您的位置:山东大学 -> 科技期刊社 -> 《山东大学学报(医学版)》

山东大学学报 (医学版) ›› 2021, Vol. 59 ›› Issue (1): 40-44.doi: 10.6040/j.issn.1671-7554.0.2020.1058

• 临床医学 • 上一篇    下一篇

86例Ⅲ型瘢痕妊娠诊治体会

霍素霞1,刘薇1,王鑫2   

  1. 山东第一医科大学附属省立医院 1. 妇科;2. 超声诊疗科, 山东 济南 250021
  • 发布日期:2021-01-09
  • 通讯作者: 刘薇. E-mail:2583546770@qq.com
  • 基金资助:
    山东省重点研发计划项目(2019GSF108183)

Experience in the treatment of 86 cases of type Ⅲ cesarean scar pregnancy

HUO Suxia1, LIU Wei1, WANG Xin2   

  1. 1. Department of Gynecology;
    2. Department of Ultrasound Diagnosis, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
  • Published:2021-01-09

摘要: 目的 探讨Ⅲ型剖宫产瘢痕妊娠(CSP)的治疗方案。 方法 回顾性分析山东第一医科大学附属省立医院妇科收治的Ⅲ型CSP患者86例,术前依据患者病情风险性的大小采取相应的手术方式。按治疗方法分为3组,A组30例行子宫动脉栓塞后清宫术、B组18例行宫腔镜下胚物清除术、C组38例行宫腔镜联合腹腔镜病灶切除+子宫瘢痕修补术。比较3组患者的孕龄、孕囊长径、瘢痕处肌层厚度、术前血清β人绒毛膜促性腺激素(β-hCG)水平、术中出血量、术后血清β-hCG下降幅度、住院时间和治疗成功率。统计分析中定量数据涉及多组的单因素方差分析或非参数检验,分类数据采用χ2检验。 结果 3组患者在年龄、剖宫产次数和距上次剖宫产手术间隔相比较差异具有可比性(P均>0.05)。3组患者孕囊长径、瘢痕处肌层厚度、术前血清β-hCG水平的差异均有统计学意义,两两多重比较显示孕囊长径A组、C组均大于B组(F=52.196,P<0.001);瘢痕处肌层厚度A组和C组低于B组(H=42.553,P<0.001);术前血清β-hCG水平A组和C组高于B组(H=9.173,P=0.010),差异均有统计学意义;而其余两两多重比较均无统计学意义。术中出血量中位数C组较A组和B组多(H=17.211,P<0.001)。手术后A、B、C三组治疗成功率分别为86.67%、88.89%和97.37%,组间比较差异无统计学意义, χ2=3.072,P=0.190术后血清β-hCG下降幅度C组最快,H=14.238,P=0.001,差异有统计学意义。 结论 研究观察表明对于孕囊或包块≤3 cm、瘢痕厚度≥2 mm的Ⅲ型CSP可行宫腔镜下胚物清除;孕囊或包块>3 cm、瘢痕厚度<2 mm可优选宫腔镜联合腹腔镜病灶切除+子宫修补术。子宫动脉栓塞术可作为CSP治疗后出血的补充治疗,一般不做预防性使用。

关键词: 瘢痕妊娠, 手术治疗, 子宫动脉栓塞, 宫腔镜, 腹腔镜, 子宫瘢痕修补术

Abstract: Objective To explore the treatment strategy of type Ⅲ cesarean scar pregnancy(CSP). Methods The records of 86 patients with type Ⅲ CSP treated in our hospital in the last decade were retrospectively reviewed. According to the surgical methods, the patients were divided into three groups. Group A(n=30)underwent curettage after uterine artery embolization, group B(n=18)received hysteroscopic curettage, and group C(n=38)received laparoscopy combined with hysteroscopic curettage and uterine scar repair. The gestational age, diameter of gestational sac, myometrium thickness, preoperative serum β-human chorionic gonadotropin(β-hCG)level, intraoperative blood loss, decrease of postoperative serum β-hCG, hospitalization time and success rate were compared among the three groups. The quantitative data involved multiple groups of one-way ANOVA or nonparametric test, and the classified data were analyzed by Chi-square test. Results There were no significant differences in maternal age, cesarean frequency and interval since the last cesarean section among the three groups(P>0.05). Gestational sac diameter was larger in group A and group C than in group B(F=52.196, P<0.001). Myometrium thickness was lower in group A and group C than in group B(H=42.553, P<0.001). Preoperative serum β-hCG was significantly higher in group A and group C than in group B(H=9.173, P=0.010). The other pairwise comparisons had no statistical significance. The median amount of intraoperative blood loss was higher in group C than in group A and group B(H=17.211, P<0.001). The success rate in groups A, B and C was 86.67%, 88.89% and 97.37%, respectively, with no significant difference(χ2=3.072, P=0.190). The mean decrease of postoperative serum β-hCG in group C was the fastest(H=14.238, P=0.001). Conclusion For type Ⅲ CSP with gestational sac or mass ≤3 cm and scar thickness ≥2 mm, hysteroscopic curettage can be selected. For gestational sac or mass >3 cm and scar thickness <2 mm, laparoscopy combined with hysteroscopic curettage is recommended. Uterine artery embolization can be used as a supplementary treatment when massive bleeding occurs after primary treatment instead of a preventive measure before curettage.

