[1]高亮,唐璟,孙鸿展.不同手术方式治疗Ⅱ型剖宫产瘢痕妊娠临床效果比较[J].新乡医学院学报,2023,40(1):059-66.[doi:10.7683/xxyxyxb.2023.01.011]
　GAO Liang,TANG Jing,SUN Hongzhan.Comparison of clinical effect of different surgical methods in the treatment of type Ⅱ cesarean scar pregnancy[J].Journal of Xinxiang Medical University,2023,40(1):059-66.[doi:10.7683/xxyxyxb.2023.01.011]
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不同手术方式治疗Ⅱ型剖宫产瘢痕妊娠临床效果比较
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《新乡医学院学报》[ISSN:1004-7239/CN:41-1186/R]

卷:
40卷
期数:
2023年1期
页码:
059-66
栏目:
临床研究
出版日期:
2023-01-05

文章信息/Info

Title:
Comparison of clinical effect of different surgical methods in the treatment of type Ⅱ cesarean scar pregnancy
作者:
高亮; 唐璟; 孙鸿展
（南京医科大学附属泰州人民医院妇产科，江苏　泰州　225300）
Author(s):
GAO Liang; TANG Jing; SUN Hongzhan
（Department of Obstetrics and Gynecology，the Affiliated Taizhou People′s Hospital of Nanjing Medical University，Taizhou 225300，Jiangsu Province，China）
关键词:
剖宫产瘢痕妊娠; 子宫动脉栓塞; 宫腔镜; 腹腔镜
Keywords:
cesarean scar pregnancy; uterine artery embolization; hysteroscopy; laparoscopy
分类号:
R714.22
DOI:
10.7683/xxyxyxb.2023.01.011
文献标志码:
A
摘要:
目的　比较不同手术方式治疗 Ⅱ 型剖宫产瘢痕妊娠（CSP）患者的临床效果及其对预后的影响。方法　选择南京医科大学附属泰州人民医院妇产科2016年6月至2019年8月收治的124例Ⅱ型CSP患者为研究对象。根据所采用的手术方式将124例患者分为A组（n=77）、B组（n=20）、C组（n=8）、D组（n=13）、E组（n=6），其中A组患者行宫腔镜瘢痕妊娠病灶清除术，B组患者行腹腔镜瘢痕妊娠病灶切除+修补术，C组患者行阴式子宫瘢痕妊娠病灶清除+修补术，D组患者于子宫动脉栓塞术（UAE）后行宫腔镜手术，E组患者于UAE后行腹腔镜手术。分别观察 5组患者的手术时间、术中出血量、术后血红蛋白下降值、术后人绒毛膜促性腺激素（HCG）下降率、HCG降至正常时间、术后月经来潮时间、住院时间、术中及术后2周内不良反应；术后随访36~48个月，观察5组有妊娠需求的CSP患者的自然妊娠、流产、再发CSP及分娩情况。结果　A组、B组、C组、D组和E组患者的手术成功率分别为84.41%（65/77）、65.00%（13/20）、87.50%（7/8）、100.00%（13/13）、100.00%（6/6），5组患者的手术成功率比较差异无统计学意义(χ2=2.014，P>0.05)。5组患者的术后HCG下降率比较差异无统计学意义（F=1.021，P>0.05）。 5组患者的手术时间、术中出血量、术后血红蛋白下降值、HCG降至正常时间、术后月经来潮时间、住院时间比较差异有统计学意义（F=54.971、13.685、6.126、3.957、13.586、13.791，P<0.05）。B组患者的手术时间、住院时间显著长于A组，术中出血量、术后血红蛋白下降值显著高于A组（P<0.05）；C组患者的手术时间显著长于A组（P<0.05）；D组患者的手术时间、HCG降至正常时间、术后月经来潮时间及住院时间显著长于A组（P<0.05）；E组患者的手术时间、HCG降至正常时间、术后月经来潮时间及住院时间显著长于A组，术中出血量显著多于A组（P<0.05）。C组患者的手术时间显著短于B组，术中出血量、术后血红蛋白下降值显著低于B组（P<0.05）；D组患者的手术时间显著短于B组，术中出血量、术后血红蛋白下降值显著低于B组，HCG降至正常时间、术后月经来潮时间显著长于B组（P<0.05）；E组患者的手术时间、HCG降至正常时间及术后月经来潮时间显著长于B组，术中出血量、术后血红蛋白下降值显著低于B组（P<0.05）。D组患者的术后月经来潮时间显著长于C组（P<0.05）；E组患者的手术时间及术后月经来潮时间显著长于C组（P<0.05）。E组患者的手术时间显著长于D组（P<0.05）。A组、B组、C组、D组和E组患者的不良反应发生率分别为15.58%（12/77）、35.00%（7/20）、12.50%（1/8）、61.54%（8/13）、50.00%（3/6）；A组与C组患者的不良反应发生率比较差异无统计学意义（χ2=0.053，P>0.05）；B组、D组、E组患者的不良反应发生率显著高于A组（χ2=5.782、13.589、4.453，P<0.05），B组、D组、E组患者的不良反应发生率显著高于C组（χ2=3.981、4.863、3.363，P<0.05）；B组、D组、E组患者的不良反应发生率组间比较差异无统计学意义（χ2=1.463、0.189、0.024，P>0.05）。A组、B组、C组、D组和E组患者中有妊娠需求者的自然妊娠率分别为84.62%（44/52）、83.33%（15/18）、80.00%（4/5）、70.00%（7/10）、75.00%（3/4），各组患者中有妊娠需求者的自然妊娠率比较差异无统计学意义（χ2=3.329，P>0.05）。A组自然妊娠中活产25例（56.82%），流产12例（27.27%），再发CSP 7例（15.91%）；B组自然妊娠者中活产12例（80.00%），流产2例（13.33%），再发CSP 1例（6.67%）；C组自然妊娠者中活产3例（75.00%），流产1例（25.00%）；D组自然妊娠者中活产5例（71.43%），流产1例（14.29%），再发CSP 1例（14.29%）；E组自然妊娠者中活产2例（66.67%），流产1例（33.33%）；5组自然妊娠者的活产率、流产率、再发CSP率比较差异无统计学意义（χ2=3.048、1.717、2.421，P>0.05）。结论　对于大部分Ⅱ型CSP患者可首选宫腔镜手术，对于有生育要求的Ⅱ型CSP患者可考虑行腹腔镜手术或阴式手术，有明显出血倾向的Ⅱ型CSP患者可选择UAE后再行宫腔镜或腹腔镜手术。
Abstract:
