剖宫产瘢痕妊娠的临床特征与处理结局

Clinical features and outcome of cesarean scar pregnancy

目的分析剖宫产瘢痕妊娠（CSP）的临床特征，评价各种治疗方案的治疗效果，尤其是基于妊娠囊腔三维构像分析（3D）的甲氨蝶呤（MTX）-子宫动脉栓塞术（UAE）．超声导航（sonogrphydirected）一定点吸胚（in-situsapiration）序贯治疗（简称3D-MESIA）的优势及可行性。方法回顾性分析北京朝阳医院从2007年1月至2014年12月资料完整的剖宫产瘢痕妊娠的病例99例，年龄22～43（34±5）岁，按照首治方案分为6组：A组：3D-MESIA51例；B组：MTX治疗8例；C组：介入化疗9例；D组：MTX＋清宫10例；E组：UAE＋清官11例；F组：直接清官10例。各组再根据CSP分型分为内生型和外生型2个亚组。从术中出血量、手术时间、术后血清β人绒毛膜促性腺激素（β-hCG）转阴时间、病灶吸收时间、住院时间、住院费用及成功率等方面对比各组和各亚组。结果（1）内生型CSP在不同清宫术式中的手术时间、术中出血量差异无统计学意义（P〉0．05）；B组内生型血清β-hCG转阴时间和包块吸收时间分别为（59．0±57．6）d及（66．2±48．7）d，较其他5组明显延长（P〈0．05）；（2）外生型CSPA组和E组的术中出血量比其他组明显减少（P〈0．05）；A组外生型血清β-hCG转阴时间和包块吸收时间分别为（35．7±9．2）d，（36．8±12．8）d，明显短于其他各组（P〈0．05）；（3）E组和F组的住院时间最短（P〈0．05），B组和F组的住院费用最少（P〈0．05）；（4）内生型CSP的成功率F组最低，但差异无统计学意义（P〉0．05）；外生型CSP的成功率A组和E组高于其他4组，差异有统计学意义（P〈0．05）。结论单纯使用药物治疗和介入化疗治疗CSP的疗效不佳，应及时清除妊娠病灶。3D-MESIA终止内生型CSP安全有效，易于实施与推广；并可以作为外生型CSP的初始治疗，如失败再使用腹腔镜下病灶去除＋瘢痕修补术作为补救措施。

Objective To analysis the clinical features of cesarean scar pregnancy （CSP）, to evaluate the therapeutic effect of various treatments, especially the feasibility and advantage of Methotrexate （MTX）-Uterine artery embolization （UAE）- Sonogrphy directed-In situs aspiration sequential therapy based on the pregnancy sac three-dimensional conformation analysis （3D-MESIA）. Methods From January 2007 to December 2014, 99 subjects who were diagnosed as CSP in Chaoyang Hospital of Capital Medical University were studied retrospectively. According to different treatment, they were divided into six groups： 51 cases treated by 3D-MESIA （group A）, 8 cases treated by systemic MTX injection （group B） , 9 cases treated by uterine artery chemoembolization or uterine artery embolization combined with systemic MTX injection （group C）, 10 cases treated by uterine curettage after systemic MTX injection （group D）, 11 cases treated by uterine curettage after uterine artery embolization （group E）, 10 cases treated by uterine curettage directly （group F ）. Each group according to the CSP classification can be divided into two subgroups： endogenous CSP and exogenous CSP. The intraoperative blood loss, operative time, [3-hCG clearance time, lesion absorption time, hospitalization time, hospitalization expenses, the success rate were compared among the six groups and two subgroups. Results （ 1 ） The operative time and blood loss of endogenous CSP had no significant difference in different operative methods （ P 〉 0. 05 ）. β-hCG clearance time and lesion absorption time of endogenous CSP in group B were significantly longer than the other five groups （P 〈 0. 05 ）. （2） The intraoperative blood loss in group A and group E compared with group D andgroup F was decreased significantly （P 〈 0. 05 ）. β-hCG clearance time and lesion absorption time of exogenous CSP in group A were significantly shorter than those in the other five groups （ P 〈 0.05 ）. （ 3 ） The hospitalization time in group E and group F were obviously shorter than that in other groups （P 〈 0. 05 ）. The hospitalization expense in group B and group F were obviously less than that in other groups （P 〈 0. 05）. （4） The success rate of endogenous CSP in group F was the lowest, but the difference had no significant statistical significance （P 〉 0. 05）. The success rate of exogenous CSP in group A and group E were obviously higher than that of the other four groups （P 〈 0. 05）. Conclusion The treatment effect of MTX therapy alone or uterine artery embolization for CSP is poor. 3D-MESIA is safe and effective for endogenous CSP. It is easy to promote and can be used as the initial treatment of exogenous CSP. If it fails, the laparoscopic removal of lesions and scar repair could be the remedial measure.