不同方式治疗剖宫产瘢痕妊娠的效果差异及对复发风险、再妊娠结局的影响

Differences in effect of different treatment modalities for cesarean scar pregnancy andtheir impacts on risk for recurrence of scar pregnancy and outcome of re-pregnancy

目的探究不同方式治疗剖宫产瘢痕妊娠的效果差异及对复发风险、再妊娠结局的影响。方法选取2012年1月至2018年1月在保定市妇幼保健院行手术治疗的剖宫产瘢痕妊娠患者178例(瘢痕妊娠组)为研究对象,根据患者治疗方式的不同分为A组(宫腹腔镜下病灶清除术+修补术)60例、B组(宫腔镜下病灶电切术)49例、C组[高强度聚焦超声(HIFU)预处理+清宫术]69例,观察各组患者手术及术后相关指标、瘢痕妊娠复发率及再妊娠结局变化。选取同时期剖宫产术后再妊娠患者116例作为对照组,Logistic回归分析影响剖宫产瘢痕妊娠发生的相关因素。结果A组手术时间及出血量均高于B组与C组,差异有统计学意义(F值分别为766.48、276.34,P<0.05);A组与B组住院费用、住院时间、β-人绒毛膜促性腺激素(β-HCG)降至正常时间、阴道流血时间、月经复潮时间均低于C组,差异有统计学意义(F值介于15.63~1364.79之间,P<0.05);A组、B组、C组在瘢痕妊娠复发率、手术成功率及并发症发生率方面差异无统计学意义(P>0.05);多因素Logistic回归分析发现,剖宫产次数及流产次数较高、前次剖宫产瘢痕妊娠有胎心、前次剖宫产瘢痕妊娠孕龄较长、子宫剩余肌层厚度较薄为剖宫产瘢痕妊娠发生的危险因素,其OR值及95%CI分别为4.133(1.652~10.340)、6.152(1.472~25.704)、5.360(2.535~11.336)、12.491(3.758~41.513)、6.228(2.111~18.375),P<0.05。结论在剖宫产瘢痕妊娠的治疗中,高强度聚焦超声预处理+清宫术具有较短的手术时间、较少的出血量,但费用较高,且术后恢复较慢;宫腹腔镜下病灶清除术+修补术手术时间及出血量较高,在术后恢复时间方面其与宫腔镜下病灶电切术相似;剖宫产次数、流产次数、前次剖宫产瘢痕妊娠有无胎心、前次剖宫产瘢痕妊娠孕龄、子宫剩余肌层厚度为剖宫产瘢痕妊娠发生的影响因素。

Objective To investigate differences in effect of different modalities for treatment of cesarean scar pregnancy and their impacts on risk for recurrence of scar pregnancy and outcome of re-pregnancy.Methods 178 patients with cesarean scar pregnancy who underwent surgical treatment at Baoding Municipal Maternal and Child Health Hospital from January 2012 to January 2018(scar pregnancy group)were selected as the study subjects.According to treatment method,they were divided into three groups:group A(laparoscopic lesion resection surgery+repair surgery,n=60),group B(hysteroscopic lesion resection,n=49)and group C[High intensity focused ultrasound(HIFU)pre-treatment+curettage,n=69].The operation condition and postoperative related indexes,scar pregnancy recurrence rate,and re-pregnancy outcomes were observed and compared among the three groups.116 patients with recurrent pregnancy after cesarean section were selected as the control group.Logistic regression was used to analyze risk factors affecting occurrence of cesarean scar pregnancy.Results The operation time and intraoperative bleeding volume in group A were longer and higher than those in group B and group C,and the differences were statistically significant(F=766.48 and 276.34 respectively,both P<0.05).And the expenses,length of hospital stay,time forβ-HCG decreasing to normal,vaginal bleeding time,and menstrual cycle recovery time of the patients in group A and group B were all lower and shorter than those in group C,and the differences were statistically significant(F values ranged from 15.63 to 1364.79,all P<0.05).There were no statistically significant differences in recurrence rate of scar pregnancy,surgical success rate and incidence of complications among the three groups(all P>0.05).Multivariate Logistic regression analysis showed that high frequencies of cesarean section and miscarriage,presence and development of fetal heart in previous cesarean scar pregnancy,long gestational weeks in previous cesarean scar pregnancy and thin residual uterine muscle layer thickness were risk factors for cesarean scar pregnancy.The OR values(95%CI)were 4.133(1.652-10.340),6.152(1.472-25.704),5.360(2.535-11.336),12.491(3.758-41.513),6.228(2.111-18.375)respectively,all P<0.05).Conclusion In treatment of cesarean scar pregnancy,HIFU pre-treatment combined with curettage has shorter operation time and less bleeding,but has higher cost and slower postoperative recovery.The operation time and bleeding volume of laparoscopic lesion resection and repair are relatively long and high,while its postoperative recovery time is similar to that of hysteroscopic lesion resection.The frequencies of cesarean sections and abortions,presence or absence of fetal heart in previous cesarean scar pregnancy,gestational age of previous cesarean scar pregnancy and thickness of remaining uterine muscle layers are the influencing factors for occurrence of cesarean scar pregnancy.