目的:剖宫产瘢痕妊娠(CSP)是一种与严重并发症相关的异位妊娠,包括明显的出血,子宫切除术的潜在需求,和危及生命的风险。目前,CSP有两种分类方法:小瓶(Ia型和IIa型)和中国专家共识(Ib型,IIb型,和IIIb型)。然而,这些方法在指导选择合适的CSP治疗方案方面存在局限性.这项研究的目的是系统地评估我们诊所中CSP的各种治疗方法的有效性。
方法:我们的研究包括2013年1月至2018年12月的906例CSP患者。采用卡方检验和logistic分析比较临床特征。计算中位数和四分位距(IQR)。我们还分析了术前应用甲氨蝶呤(MTX)是否可以改善手术结局以及误诊的CSP患者的相关特征。
结果:胎龄有显著差异,孕囊直径,孕囊宽度,孕囊面积,残余子宫肌层厚度,阴道出血和术前血红蛋白水平(p<0.001),但不在残留组织的发生率(p=0.053)。其他因素(术中失血,血红蛋白下降,手术后的第一血红蛋白,总住院时间,手术后住院,输血和导管引流的持续时间)显着不同(p<0.001)。对于Ia型和Ib型CSP,39.3%和40.2%的患者在超声下进行了扩张和刮宫(D&E)治疗,分别。对于IIa型和IIIb型CSP,29.9%和62.7%的患者接受剖腹手术治疗,分别。手术方法没有差异,MTX组和非MTX组之间的残留组织和再次手术(p=0.20),但是肝损伤,MTX组住院时间和疼痛感知更显著。值得注意的是,14%的患者被误诊为宫内妊娠。IIa型CSP患者的误诊发生率高于Ia型CSP患者(p<0.001)。
结论:对于I型CSP患者,应建议在超声下进行D&E或在宫腔镜下进行D&E。对于IIIb型CSP患者,应使用手术切除。目前很难为IIa型或IIb型CSP患者选择合适的治疗方法。
OBJECTIVE: Cesarean scar pregnancy (CSP) is a type of ectopic pregnancy associated with severe complications, including significant hemorrhage, the potential need for hysterectomy, and life-threatening risks. Currently, two classification methods exist for CSP: Vial (type Ia and IIa) and Chinese Expert\'s Consensus (type Ib, type IIb, and type IIIb). However, these methods have limitations in guiding the selection of appropriate treatment plans for CSP. The purpose of this study was to systematically evaluate the effectiveness of various treatments for CSP within our clinic.
METHODS: Our study included 906 patients with CSP from January 2013 to December 2018. The chi-squared test and logistic analysis were used to compare the clinical characteristics. The median and interquartile range (IQR) was calculated. We also analyzed whether preoperative application of methotrexate (MTX) could improve surgical outcomes and the relevant characteristics of misdiagnosed CSP patients.
RESULTS: There was a significant difference in gestational age, gestational sac diameter, gestational sac width, gestational sac area, remnant myometrial thickness, vaginal bleeding and preoperative hemoglobin levels (p < 0.001) but not in the incidence of residual tissue (p = 0.053). The other factors (intraoperative blood loss, hemoglobin decline, first hemoglobin after operation, total hospital stay, hospital stay after operation, transfusion and duration of catheter drain) were significantly different (p < 0.001). For type Ia and type Ib CSP, 39.3% and 40.2% of patients were treated with dilatation and curettage (D&E) under ultrasound, respectively. For type IIa and type IIIb CSP, 29.9% and 62.7% of patients were treated with laparotomy, respectively. There were no differences in surgical methods, residual tissue and reoperation between the MTX and non-MTX groups (p = 0.20), but liver damage, hospital stay and pain perception were more remarkable in the MTX group. It is noteworthy that 14% of the patients were misdiagnosed with an intrauterine pregnancy. The incidence of misdiagnosis in type IIa CSP patients was higher than that in type Ia CSP patients (p < 0.001).
CONCLUSIONS: For type I CSP patients, D&E under ultrasound or D&E under hysteroscopy should be recommended. For type IIIb CSP patients, operative resection should be used. It is currently difficult to choose the appropriate treatment methods for type IIa or type IIb CSP patients.