Key words: Cesarean scar pregnancy, Surgical treatment, Uterine artery embolization, Hysteroscopy, Laparoscopy, Uterine scar repair

中图分类号: 

  • R714.1
[1] Timor-Tritsch IE, Monteagudo A, Calì G, et al. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis[J]. Obstet Gynecol Clin North Am, 2019, 46(4): 797-811.
[2] 林蓉, 韦娟冰, 王金华. 29例子宫切口瘢痕妊娠治疗方法的临床观察[J]. 生殖医学杂志, 2017, 26(5): 486-489.
[3] 中华医学会妇产科学分会计划生育学组. 剖宫产术后子宫瘢痕妊娠诊治专家共识(2016)[J]. 中华妇产科杂志, 2016, 51(8): 568-572.
[4] Glenn TL, Bembry J, Findley AD, et al. Cesarean Scar Ectopic Pregnancy: Current Management Strategies [J]. Obstet Gynecol Surv, 2018, 73(5): 293-302.
[5] Tumenjargal A, Tokue H, Kishi H, et al. Uterine Artery Embolization Combined with Dilation and Curettage for the Treatment of Cesarean Scar Pregnancy: Efficacy and Future Fertility [J]. Cardiovasc Intervent Radiol, 2018, 41(8): 1165-1173.
[6] 康彦君, 班艳丽, 张腾, 等. 子宫瘢痕妊娠实用临床分型及应用价值探讨[J]. 现代妇产科进展, 2019, 28(10): 731-735. KANG Yanjun, BAN Yanli, ZHANG Teng, et al. Practical clinical classification and its application in treatment of cesarean scar pregnancy [J]. Progress in Obstetrics and Gynecology, 2019, 28(10): 731-735.
[7] Gonzalez N, Tulandi T. Cesarean Scar Pregnancy: A Systematic Review [J]. J Minim Invasive Gynecol, 2017, 24(5): 731-738.
[8] 白亮亮, 李甜甜, 李宗明, 等. 刮宫术前行预防性子宫动脉栓塞治疗瘢痕妊娠的必要性[J]. 中国介入影像与治疗学, 2018, 15(1): 47-50. BAI Liangliang, LI Tiantian, LI Zongming, et al. Necessity of prophylactic uterine artery embolization before curettage in treatment of cesarean scar pregnancy [J]. Chinese Journal of Interventional Imaging and Therapy, 2018, 15(1): 47-50.
[9] Zhang G, Li J, Tang J, et al. Role of collateral embolization in addition to uterine artery embolization followed by hysteroscopic curettage for the management of cesarean scar pregnancy [J]. BMC Pregnancy Childbirth, 2019, 19(1): 502.
[10] Chen H, Zhou J, Wang H, et al. The Treatment of Cesarean Scar Pregnancy with Uterine Artery Embolization and Curettage as Compared to Transvaginal Hysterotomy [J]. Eur J Obstet Gynecol Reprod Biol, 2017, 214: 44-49.
[11] Keung JJ, Spies JB, Caridi TM. Uterine artery embolization: a review of current concepts [J]. Best Pract Res Clin Obstet Gynaecol, 2018, 46(1): 66-73.
[12] Qian ZD, Weng Y, Du YJ, et al. Management of persistent cesarean scar pregnancy after curettage treatment failure [J]. BMC Pregnancy Childbirth, 2017, 17(1): 208.
[13] 安瑞, 李长东. 剖宫产瘢痕妊娠发病机制及影响因素[J]. 中国计划生育学杂志, 2018, 26(7): 643-646. AN Rui, LI Changdong. Pathogenesis and influencing factors of cesarean scar pregnancy [J]. Chinese Journal of Family Planning, 2018, 26(7): 643-646.
[14] Ying X, Zheng W, Zhao L, et al. Clinical characteristics and salvage management of persistent cesarean scar pregnancy [J]. J Obstet Gynaecol Res, 2017, 43: 1293-1298.
[15] 李旺, 邹凌霄, 潘琼, 等. 剖宫产子宫切口瘢痕缺陷的宫腔镜手术治疗[J]. 中国实用妇科与产科杂志, 2018, 34(8): 865-869. LI Wang, ZOU Lingxiao, PAN Qiong, et al. Hysteroscopic surgery treatment for cesarean scar diverticulum [J]. Chinese Journal of Practical Gynecology and Obstetrics, 2018, 34(8): 865-869.
[16] 王光伟, 刘晓菲, 王丹丹, 等. 选择性子宫动脉栓塞术联合宫腔镜手术治疗外生型剖宫产术后子宫瘢痕妊娠67例临床分析[J]. 中华妇产科杂志, 2015, 50(8): 576-580.
