阴式手术治疗Ⅱ型子宫瘢痕妊娠失败的危险因素分析

Failure in vaginal surgery for the treatment of type Ⅱ cesarean scar pregnancy:An analysis of risk factors

目的:回顾性分析利用经阴道子宫瘢痕处妊娠物清除术±子宫修补术治疗Ⅱ型剖宫产术后子宫瘢痕妊娠(cesarean scar pregnancy,CSP)失败的危险因素,为临床治疗提供参考依据。方法:选取2016年4月至2018年3月在我院确诊为Ⅱ型CSP并实施阴式手术治疗的共计98例患者纳入研究。其中成功实施经阴道子宫瘢痕处妊娠物清除术+子宫修补术的患者82例,仅行经阴道子宫瘢痕处妊娠物清除术而无法行子宫修补术患者14例,术中因手术困难转腹腔镜患者2例。我们将前82例定义为阴式手术治疗成功组,后16例为治疗失败组。分别通过卡方、t或秩和检验对治疗成功组和失败组的一般情况进行比较,并通过单因素及多因素logistic回归分析筛选出影响阴式手术治疗Ⅱ型CSP的高危因素。采用绘制ROC曲线寻找截断值。结果:2组患者在年龄、停经天数、剖宫产次数、上次剖宫产距本次妊娠的时间、孕囊大小、术前血HCG、瘢痕厚度、术前是否甲氨蝶呤(methotrexate,MTX)预处理以及术中出血等方面无统计学意义(P>0.05)。2组患者在瘢痕距离宫颈外口的距离(3.364±0.802、4.050±0.701)、住院天数(5.560±1.813、6.560±1.711)等方面比较有统计学差异(P<0.05)。瘢痕距宫颈外口的距离经单因素及多因素logistic回归分析均是影响阴式手术治疗Ⅱ型CSP的高危因素(单因素OR=0.289,95%CI=0.126~0.659,P=0.003;多因素OR=0.177,95%CI=0.051~0.611,P=0.006)。采用ROC曲线,瘢痕距宫颈外口的距离最佳截断值为4.25 cm(灵敏度87.3%,特异度50.0%,正确率73.7%)。结论:阴式手术作为治疗Ⅱ型CSP较为安全的治疗方式之一,应当选择适合该治疗方式的患者。当瘢痕距宫颈外口的距离大于4.25 cm时若行阴式手术治疗应术前充分告知患者手术风险,做好必要时转腹腔镜或者介入治疗的准备或者尝试采取其他的治疗方式。

Objective:To investigate the risk factors for failure in transvaginal debridement of pregnancy tissue at cesarean scar with or without uterus repair in the treatment of type Ⅱ cesarean scar pregnancy(CSP)using a retrospective analysis,and to provide a reference for clinical treatment. Methods:A total of 98 patients who were diagnosed with type Ⅱ CSP and underwent vaginal surgery in our hospital from April 2016 to March 2018 were enrolled. Among these patients,82 underwent successful transvaginal debridement of pregnancy tissue at cesarean scar and uterus repair,14 underwent transvaginal debridement alone,and 2 were converted to laparoscopy due to surgical difficulties. The former 82 patients were enrolled as successful vaginal surgery group,and the remaining 16 patients were enrolled as treatment failure group. The chi-square test,the t-test,and the rank sum test were used for comparison of the general status between the two groups,and univariate and multivariate logistic regression analyses were used to screen out the high-risk factors for vaginal surgery in the treatment of type Ⅱ CSP. The receiver operating characteristic(ROC)curve was plotted to determine cut-off values. Results:There were no significant differences between the two groups in age,number of days of menopause,number of times of cesarean section,time from the last cesarean section to this pregnancy,diameter of pregnancy sac,preoperative HCG,scar thickness,whether methotrexate pretreatment was performed before surgery,and intraoperative bleeding(P>0.05). There were significant differences between the two groups in the distance from scar to external cervical orifice(3.364±0.802 vs. 4.050±0.701,P<0.05)and length of hospital stay(5.560±1.813 days vs 6.560±1.711 days,P<0.05). The univariate and multivariate logistic regression analyses showed that distance from scar to external cervical orifice was a high-risk factor for failure in vaginal surgery for the treatment of type Ⅱ CSP(univariate:odds ratio[OR]=0.289,95% confidence interval[CI]:0.126-0.659,P=0.003;multivariate:OR=0.177,95%CI=0.051 to 0.611,P=0.006). The ROC curve showed that distance from scar to external cervical orifice had a sensitivity of 87.3%,a specificity of 50.0%,and an accuracy of 73.7% at the optimal cut-off value of 4.25 cm. Conclusion:Vaginal surgery is a relatively safe method for the treatment of type Ⅱ CSP,and patients suitable for this method should be selected. When the distance from scar to external cervical orifice is greater than 4.25 cm,patients should be fully informed of risks before surgery,and preparations for laparoscopy or interventional therapy should be made,or other treatment methods should be adopted.