Objective　To compare the therapeutic effect of different surgical methods in the treatment of the type Ⅱ cesarean scar pregnancy(CSP) and their effect on prognosis of CSP patients.Methods　A total of 124 patients with type Ⅱ CSP admitted to the Department of Obstetrics and Gynecology,the Affiliated Taizhou People′s Hospital of Nanjing Medical University from June 2016 to August 2019 were selected as the study subjects.The 124 patients were divided into group A(n=77),group B(n=20),group C(n=8),group D(n=13) and group E(n=6) according to the operation methods.The patients in group A underwent hysteroscopic debridement of scar pregnancy focus,the patients in group B underwent laparoscopic cicatricial pregnancy focus resection and repair,the patients in group C underwent vaginal uterine scar pregnancy focus debridement and repair,the patients in group D underwent hysteroscopic surgery after uterine artery embolization(UAE),and the patients in group E underwent laparoscopic surgery after UAE.The time of operation,the amount of blood loss during operation,the decrease value of postoperative hemoglobin,the decrease rate of postoperative human chorionic gonadotropin(HCG),the time of HCG decreasing to normal,the time of menstruation after operation,the hospitalization time,the adverse reactions during operation and 2 weeks after operation of patients were compared among the five groups.All patients were followed up for 36-48 months,and the spontaneous pregnancy,abortion,recurrent CSP and delivery of CSP patients with fertility requirements in the five groups were observed.Results　The operation success rate of patients in group A,group B,group C,group D,group E was 84.41%(65/77),65.00%(13/20),87.50%(7/8),100.00%(13/13),100.00%(6/6),respectively;there was no significant difference in the operation success rate of patients among the five groups (χ2=2.014,P>0.05).There was no significant difference in the postoperative decrease rate of HCG of patients among the five groups (F=1.021,P>0.05).There were significant differences in the operation time,the amount of blood loss during operation,the decrease value of postoperative hemoglobin,the time of HCG decreasing to normal,the time of menstruation after operation and the hospitalization time among the five groups(F=54.971,13.685,6.126,3.957,13.586,13.791;P<0.05).The operation time and hospitalization time of patients in group B were significantly longer than those in group A,and the amount of blood loss during operation and the decrease value of postoperative hemoglobin after operation were significantly higher than those in group A (P<0.05).The operation time in group C was significantly longer than that in group A (P<0.05).The operation time,the time of HCG decreasing to normal,the time of menstruation after operation and the hospitalization time of patients in group D were significantly longer than those in group A (P<0.05).The operation time,the time of HCG decreosing to normal,the time of menstruation after operation and the hospitalization time of patients in group E were significantly longer than those in group A,and the amount of blood loss during operation was significantly higher than that in group A (P<0.05).The operation time of patients in group C was significantly shorter than that in group B,and the amount of blood loss during operation and decrease value of