剖宫产术后子宫瘢痕妊娠期待治疗11例临床分析

Expectant management of 11 cases of cesarean scar pregnancy

目的探讨剖宫产术后子宫瘢痕妊娠（CSP）期待治疗的条件及危险因素。方法收集2015年1月至2017年3月于广州医科大学附属第三医院就诊的11例孕早期诊断为CSP的孕妇，其中9例期待治疗至孕晚期（孕晚期组），2例期待治疗至孕中期终止妊娠（孕中期组）。比较两组孕妇的诊断孕周、CSP分型、孕次、产次、流产次数、既往剖宫产术次数、终止妊娠的孕周、产后出血量、产前及产后血红蛋白水平、妊娠结局和产科并发症等。结果孕晚期组9例孕妇，期待治疗均成功，于孕33周“～36周“终止妊娠；孕中期组2例孕妇，均因子宫破裂终止妊娠（分别为孕17周“、17周”）。孕晚期组与孕中期组孕妇的孕次、产次及既往剖宫产术次数分别比较，差异均无统计学意义（P均〉0．05）；两组孕妇流产次数[分别为（1．3±1．1）、（4．0±2．8）次]比较，差异有统计学意义（P〈O．05）。孕晚期组9例孕妇中，7例为CSPI型，2例为CSPⅡ型；孕中期组2例孕妇均为CSPⅢ型。11例孕妇，术后病理诊断均为胎盘植入；无孕产妇死亡；6例行子宫次全切除术（6／11）；11例孕妇产后出血量为（3582±510）ml。9例新生儿存活。结论对于诊断为CSPI型或Ⅱ型、强烈要求继续妊娠的孕妇，在充分知情产前或产后出血、子宫破裂、子宫切除等风险后，可于三级医疗机构严密监测下继续妊娠；CSP期待治疗至孕晚期的方案仍需深入研究。

Objective To explore the natural courses of 11 patients with cesarean scar pregnancy （CSP） with expectant management. Methods Eleven patients with CSP who were diagnosed in the first trimester in the Third Affiliated Hospital of Guangzhou Medical University from January 2015 to March 2017 were recruited. All of them received expectant management. Nine pregnancies continued to the third trimester （the third trimester group）, and 2 patients were expected to the second trimester （the second trimester group）. The gestational age at diagnosis, CSP type, gravidity, parity, miscarriage and previous cesarean section history, gestational weeks at termination, amount of postpartum hemorrhage, prenatal and postnatal hemoglobin levels, pregnancy outcomes and obstetric complications were compared between the two groups. Results The third trimester group terminated pregnancies between 33 ＋2 and 36＋5 weeks. The second trimester group terminated in the second trimester because of rupture of uterus （at 17＋2, 17＋3 weeks）. There was no statistical difference between the two groups regarding the number of gravidity, parity and previous cesarean section （all P〉0.05）. The number of miscarriage in the second trimester group was 4.0±2.8, and in the third trimester group was 1.3±1.1 （P〈0,05）. In the third trimester group, 7 cases were CSP type I and 2 cases were CSP ]1. In the second trimester group, 2 cases were both CSP type m. Eleven cases were diagnosed placenta accreta pathologically. There was no maternal death, and 6 cases received hysterectomy