目的:剖宫产瘢痕妊娠可导致不同程度的并发症。有很多治疗方法,但是没有统一或公认的治疗策略。本系统评价和网络荟萃分析旨在观察剖宫产瘢痕妊娠患者治疗方式的有效性和安全性。
方法:MEDLINE,Embase,从开始到2024年1月31日,搜索了Cochrane中央控制试验登记册。此外,我们手动搜索相关综述和荟萃分析,寻找更多参考.
方法:我们的研究纳入了通过超声成像或磁共振成像诊断为剖宫产瘢痕妊娠的至少10名女性的头对头试验,包括主要干预措施和任何补充措施的详细描述。纽卡斯尔-渥太华量表得分<4的试验因质量低而被排除。
方法:我们对剖宫产瘢痕妊娠进行了随机效应网络荟萃分析和综述。治疗疗效和安全性的团体数据,生殖结果,研究设计,和人口统计学特征是按照预定义的协议提取的。使用Cochrane偏见风险工具进行随机对照试验,并使用纽卡斯尔-渥太华量表进行队列研究和病例系列评估研究质量。主要结果是疗效(初始治疗成功)和安全性(并发症),其中使用具有随机效应的成对和网络荟萃分析,汇总优势比和累积排名曲线下的表面。
结果:纳入了73项试验(7项随机对照试验),评估了总共8369名女性和17种治疗方式。网络荟萃分析基于来自73项报告成功率的试验和55项报告并发症的试验的数据。研究结果表明,腹腔镜检查,经阴道切除术,宫腔镜刮宫术,高强度聚焦超声联合抽吸刮宫显示出最高的治愈率,在累积排名曲线下的表面排名分别为91.2、88.2、86.9和75.3。当与抽吸刮宫相比时,疗效的比值比(95%置信区间)如下:腹腔镜检查为6.76(1.99-23.01),5.92(1.47-23.78)用于经阴道切除术,用于宫腔镜刮治的5.00(1.99-23.78),高强度聚焦超声联合抽吸刮除术为3.27(1.08-9.89)。在接受子宫动脉化疗栓塞后更容易发生并发症,抽吸刮宫,甲氨蝶呤+宫腔镜刮治,和全身性甲氨蝶呤;宫腔镜刮宫,高强度聚焦超声联合抽吸刮宫术,和Lap比来自有限证据的其他选择更安全;所有数据的置信区间都很宽。
结论:我们的研究结果表明腹腔镜检查,经阴道切除术,宫腔镜刮宫术,高强度聚焦超声联合抽吸刮宫术具有优异的疗效,减少了并发症。不建议使用甲氨蝶呤(局部引导注射和全身给药)作为独立的药物治疗。
OBJECTIVE: Cesarean scar pregnancy may lead to varying degrees of complications. There are many treatment methods for it, but there are no unified or recognized treatment strategies. This systematic review and network meta-analysis aimed to observe the efficacy and safety of treatment modalities for patients with cesarean scar pregnancy.
METHODS: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from their inception to January 31, 2024. In addition, relevant reviews and meta-analyses were manually searched for additional references.
METHODS: Our study incorporated head-to-head trials involving a minimum of 10 women diagnosed with cesarean scar pregnancy through ultrasound imaging or magnetic resonance imaging, encompassing a detailed depiction of primary interventions and any supplementary measures. Trials with a Newcastle-Ottawa scale score <4 were excluded because of their low quality.
METHODS: We conducted a random-effects network meta-analysis and review for cesarean scar pregnancy. Group-level data on treatment efficacy and safety, reproductive outcomes, study design, and demographic characteristics were extracted following a predefined protocol. The quality of studies was assessed using the Cochrane risk-of-bias tools for randomized controlled trials and the Newcastle‒Ottawa scale for cohort studies and case series. The main outcomes were efficacy (initial treatment success) and safety (complications), of which summary odds ratios and the surface under the cumulative ranking curve using pairwise and network meta-analysis with random effects.
RESULTS: Seventy-three trials (7 randomized controlled trials) assessing a total of 8369 women and 17 treatment modalities were included. Network meta-analyses were rooted in data from 73 trials that reported success rates and 55 trials that reported complications. The findings indicate that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound combined with suction curettage demonstrated the highest cure rates, as evidenced by surface under the cumulative ranking curve rankings of 91.2, 88.2, 86.9, and 75.3, respectively. When compared with suction curettage, the odds ratios (95% confidence intervals) for efficacy were as follows: 6.76 (1.99-23.01) for laparoscopy, 5.92 (1.47-23.78) for transvaginal resection, 5.00 (1.99-23.78) for hysteroscopic curettage, and 3.27 (1.08-9.89) for high-intensity focused ultrasound combined with suction curettage. Complications were more likely to occur after receiving uterine artery chemoembolization, suction curettage, methotrexate+hysteroscopic curettage, and systemic methotrexate; hysteroscopic curettage, high-intensity focused ultrasound combined with suction curettage, and Lap were safer than the other options derived from finite evidence; and the confidence intervals of all the data were wide.
CONCLUSIONS: Our findings indicate that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound combined with suction curettage procedures exhibit superior efficacy with reduced complications. The utilization of methotrexate (both locally guided injection and systemic administration) as a standalone medical treatment is not recommended.