早期剖宫产术后子宫瘢痕妊娠保守治疗的临床观察

Study on conservative treatment for early cesarean scar pregnancy after cesarean section

目的对早期剖宫产术后子宫瘢痕妊娠(CSP)保守治疗的方法行疗效对比,比较不同保守方法处理早期剖宫产术后子宫瘢痕妊娠的结局,评价甲氨蝶呤孕囊穿刺治疗早期剖宫产术后子宫瘢痕妊娠的安全性及可行性。方法回顾性分析2010年7月至2015年10月在河北省沧州市中心医院保守治疗的早期剖宫产术后子宫瘢痕妊娠患者的临床资料共46例,按不同治疗方式将其分为3组,甲氨蝶呤+穿刺组14例,肌肉注射甲氨蝶呤,1周后行孕囊穿刺;甲氨蝶呤+清宫组17例,在B超导视下清宫术;单纯药物组15例,甲氨蝶呤或加用米非司酮。比较其治疗结局。结果 1治疗方式:甲氨蝶呤+穿刺组14例,3例血清β-人绒毛膜促性腺激素(HCG)下降不满意,行二次穿刺,14例均保守成功;甲氨蝶呤+清宫组17例,2例患者因阴道出血提前行清宫术失败,最终行开腹病灶切除术,其余15例患者,4例清宫失败,改腹腔镜病灶切除术,17例治疗成功11例;单纯药物组15例,因β-HCG下降不满意、持续包块或阴道出血,3例行腹腔镜病灶切除术;2例行宫腔镜下病灶切除术。15例中10例患者单纯药物治疗成功。2血清β-HCG降至正常时间、包块消失时间、治疗后住院时间。甲氨蝶呤+穿刺组与甲氨蝶呤+清宫组比较,包块消失时间差异无统计学意义(P>0.05),血清β-HCG降至正常时间,治疗后住院时间差异均有统计意义(P<0.05);甲氨蝶呤+穿刺组与单纯药物组相比,血清β-HCG降至正常时间、包块消失时间、治疗后住院时间差异均有统计意义(P<0.05)。3治疗成功率:甲氨蝶呤+穿刺组与甲氨蝶呤+清宫组及单纯用药组进行两两比较,甲氨蝶呤+穿刺组分别与之相比,其治疗成功率明显高于其他2组,差异均有统计学意义(P<0.05)。结论应用甲氨蝶呤肌肉注射后行孕囊穿刺治疗早期剖宫产术后子宫瘢痕妊娠为有效、安全的保守治疗方法。

Objective The objective of the study was to evaluate the efficacy and safety of conservative treatment of methotrexate（MTX）therapy combined with gestational sac puncture on cesarean scar pregnancy（CSP）.Methods A retrospective analysis was performedon 46 patients of CSP who received conservative treatment in Cangzhou Central hospital from July 2010 to October 2015.The patients were divided into three groups according to different treatment,group A（gestational sac puncture group,n=14）,group B（curettage group,n=17）and group C（drug group,n=15）.The clinical efficacy of three groups was analyzed.Results All 14 patients were cured in group A.17 patients were treated by MTX therapy and curettage in group B,11 of whom were cured.15 patients were treated by MTX or MTX combined with Mifepristone therapy in drug group,10 of whom were cured.The cure rate of treatment in group A was significantly higher than that in other groups,and there was statistically significantdifference（P〈0.05）.The difference in time for serumβ-human chorionic gonadotropin（β-HCG）level decreasing to normal,hospitalization and mass extinction between group A and group C was statistically significant（P〈0.05）.The difference in time for serumβ-human chorionic gonadotropin（β-HCG）level decreasing to normal and hospitalizationbetween group A and group B was statistically significant（P〈0.05）.While the difference in time for mass extinction between group A and group B was not statistically significant（P〉0.05）.Conclusion MTX therapy combined with gestational sac is superior to drug and MTX therapy combined with curettage.It is also an effective and safe therapy for early cesarean scar pregnancy after cesarean section.