1～3个月逐渐吸收.结论 B超指引下清宫术可以用于CSP患者的早期治疗,停经天数短、血hCG值低、胎囊小、妊娠组织侵入瘢痕肌层浅、血流不丰富的CSP通过清宫治疗可以达到安全而有效的治疗目的.

Objective The present study sought to investigate the predictors of successful dilatation and curettage （D＆C） in treatment of cesarean scar pregnancy （CSP）.Methods Retrospective analysis was conducted in 84 CSP patients undergoing D＆C from January 2013 to December 2014.Failure was defined as D＆C followed by transcatheter uterine arterial embolization due to uncontrolled hemorrhage.Substratification of success group as residue group or non-residue group was performed according to the residues at the site of cesarean scar after D＆C.The univariate logistic regression and linear regression were used to assess the predictors of the failure and residues.ROC curve was used to assess the cut-off values of the predictors.Results D＆C under ultrasound guidance succeeded in 75 patients （89.3%） and 36 patients had residues at the site of cesarean scar among them （48%）,9 patients failed in D＆C （10.7%）.High Serum human chorionic-gonadotropin （hCG）,small gestation sac （GS）,thin cesarean scar myometrium thickness （CSM） and low peritrophoblastic flow resistance index （RI） were risk factors of D＆C failure in treatment of CSP.That serum hCG 〉97 006 U/L was prime predictor of failure （predictive value 100%,95% CI 94.9%-100%）.High success ratio was observed in patients with serum hCG 〈 58 076 U/L,GS ≤19 mm,CSM 〉2.7 mm,and RI 〉0.25.And days of menopause ≤41 d,GS ≤15 mm,CSM 〉 3.7 mm,RI 〉 0.4 and serum hCG 〈 3 935 U/L were predictors of complete success of D＆C.The postponed restoration of menstruation was observed in patients with residues,which did not induce amenorrhea and disappeared in 1-3 months after procedures.Conclusion Early diagnosis and treatment is associated with successful D＆C in treatment of CSP.HCG,GS,CSM and RI are valuable in predicting the prognosis of D＆C in treatment of CSP.