[17] Zhang Y, Chen L, Zhou M, et al. Risk factors of persistent cesarean scar pregnancy after dilation and curettage: a matched case-control study [J]. Taiwan J Obstet Gynecol, 2020, 59(2): 237-242.
[18] Qi F, Chai ZY, Liu MM, et al. Type 2 Cesarean Scar Pregnancy Successfully Treated via Hysteroscopy-Assisted Laparoscopy [J]. J Minim Invasive Gynecol, 2019, 26(7): 1273-1281.
[19] Lee CL, Wang CJ, Chao A, et al. Laparoscopic management of an ectopic pregnancy in a previous Caesarean section scar [J]. Hum Reprod, 1999, 14(5): 1234-1236.
[20] Qi F, Chai ZY, Liu MM, et al. Type 2 Cesarean Scar Pregnancy Successfully Treated via Hysteroscopy-Assisted Laparoscopy [J]. J Minim Invasive Gynecol, 2019, 26(7): 1273-1281.
[21] Gonzalez N, Tulandi T. Cesarean scar pregnancy: a systematic review [J]. J Minim Invasive Gynecol, 2017, 24(5): 731-738.
[22] Glenn TL,Bembry J,Findley AD,et al.Cesarean scar ectopic pregnancy: current management strategies [J]. Obstet Gynecol Surv, 2018, 73(5): 293-302.
[23] Chai ZY, Zhang SS, Hu XH, et al. Successful Resection of an 11-Week Cesarean Scar Pregnancy With a Combination of Laparoscopy and Hysteroscopy [J]. J Minim Invasive Gynecol, 2018, 25: 320-321.
[24] Maheux-Lacroix S, Li F, Bujold E, et al. Cesarean scar pregnancies: a systematic review of treatment options [J]. J Minim Invasive Gynecol, 2017, 24(6): 915-925.
[25] Wang G, Liu X, Bi F, et al. Evaluation of the efficacy of laparoscopic resection for the management of exogenous cesarean scar pregnancy [J]. Fertil Steril, 2014, 101(5): 1501-1507.
[26] 王珏, 杜琰, 华克勤, 等. 剖宫产术后子宫切口憩室流行病学特征及其影响因素的研究进展[J]. 复旦学报(医学版), 2018, 45(2): 271-276. WANG Jue, DU Yan, HUA Keqin, et al. Research progress of epidemiological characteristics and influencing factors of cesarean scar defect after cesarean section [J]. Fudan University Journal of Medical Sciences, 2018, 45(2): 271-276.
[27] Lu YM, Guo YR, Zhou MY. Indwelling Intrauterine Foley Balloon Catheter for Intraoperative and Postoperative Bleeding in Cesarean Scar Pregnancy [J]. J Minim Invasive Gynecol, 2020, 27(1): 94-99.
[1] 薛莹,周兴国,王宇,王德海,丁印鲁. 左侧巨大十二指肠旁疝1例报道[J]. 山东大学学报 (医学版), 2022, 60(8): 127-129.
[2] 张信美,徐萍. 子宫腺肌病的手术治疗策略[J]. 山东大学学报 (医学版), 2022, 60(7): 26-31.
[3] 李博,刘竞芳,鲍金鹏,李祥泽,秦广洋,田虎. 三维可视化联合吲哚菁绿荧光影像技术在51例原发性肝癌腹腔镜切除术中的应用价值[J]. 山东大学学报 (医学版), 2022, 60(3): 83-88.
[4] 王沂峰,何丽清. 外阴癌腹股沟淋巴结手术的研究进展[J]. 山东大学学报 (医学版), 2021, 59(9): 103-109,116.
[5] 仲明惟,胡三元. 我国腹腔镜技术治疗肥胖症手术方式的探索[J]. 山东大学学报 (医学版), 2021, 59(9): 72-77, 96.
[6] 王璐,赵新蕊,朱琳. 25例早期宫颈癌无瘤化免举宫腹腔镜子宫切除术临床效果[J]. 山东大学学报 (医学版), 2021, 59(6): 76-80.
[7] 刘超,闫动,李香,张蕾,李燕. 腹腔镜辅助经脐小切口治疗小儿美克尔憩室的临床分析[J]. 山东大学学报 (医学版), 2020, 1(9): 40-44.
[8] 张召义,韩婷,孙艳萍,李波. 聚乙二醇电解质散在40例妇科腹腔镜术前肠道准备中的应用[J]. 山东大学学报 (医学版), 2020, 58(2): 49-53.
[9] 王波,熊颖,倪志福,屈振繁. 加速康复外科理念在1~3岁日间疝手术中的应用[J]. 山东大学学报 (医学版), 2020, 58(12): 92-96.
[10] 刘娅,王雅芬,朱琳,张萍,马德美. 53例子宫内膜息肉恶变趋势的危险因素[J]. 山东大学学报 (医学版), 2020, 58(1): 39-42.
[11] 张照鹏,邢乃栋,张翔,阎磊,徐忠华. 160例腹腔镜根治性膀胱切除术后淋巴漏的影响因素分析[J]. 山东大学学报 (医学版), 2020, 58(1): 67-72.
[12] 孙志刚,时鹏,田兴松. 乳腺癌术后促纤维增生性肌纤维母细胞瘤1例[J]. 山东大学学报 (医学版), 2020, 58(1): 121-124.
[13] 董昌正,周伟,李风周,臧义丰,丁印鲁. 全腹腔镜下全胃+胆囊+阑尾切除经自然腔道取标本手术1例[J]. 山东大学学报 (医学版), 2019, 57(7): 122-124.
[14] 华克勤,李珺玮,陈义松. 单孔腹腔镜在盆底功能障碍中的应用[J]. 山东大学学报 (医学版), 2019, 57(12): 10-14.
[15] 关小明,张意茗,范晓东. 单孔腹腔镜技术的发展及展望[J]. 山东大学学报 (医学版), 2019, 57(12): 5-9.
Viewed
Full text


