剖宫产术后瘢痕子宫早期妊娠药物流产结局的影响因素分析

Analysis of influencing factors on drug abortion outcome of early pregnancy with cesarean scar uterus after cesarean section

目的 分析剖宫产术后瘢痕子宫早期妊娠药物流产结局的影响因素。方法 选取2019年1月-2023年12月北京市通州区中西医结合医院妇产科因意外妊娠需药物流产的272例早期妊娠剖宫产术后瘢痕子宫孕妇为研究对象,根据药物流产结果分失效组和有效组。收集体重指数、妊娠次数、停经时间、避孕方式、哺乳期早孕、既往流产史、剖宫产次数、子宫位置、慢性盆腔炎史、孕囊直径、孕囊与瘢痕间距、距前次剖宫产时间、促卵泡素(FSH)、促黄体素(LH)、雌二醇(E_(2))、孕酮(P)、瘢痕愈合情况,采用多因素Logistic回归分析剖宫产术后瘢痕子宫早期妊娠药物流产结局的影响因素并建立Logistic(P)回归方程模型,绘制受试者工作特征(Receiver operating characteristic curve,ROC)曲线分析Logistic(P)对剖宫产术后瘢痕子宫早期妊娠药物流产结局的预测价值。结果 完成有效调查的孕妇共252例,药物流产结果显示,药物流产失效41例、有效211例,占比分别为16.27%、83.73%。与有效组比较,失效组哺乳期早孕例数、剖宫产次数≥2次例数、子宫位置非水平位例数、慢性盆腔炎史例数、孕囊直径、血清P水平、瘢痕缺损例数升高,孕囊与瘢痕间距缩小,差异有统计学意义(P<0.05)。孕囊与瘢痕间距、瘢痕缺损是剖宫产术后瘢痕子宫早期妊娠药物流产失效的独立保护因素,血清P水平是剖宫产术后瘢痕子宫早期妊娠药物流产失效的独立危险因素(P<0.05)。根据变量回归系数表建立回归方程模型,Logistic(P)=-4.033-0.546×孕囊与瘢痕间距+0.192×P-1.125×瘢痕缺损,拟合度良好,绘制剖宫产术后瘢痕子宫早期妊娠药物流产结局的Logistic回归模型预测效能的ROC曲线,结果显示ROC曲线下面积(Area under curve,AUC)为0.875,95%CI为0.828~0.913,敏感度为85.37%,特异度为72.04%。结论 剖宫产术后瘢痕子宫早期妊娠药物流产失效率较高,在制定药物流产方案时需考虑孕囊与瘢痕间距、瘢痕缺损、血清P水平。

Objective To analyse the outcome of drug abortion of early pregnancy with cesarean scar uterus after cesarean section and its influencing factors.Methods 272 pregnant women with scarred uterus after cesarean section due to accidental pregnancy requiring medication abortion in the hospital from January 2019 to December 2023 were selected as research subjects.The patients were divided into ineffective group and effective group based on the results of medication abortion.Data on body mass index,number of pregnancies,duration of amenorrhea,contraceptive methods,early pregnancy during lactation,history of previous abortions,number of cesarean sections,uterine position,history of chronic pelvic inflammatory disease,diameter of gestational sac,distance between gestational sac and scar,time since the previous cesarean section,follicle-stimulating hormone(FSH),luteinizing hormone(LH),estradiol(E_2),progesterone(P),and scar healing condition were collected.Multivariate Logistic regression analysis was used to investigate the influencing factors of medical abortion outcomes in early pregnancy with scarred uterus after cesarean section,and a Logistic(P) regression equation model was established.Receiver operating characteristic(ROC) curve analysis was performed to evaluate the predictive value of Logistic(P) for the outcome of medical abortion in early pregnancy with scarred uterus after cesarean section.Results A total of 252 pregnant women completed the effective investigation.The results of drug abortion showed that 41 cases were invalid and 211 cases were effective,accounting for 16.27% and 83.73% respectively.The number of early pregnancy during lactation,the number of cesarean section ≥2 times,the number of non-horizontal uterine position,the number of chronic pelvic inflammatory history,the diameter of the gestational sac,the serum P level,and the number of scar healing condition in the ineffective group were higher than those in the effective group,and the distance between the gestational sac and scar was lower than that in the effective group(P<0.05).The distance between pregnant sac and scar and scar healing condition were independent protective factors for drug abortion failure in early pregnancy with cesarean scar uterus after cesarean section,and serum P level was independent risk factor for drug abortionfailure in early pregnancy with cesarean scar uterus after cesarean section(P<0.05).Based on the variable regression coefficient table,a regression equation model was established:Logistic(P)=-4.033-0.546× spacing between pregnant sac and scar+0.192×p-1.125×scar healing condition,with good fit.The ROC curve for predicting the outcome of medical abortion in early pregnancy with scarred uterus after cesarean section was plotted based on the Logistic regression model.The results showed that the area under the ROC curve(AUC) was 0.875,with a 95%CI of 0.828 to 0.913,a sensitivity of 85.37%,and a specificity of 72.04%.Conclusion The failure rate of drug abortion in the early stage of cesarean scar uterus after cesarean section is high,so the distance between pregnant sac and scar,scar defect and serum P level should be considered in the planning of drug abortion.