超声监测下清宫术治疗剖宫产瘢痕妊娠的临床价值

Value of ultrasound-guided uterine dilatation and curettage in the treatment of cesarean scar pregnancy

目的探讨超声监测下清宫术治疗剖宫产术后子宫瘢痕妊娠(CSP)的有效性、安全性及治疗失败的相关危险因素。方法回顾分析2015年1月至2020年6月青岛大学附属医院收治的299例以超声监测下清宫术为初始治疗方案的CSP患者的临床资料,分别采用中华医学会分型及实用临床分型;根据清宫前是否行子宫动脉栓塞(UAE)预处理分为UAE组及直接清宫组,将术中更改术式或术后行补充治疗定义为失败。应用单因素分析及logistic回归分析CSP清宫失败的危险因素,通过ROC曲线计算各危险因素的最佳预测值。结果Ⅱ型CSP患者UAE预处理后清宫与直接清宫的成功率比较,差异无明显统计学意义(P>0.05)。直接清宫组中Ⅰ型、Ⅱa型CSP清宫成功率分别为97.7%(125/128)、93.3%(112/120);成功组与失败组的瘢痕厚度、血β-HCG值、孕囊大小、临床分型、血流信号相比,差异有统计学意义(P<0.05)。logistic分析显示,孕囊最大径线、瘢痕厚度、血β-HCG值是清宫失败的危险因素(P<0.05)。孕囊最大径线3.3cm、瘢痕厚度2.4mm、血β-HCG值43720U/L为预测清宫失败的最佳阈值点。结论实用临床分型具有较高的临床应用价值。瘢痕厚度>2.4mm、孕囊最大径线<3.3cm、血β-HCG值<43720U/L为超声监测下清宫术治疗成功的截断值,可为治疗方式的选择提供依据。

Objective:To investigate the efficacy and safety of ultrasound-guided uterine dilatation and curettage(D&C)in the treatment of cesarean scar pregnancy(CSP)and the related predictors associated with the treatment failure.Methods:A retrospective analysis was performed on the clinical data of 299 CSP patients admitted to the Affiliated Hospital of Qingdao University from January 2015 to June 2020,who were given ultrasound-guided D&C as initial strategy.The patients were classified according to classification of Chinese Medical Association and Practical Clinical Classification.All patients were divided into two groups according to whether performed uterine artery embolization(UAE)before D&C.Failure was defined as changing surgical procedure or receiving supplementary therapy.Univariate analysis and logistic regression analysis were used to analyze the predictors of the failure,and ROC curve was used to assess the cut-off values of predictors.Results:There was no significant difference in the success rate between UAE group and D&C group in typeⅡCSP patients.Ultrasound-guided D&C succeeded in 249 patients(91.2%),the cure rates of typeⅠand typeⅡa CSP were 97.7%(125/128)and 93.3%(112/120),respectively.Univariate analysis showed that there was a statistically significant difference in scar thickness,preoperative serumβ-human chorionic gonadotropin(β-HCG)level,fetal sac size,clinical classification and the grade of blood flow(P<0.05).Logistic regression multivariate analysis showed the risk factors associated with the unsuccessful group were scar thickness,serumβ-HCG level and maximum diameter line of pregnancy sac(P<0.05).ROC curve showed that the predictive value of treatment failure was best when the maximum diameter line of pregnancy sac was 3.3cm,the scar thickness was 2.4mm,and the serumβ-HCG was 43720U/L.Conclusion:Practical Clinical Classification has a high value of clinical application.The scar thickness>2.4mm,the maximum diameter line of gestational sac<3.3cm and the serumβ-HCG<43720U/L are the cut-off values of successful ultrasound-guided curettage,which can provide the basis for the management of cesarean scar pregnancy.