109例宫角妊娠手术治疗的临床疗效分析

Clinical analysis of surgical treatment of cornual pregnancy of 109 cases

目的探讨宫角妊娠的临床特点并比较各种手术方式的疗效,分析术后发生持续性异位妊娠(PEP)的高危因素。方法本研究为单中心回顾性研究,收集2012年6月至2020年12月在中国医学科学院北京协和医学院北京协和医院接受手术治疗的宫角妊娠患者,手术治疗方式包括清宫术(在超声监视下或腹腔镜监视下)、宫角切开取胚或宫角切除术(手术入路为腹腔镜或开腹)。采集接受手术治疗的宫角妊娠患者的术前基线资料、围手术期治疗及术后是否发生PEP等临床资料,比较各种手术方式的疗效,并分析发生术后PEP的高危因素。结果本研究共纳入109例经手术治疗明确诊断的宫角妊娠患者,其年龄为(32.9±4.8)岁;其中18例术后发生了PEP,术后PEP的发生率为16.5%(18/109)。经产妇(OR=7.639,95%CI为2.063~28.279,P=0.001)、病灶最大径<1.5 cm(OR=8.600,95%CI为2.271~32.571,P=0.002)是影响宫角妊娠患者术后发生PEP的危险因素。在宫角妊娠的各种手术治疗方法中,超声监视下清宫术后PEP的发生率最高(56.0%,14/25),明显高于腹腔镜监视下清宫术(1/10;χ^(2)=6.172,P=0.013);清宫术后PEP的发生率(42.9%,15/35)显著高于宫角切开取胚或宫角切除术(4.1%,3/74;χ^(2)=25.950,P<0.01)。宫角妊娠手术中切除患侧输卵管及围手术期使用甲氨蝶呤(MTX)的患者术后PEP的发生率分别与未处理者比较,差异均无统计学意义(P均>0.05)。结论经产妇、病灶最大径<1.5 cm以及超声引导下清宫术是宫角妊娠术后发生PEP的危险因素。宫角妊娠患者宜行宫角切开取胚或宫角切除术;若患者具备行清宫术的条件,建议在腹腔镜监视下进行。对于手术病灶清除确切的患者,不推荐常规预防性使用MTX。

Objective To study the clinical characteristics of cornual pregnancy and compare the effects of various surgical methods on the outcomes.Methods This was a single-center retrospective study.The clinical records of patients with cornual pregnancy who underwent surgery in Peking Union Medical College Hospital from June 2012 to December 2020 were collected.Surgical interventions included curettage(guided by ultrasound or monitored by laparoscope),and cornuostomy/cornectomy(the surgical approach by laparoscopy or laparotomy).The baseline data,perioperative treatment and whether persistent ectopic pregnancy(PEP)occurred after surgery were collected and analyzed statistically.Results A total of 109 patients with cornual pregnancy diagnosed by surgical treatment were included in this study,whose average age was(32.9±4.8)years.Among them,the incidence of postoperative PEP was 16.5%(18/109).The risk of PEP in multipara was significantly higher than that in nulliparous women(OR=7.639,95% CI:2.063-28.279,P=0.001).The risk of PEP in patients with the maximum diameter of lesion<1.5 cm was significantly higher than that in patients with the maximum diameter of lesion≥1.5 cm(OR=8.600,95%CI:2.271-32.571,P=0.002).Among all surgical approaches for cornual pregnancy,the proportion of PEP in curettage under ultrasound monitoring was the highest(56.0%,14/25),which was higher than that in curettage under laparoscope monitoring(1/10;χ^(2)=6.172,P=0.013);the proportion of PEP in curettage group(42.9%,15/35)was higher than that in cornuostomy/cornectomy group(4.1%,3/74;χ^(2)=25.950,P<0.01).Neither salpingectomy in the operation nor the routine use of methotrexate(MTX)in perioperative period could significantly reduce the incidence of PEP(all P>0.05).Conclusions Among the patients with cornual pregnancy,multipara,the maximum diameter of lesion<1.5 cm and ultrasound-guided curettage are the risk factors of PEP after operation.Cornuostomy or cornectomy is recommended for patients with cornual pregnancy.If the patients would perform the curettage operation,laparoscopic monitoring is recommended.For patients with possible satisfactory operation outcome,it is not recommended to use MTX as a routine preventing measure.