高强度聚焦超声治疗剖宫产瘢痕妊娠临床效果分析

Analysis of clinical effect by high-intensity focused ultrasound in the treatment of cesarean scar pregnancy

目的探讨高强度聚焦超声(HIFU)消融治疗剖宫产瘢痕妊娠(CSP)的临床疗效。方法选取40例CSP患者作为研究对象,随机分为对照组和观察组,每组20例。对照组采取肌内注射甲氨蝶呤(MTX)治疗,观察组采取HIFU治疗,超声对患者靶区的周边血流、孕囊大小的变化进行观察。术后3~7 d复查血β-人绒毛膜促性腺激素(β-HCG)。两组治疗后均行宫腔镜清宫术及门诊随访。比较两组治疗后血β-HCG下降至阴性时间、术中出血量、月经恢复正常时间、住院时间、治疗成功率。结果观察组治疗后即时超声检查瘢痕妊娠病灶周边血流明显减少,病灶内可见液化区,妊娠囊均有所缩小。HIFU治疗3~7 d清宫术后复查血β-HCG以每周30%~50%的速度逐渐下降。其中18例患者一次性清宫术完全清除妊娠物,术中出血20~80 ml。对照组血β-HCG以每周15%~20%的速度逐渐下降,血β-HCG下降慢,有14例予术后4~7 d行清宫术,有6例治疗7 d后效果欠佳予重复药物治疗再行清宫术,本研究中无子宫切除并发症出现。观察组血β-HCG下降至阴性的时间为(28.3±7.6)d,术中出血量为(35.5±3.5)ml,住院时间为(6.0±2.5)d,月经恢复正常时间为(28.0±7.5)d,治疗成功率为90.0%(18/20);对照组血β-HCG下降至阴性的时间为(39.2±6.4)d,术中出血量为(183.6±83.3)ml,住院时间为(14.0±3.5)d,月经恢复正常时间为(41.8±4.5)d,治疗成功率为75.0%(15/20);观察组血β-HCG恢复至阴性时间、术中出血量、住院时间及月经恢复正常时间均少于对照组,治疗成功率高于对照组,组间比较差异有统计学意义(P<0.05)。观察组有3例治疗区轻度腹部胀痛及骶骨部胀痛,有1例治疗区皮肤有热烫不适,术中均予盐酸哌替啶肌内注射缓解疼痛,术后无需特殊处理,观察组均未出现肠道损伤、尿储留、神经损伤等并发症;对照组有5例出现口腔溃疡,有2例出现腹泻消化道反应。结论 HIFU治疗CSP是一种安全、无创、效果显著的治疗方法 ,值得临床推广应用。

Objective To investigate clinical effect by high-intensity focused ultrasound （HIFU） ablation therapy in the treatment of cesarean scar pregnancy （CSP）. Methods A total of 40 CSP patients as study subjects were randomly divided into control group and observation group, with 20 cases in each group. The control group received intramuscular injection of methotrexate （MTX） for treatment, and the observation group received HIFU treatment. Observation of changes in peripheral blood flow of target section and gestational sac size was made by ultrasound. Serum β -human chorionic gonadotropin （ β -HCG） was detected in postoperative 3-7 d. Both groups received hysteroscopic complete curettage of uterine cavity and outpatient follow-up after treatment. Comparison was made on serum β -HCG negative reduction time, intraoperative bleeding volume, menstruation recovery time, hospital stay time, and treatment success rate between the two groups after treatment. Results Realtime ultrasound examination of cesarean scar lesion in the observation group after treatment showed obviously reduced peripheral blood flow, along with fluidized zone in lesion and reduced gestational sac. Reexamination of serum β-HCG after 3-7 d of HIFU treatment and complete curettage of uterine cavity showed reduction speed by 30%-50% per week. There were 18 cases with complete pregnancy tissue clearance by one-time complete curettage of uterine cavity, with intraoperative bleeding volume as 20-80 ml. The control group had reduction speed of serum β-HCG by 15%-20% per week. There were 14 cases receiving complete curettage of uterinecavity in postoperative 4-7 d, and 6 cases receiving secondary complete curettage of uterine cavity due to poor curative effect after 7 d of treatment. There was no case with hysterectomy complications during treatment. The observation group had serum β -HCG negative reduction time as （28.3 ± 7.6） d, intraoperative bleeding volume as （35.5± 3.5） ml, hospital stay time as （6.0± 2.5） d, menstruation recovery time as （28.0± 7：5） d, and treatment success rate as 90.0% （18/20）. The control group had serum β -HCG negative reduction time as （39.2 ± 6.4） d, intraoperative bleeding volume as （183.63 ±83.3） ml, hospital stay time as （14.0 ± 3.5） d, menstruation recovery time as （41.8± 4.5） d, and treatment success rate as 75.0% （15/20）. The observation group had all less serum -HCG negative reduction time, intraoperative bleeding volume, hospital stay time, menstruation recovery time, and higher treatment success rate than the control group, and the difference had statistical significance between the two groups （P〈0.05）.＇ The observation group had 3 cases with mild abdominal and sacral distension pain in treatment region and 1 case with skin heat and discomfort. They all received intramuscular injection of pethidine hydrochloride in treatment for pain relief, without special treatment after operation. There were no complications of intestinal injury, urinary retention, and nerve injury. The control group had 5 cases with dental ulcer and 2 cases with diarrhea and gastrointestinal reaction. Conclusion As a safe, noninvasive treatment method with excellent effect in treating CSP, HIFU is worth clinical promotion and application.