postoperative hemoglobin were significantly lower than those in group B (P<0.05).The operation time of patients in group D was significantly shorter than that in group B,the amount of blood loss during operation and the decrease value of postoperative hemoglobin were significantly lower than those in group B,while the time of HCG decreasing to normal and the time of menstruation after operation were significantly longer than those in group B (P<0.05).The operation time,the time of HCG decreasing to normal and the time of menstruation after operation of patients in group E were significantly longer than those in group B,while the amount of blood loss during operation and the decrease value of postoperative hemoglobin were significantly lower than those in group B (P<0.05).The time of menstruation after operation of patients in group D was significantly longer than that in group C (P<0.05).The operation time and the time of menstruation after operation of patients in group E were significantly longer than those in group C (P<0.05).The operation time of patients in group E was significantly longer than that in group D (P<0.05).The incidence of adverse reactions in group A,group B,group C,group D,group E was 15.58%(12/77),35.00%(7/20),12.50%(1/8),61.54%(8/13) and 50.00%(3/6),respectively;there was no significant difference in the incidence of adverse reactions of patients between group A and group C(χ2=0.053，P>0.05);the incidence of adverse reactions of patients in group B,group D and group E was significantly higher than that in group A (χ2=5.782,13.589,4.453;P<0.05),and that in group B,group D and group E was significantly higher than that in group C (χ2=3.981,4.863,3.363;P<0.05);there was no significant difference in the incidence of adverse reactions of patients among group B,group D and group E(χ2=1.463,0.189,0.024;P>0.05).The natural pregnancy rates of patients with pregnancy needs in group A,group B,group C,group D and group E was 84.62%(44/52),83.33%(15/18),80.00%(4/5),70.00%(7/10) and 75.00%(3/4),respectively;there was no significant difference in the natural pregnancy rate among the patients with pregnancy demand in each group(χ2=3.329,P>0.05).In group A,there were 25 cases(56.82%) of live birth,12 cases(27.27%)of abortion and 7 cases(15.91%) of recurrent CSP;in group B,there were 12 cases(80.00%) of live birth,2 cases(13.33%) of abortion and 1 case(6.67%) of recurrent CSP;in group C,there were 3 cases(75.00%) of live birth and 1 case(25.00%) of abortion;in group D,there were 5 cases(71.43%) of live birth,1 case(14.29%) of abortion and 1 case(14.29%) of recurrent CSP;in group E,there were 2 cases(66.67%)of live birth and 1 case(33.33%) of abortion.There was no significant difference in the live birth rate,abortion rate and recurrent CSP rate among the five groups(χ2=3.048,1.717,2.421;P>0.05).Conclusion　Hysteroscopic surgery is the first choice for most patients with type Ⅱ CSP.Laparoscopic surgery or vaginal surgery can be considered for type Ⅱ CSP patients with fertility requirements,and type Ⅱ CSP patients with obvious bleeding tendency can choose hysteroscopy or laparoscopy after UAE.

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更新日期/Last Update: 2023-01-05