剖宫产瘢痕妊娠超声分类诊疗的临床价值

The Clinical Value of the Classification of Cesarean Scar Pregnancy in the Diagnosis and Treatment

目的:探讨剖宫产瘢痕妊娠(CSP)根据超声检查提示分类诊疗的临床价值。方法:回顾性分析2014年11月至2017年6月青岛大学附属医院收治的228例CSP患者的临床资料,根据超声检查分为三类:Ⅰ类子宫下段妊娠完整孕囊型(30例),Ⅱ类剖宫产切口妊娠完整孕囊型(170例),Ⅲ类混杂回声团型(28例)。比较分析三类CSP患者出血相关风险指标:残余肌层厚度(0. 2 cm、0. 2～0. 3 cm及0. 3 cm)、孕囊最大直径(3 cm、5 cm)及孕囊周围血流信号与其治疗方式及结局的关系。结果:(1)Ⅰ类:以清宫术为主(86. 7%),其中B超引导下清宫术占53. 8%。(2)Ⅱ类:大部分以清宫术(56. 5%)及经阴道妊娠组织清除术(21. 8%)为主。残余肌层厚度<0. 2 cm分别与≥0. 2 cm及≥0. 2 cm～<0. 3 cm比较,各种治疗方式构成比间的差异有统计学意义(P <0. 05),而在≥0. 2 cm～<0. 3 cm与≥0. 3 cm比较,各种治疗方式构成比间的差异无统计学意义(P> 0. 05)。随着残余肌层厚度的减少,清宫术比例降低,UAE、剖腹探查术的比例增加。孕囊最大直径在<3 cm与≥3 cm及<5 cm与≥5 cm间比较,各种治疗方式构成比间的差异均有统计学意义(P<0. 05)。当残余肌层厚度<0. 2 cm或孕囊最大直径≥3 cm时,孕囊周围有血流信号其清宫术、阴式手术所占比例减少,UAE、剖腹探查术所占比例增高,有无血流信号间各种治疗方式构成比的差异均有统计学意义(P<0. 05)。(3)Ⅲ类:当残余肌层厚度<0. 2 cm或孕囊直径≥3 cm时,剖腹探查术及UAE为主要治疗方式(分别占70. 0%、60. 8%),各种治疗方式构成比间的差异有统计学意义(P<0. 05)。结论:Ⅰ类CSP患者适合清宫术,B超引导下清宫术安全性更高。Ⅱ类患者当孕囊直径<3 cm、残余肌层厚度≥0. 2 cm或孕囊周边无血流信号时虽不建议直接清宫,但适合行B超引导下清宫术及经阴妊娠组织清除术。Ⅲ类CSP患者建议行UAE后再清宫或开腹手术。

Objective： To determine the clinical value of the classification of cesarean scar pregnancy（ CSP） in the diagnosis and treatment by ultrasonography.Methods： The clinical data of 228 cases of CSP in the Affiliated Hospital of Qingdao University from November 2014 to June 2017 was analyzed retrospectively.Three types were classified according to the ultrasound examination： TypeⅠ with complete gestational sac implanted in the lower segment of uterus（ 30 cases）,TypeⅡ with complete gestational sac implanted at the cesarean scar（ 170 cases） and TypeⅢ mixed echo（ 28 cases）.The factors of hemorrhage risk including residual muscle layer（ 0. 2 cm,0. 2 ～0. 3 cm and 0. 3 cm）,maximum diameter of gestational sac（ 3 cm,5 cm） and blood flow signal around the gestational sac were analyzed and compared in the three groups.The relationships between these factors,treatment and outcomes were also analyzed. Results：（1） Type Ⅰ： The most common treatment was uterine curettage（ 86. 7%）,in which curettage guided by B-mode ultrasonography accounted for 53. 8%.（2）TypeⅡ： The most common treatment was uterine curettage（ 56. 5%） and operation through vaginal（ 21. 8%）.The difference of treatment was significant between the cases with the thickness of residual muscle layer〈 0. 2 cm,≥0. 2 cm and ≥0. 2 cm ～ 〈0. 3 cm.There was no significant difference of treatment between the cases with the thickness of residual muscle layer≥0. 2 cm ～ 〈0. 3 cm and ≥0. 3 cm（ P〉0. 05）.With the decrease of the thickness of residual muscle layer,the proportion of curettage reduced and the proportion of UAE,laparoscopic surgery and laparotomy increased. The difference of treatment was statistically significant（ P〈 0. 05） between the cases with the maximum diameter of gestational sac 〈3 cm,≥3 cm ～ 〈5 cm and ≥5 cm.The proportion of curettage and operation through vaginal reduced and the proportion of UAE and laparotomy increased when the residual muscle layer thickness was 0. 2 cm,the diameter of gestational sac ≥3 cm or blood flow signal around the gestational sac detected.The difference of treatment was statistically significant（ P〈0. 05） between the cases with blood flow signal around the gestational sac or without.（3）TypeⅢ： The most common treatment was laparotomy（ 70. 0%） and UAE（ 60. 9%） when the residual muscle layer thickness〈 0. 2 cm or the diameter of gestational sac ≥3 cm.There was significant difference when comparing the constitution of treatment（ P〈0. 05）.Conclusions： Uterine curettage is appropriate for patients with TypeⅠ CSP,especially safer with B-mode ultrasonography guidance.For patients with TypeⅡ CSP,curettage is not recommended when the diameter of the gestational sac is 3 cm,the thickness of the residual muscular layer is ≥0. 2 cm or no blood flow signal around the gestational sac detected. However,the curettage with guidance of B-mode ultrasonography and gestational sac was oprated through voginal are recommended.For patients with TypeⅢ CSP,curettage after UAE or laparotomy is recommended.