Abstract

Cited

  Shared   
  Discussed   
[1] 肖伟玲,林亚杰,牟东珍,孙萍,梁淑娟 . 分泌型人IL-1β表达载体的构建及在H7402细胞中的表达[J]. 山东大学学报(医学版), 2008, 46(2): 119 -122 .
[2] 孙维彤,邹伟伟,李爱国,席延伟,张娜. 脂质体粒径对促进托氟啶口服吸收的影响[J]. 山东大学学报(医学版), 2007, 45(6): 639 -642 .
[3] 于清梅,武玉玲,宋海岩,尹华伟,庄园 . p38丝裂原活化蛋白激酶在小鼠早期胚胎及围植入期子宫内膜的表达[J]. 山东大学学报(医学版), 2008, 46(2): 123 -127 .
[4] 张勇,叶静,郭新星,肖水清. 牙周膜牵张成骨快速移动牙牙髓中IL-8表达的变化[J]. 山东大学学报(医学版), 2008, 46(4): 379 -381 .
[5] 高静,陈雯,张同霞,王小花,戴廷军,姚红,赵秀鹤,迟兆富,单培彦 . 颞叶癫痫大鼠海马线粒体细胞色素氧化酶亚基Ⅲ和Ⅳ表达的变化[J]. 山东大学学报(医学版), 2007, 45(8): 817 -820 .
[6] 刘益民,杜鲁涛,王丽丽,蒋秀梅,李娟,曲爱林,王海燕,郑桂喜,张欣,杨咏梅,王传新. 膀胱癌患者血清microRNA检测中内参基因的筛选及验证[J]. 山东大学学报(医学版), 2014, 52(5): 86 -91 .
[7] . 干细胞标记物LGR5在结直肠癌发生发展中的表达及意义[J]. 山东大学学报(医学版), 2009, 47(8): 85 -88 .
[8] 杨奎忠,孙雪飞,项继顺,杜庆聪,黄凤昌 . c-FLIP反义寡核苷酸对食管癌EC109细胞裸鼠移植瘤抑制作用的实验研究[J]. 山东大学学报(医学版), 2007, 45(12): 1234 -1238 .
[9] 俞新爽,韩俊庆,王兴文,盛巍,王瑜. 乳腺癌患者细胞免疫水平与预后危险因素的关系及临床意义[J]. 山东大学学报(医学版), 2007, 45(9): 934 -937 .
[10] 王海峰,史本康,张克勤,李永智,朱耀丰,王海新. B超检测的精索静脉直径及返流与术后精液质量的关系[J]. 山东大学学报(医学版), 2007, 45(7): 751 -752 .