PDF(Pubmed)
Abstract：
BACKGROUND: Cesarean scar ectopic pregnancies (CSEPs) are associated with significant maternal morbidity and termination is often recommended in the early first trimester. Management of more advanced cases is challenging due to higher risks of major intraoperative hemorrhage. Hysterectomy is currently the intervention of choice for advanced cases. This study aimed to investigate if advanced live CSEPs could be managed effectively conservatively using suction curettage and interventional radiology.
METHODS: A retrospective single-center cohort study was performed. A total of 371 women diagnosed with CSEP were identified between January 2008 and January 2023. A total of 6% (22/371) women had an advanced live CSEP with crown-rump length (CRL) of ≥40 mm (≥10 weeks\' gestation). Of these, 77% (17/22) opted for surgical intervention, whilst the remaining five continued their pregnancies. A preoperative ultrasound was performed in each patient. All women underwent suction curettage under ultrasound guidance and insertion of Shirodkar cervical suture as a primary hemostatic measure combined with uterine artery embolization (UAE) if required. The primary outcome was rate of blood transfusion. Secondary outcomes were estimated intraoperative blood loss, UAE, intensive care unit admission, reintervention, hysterectomy, hospitalization duration and rate of retained products of conception. Descriptive statistics were used to describe these variables.
RESULTS: Median CRL of the 17 patients included was 54.1 mm (range: 40.0-85.7) and median gestational age based on CRL was 12 + 3 weeks (range: 10 + 6-15 + 0). On preoperative ultrasound scan placental lacunae were recorded in 76% (13/17) of patients and color Doppler score was ≥3 in 67% (10/15) of patients. At surgery, Shirodkar cervical suture was used in all cases. It was successful in achieving hemostasis by tamponade in 76% (13/17) of patients. In the remaining 24% (4/17) patients tamponade failed to achieve complete hemostasis and UAE was performed to stop persistent arterial bleeding into the uterine cavity. Median intraoperative blood loss was 800 mL (range: 250-2500) and 41% (7/17) women lost >1000 mL. 35% (6/17) needed blood transfusion. No women required hysterectomy.
CONCLUSIONS: Surgical evacuation with Shirodkar cervical suture and selective UAE is an effective treatment for advanced live CSEPs.
METHODS: A retrospective single-center cohort study was performed. A total of 371 women diagnosed with CSEP were identified between January 2008 and January 2023. A total of 6% (22/371) women had an advanced live CSEP with crown-rump length (CRL) of ≥40 mm (≥10 weeks\' gestation). Of these, 77% (17/22) opted for surgical intervention, whilst the remaining five continued their pregnancies. A preoperative ultrasound was performed in each patient. All women underwent suction curettage under ultrasound guidance and insertion of Shirodkar cervical suture as a primary hemostatic measure combined with uterine artery embolization (UAE) if required. The primary outcome was rate of blood transfusion. Secondary outcomes were estimated intraoperative blood loss, UAE, intensive care unit admission, reintervention, hysterectomy, hospitalization duration and rate of retained products of conception. Descriptive statistics were used to describe these variables.
RESULTS: Median CRL of the 17 patients included was 54.1 mm (range: 40.0-85.7) and median gestational age based on CRL was 12 + 3 weeks (range: 10 + 6-15 + 0). On preoperative ultrasound scan placental lacunae were recorded in 76% (13/17) of patients and color Doppler score was ≥3 in 67% (10/15) of patients. At surgery, Shirodkar cervical suture was used in all cases. It was successful in achieving hemostasis by tamponade in 76% (13/17) of patients. In the remaining 24% (4/17) patients tamponade failed to achieve complete hemostasis and UAE was performed to stop persistent arterial bleeding into the uterine cavity. Median intraoperative blood loss was 800 mL (range: 250-2500) and 41% (7/17) women lost >1000 mL. 35% (6/17) needed blood transfusion. No women required hysterectomy.
CONCLUSIONS: Surgical evacuation with Shirodkar cervical suture and selective UAE is an effective treatment for advanced live CSEPs.
摘要：
背景：剖宫产瘢痕异位妊娠（CSEP）与显著的产妇发病率相关，通常建议在孕早期终止妊娠。由于术中大出血的风险较高，对更晚期病例的管理具有挑战性。子宫切除术目前是晚期病例的首选干预措施。这项研究旨在调查是否可以使用抽吸刮治和介入放射学对先进的活CSEP进行有效的保守管理。
方法：进行回顾性单中心队列研究。在2008年1月至2023年1月期间，共有371名被诊断为CSEP的妇女被确认。共有6％（22/371）的女性患有晚期实时CSEP，冠臀长度（CRL）≥40mm（妊娠≥10周）。其中,77%(17/22)选择手术干预，其余5人继续怀孕。对每位患者进行术前超声检查。所有女性均在超声引导下进行抽吸刮治，并在必要时插入Shirodkar宫颈缝合线作为主要止血措施，并结合子宫动脉栓塞（UAE）。主要结果是输血率。次要结果是估计术中失血量，阿联酋，重症监护室入院,再干预,子宫切除术,住院时间和受孕产品残留率。使用描述性统计来描述这些变量。
结果：纳入的17例患者的CRL中位数为54.1mm（范围：40.0-85.7），基于CRL的中位孕龄为12+3周（范围：10+6-15+0）。在术前超声扫描中，76％（13/17）的患者记录了胎盘腔隙，而67％（10/15）的患者彩色多普勒评分≥3。在手术中，所有病例均采用Shirodkar宫颈缝合术。76%(13/17)的患者通过填塞成功实现止血。在其余24％（4/17）的患者中，填塞未能实现完全止血，并进行了UAE以阻止持续性动脉出血进入子宫腔。术中失血中位数为800mL（范围：250-2500），41％（7/17）的女性失血量>1000mL。35%(6/17)需要输血。没有妇女需要子宫切除术。
结论：Shirodkar宫颈缝合术和选择性UAE手术是晚期活CSEP的有效治疗方法。
方法：进行回顾性单中心队列研究。在2008年1月至2023年1月期间，共有371名被诊断为CSEP的妇女被确认。共有6％（22/371）的女性患有晚期实时CSEP，冠臀长度（CRL）≥40mm（妊娠≥10周）。其中,77%(17/22)选择手术干预，其余5人继续怀孕。对每位患者进行术前超声检查。所有女性均在超声引导下进行抽吸刮治，并在必要时插入Shirodkar宫颈缝合线作为主要止血措施，并结合子宫动脉栓塞（UAE）。主要结果是输血率。次要结果是估计术中失血量，阿联酋，重症监护室入院,再干预,子宫切除术,住院时间和受孕产品残留率。使用描述性统计来描述这些变量。
结果：纳入的17例患者的CRL中位数为54.1mm（范围：40.0-85.7），基于CRL的中位孕龄为12+3周（范围：10+6-15+0）。在术前超声扫描中，76％（13/17）的患者记录了胎盘腔隙，而67％（10/15）的患者彩色多普勒评分≥3。在手术中，所有病例均采用Shirodkar宫颈缝合术。76%(13/17)的患者通过填塞成功实现止血。在其余24％（4/17）的患者中，填塞未能实现完全止血，并进行了UAE以阻止持续性动脉出血进入子宫腔。术中失血中位数为800mL（范围：250-2500），41％（7/17）的女性失血量>1000mL。35%(6/17)需要输血。没有妇女需要子宫切除术。
结论：Shirodkar宫颈缝合术和选择性UAE手术是晚期活CSEP的有效治疗方法。
