目的:探讨齐鲁医院分型在治疗剖宫产术后子宫瘢痕妊娠(CSP)的临床疗效。方法:选取2020年1月至2020年12月在山东省临沂市人民医院妇科收治的78例CSP患者的临床资料,依据齐鲁医院分型诊治:分为I型组、IIa型组、IIb型组、IIIa型组、IIIb组及IIIc型组。分析各组患者的一般资料、临床疗效。结果:78例CSP患者均经我院经阴道超声进行明确诊断,依据齐鲁医院分型对于CSP患者进行诊治:I型29例,IIa型21例,IIb型6例,IIIa型10例,IIIb型11例,IIIc型1例。在CSP不同分型中年龄、距离上一次剖宫产时间比较,差异均无统计学意义(P > 0.05)。不同分型中停经时间、剖宫产次数、术前β-HCG水平比较,差异有统计学意义(P < 0.05)。74例CSP患者在术后2月内月经复潮,比例为94.87%,3例CSP患者需要二次手术,3例术中需要中转手术方式,总体治疗成功率为92.3% (72/78)。结论:对于CSP患者,依据齐鲁医院分型进行诊治,手术均获得了较好的治疗效果,无因术中大出血而切除子宫。此分型适用于临床,简便可行,能够对患者的病情充分地评估,推荐的治疗方案,成功率高,并发症少,值得进一步应用于临床及推广。 Objective: To investigate the clinical efficacy of Qilu Hospital classification in the treatment of cesarean scar pregnancy (CSP). Methods: The clinical data of 78 patients with CSP admitted to the Department of Gynecology, Linyi People’s Hospital of Shandong Province from January 2020 to December 2020 were selected and divided into type I group, type IIa group, type IIb group, type IIIa group, and type IIIb IIIc group according to the classification of Qilu Hospital. The general data and clinical efficacy of patients in each group were analyzed. Results: Seventy-eight patients with CSP were diagnosed by transvaginal ultrasonography in our hospital. The patients with CSP were diagnosed and treated according to Qilu Hospital classification: 29 cases of type I, 21 cases of type IIa, 6 cases of type IIb, 10 cases of type IIIa, 11 cases of type IIIb, and 1 case of type IIIc. There were no significant differences in age or time from the last cesarean section among the different types of CSP (P > 0.05). There were significant differences in menopause time, number of cesarean sections, and preoperative β-hCG levels among different types (P < 0.05). Seventy-four CSP patients had resumption of menses within 2 months after surgery, with a proportion of 94.87%, 3 CSP patients required a second operation, and 3 patients required intraoperative conversion to surgical methods, with an overall treatment success rate of 92.3% (72/78). Conclusion: For patients with CSP, according to the classification of Qilu Hospital, the operation obtained a better therapeutic effect, and no uterus was removed due to intraoperative massive hemorrhage. This classification is suitable for clinical use, simple and feasible, and can fully evaluate the patient’s condition. The recommended treatment has high success rate, with fewer complications. It is worthy of further clinical application and promotion.
目的:探讨齐鲁医院分型在治疗剖宫产术后子宫瘢痕妊娠(CSP)的临床疗效。方法:选取2020年1月至2020年12月在山东省临沂市人民医院妇科收治的78例CSP患者的临床资料,依据齐鲁医院分型诊治:分为I型组、IIa型组、IIb型组、IIIa型组、IIIb组及IIIc型组。分析各组患者的一般资料、临床疗效。结果:78例CSP患者均经我院经阴道超声进行明确诊断,依据齐鲁医院分型对于CSP患者进行诊治:I型29例,IIa型21例,IIb型6例,IIIa型10例,IIIb型11例,IIIc型1例。在CSP不同分型中年龄、距离上一次剖宫产时间比较,差异均无统计学意义(P > 0.05)。不同分型中停经时间、剖宫产次数、术前β-HCG水平比较,差异有统计学意义(P < 0.05)。74例CSP患者在术后2月内月经复潮,比例为94.87%,3例CSP患者需要二次手术,3例术中需要中转手术方式,总体治疗成功率为92.3% (72/78)。结论:对于CSP患者,依据齐鲁医院分型进行诊治,手术均获得了较好的治疗效果,无因术中大出血而切除子宫。此分型适用于临床,简便可行,能够对患者的病情充分地评估,推荐的治疗方案,成功率高,并发症少,值得进一步应用于临床及推广。
剖宫产术后子宫瘢痕妊娠,齐鲁医院分型,手术治疗
Dongmei Li1, Surong Wang2, Tianfeng Liu2
1Shandong First Medical University, Jinan Shandong
2Department of Gynecology, Linyi People’s Hospital, Linyi Shandong
Received: May 17th, 2021; accepted: Jun. 3rd, 2021; published: Jun. 21st, 2021
Objective: To investigate the clinical efficacy of Qilu Hospital classification in the treatment of cesarean scar pregnancy (CSP). Methods: The clinical data of 78 patients with CSP admitted to the Department of Gynecology, Linyi People’s Hospital of Shandong Province from January 2020 to December 2020 were selected and divided into type I group, type IIa group, type IIb group, type IIIa group, and type IIIb IIIc group according to the classification of Qilu Hospital. The general data and clinical efficacy of patients in each group were analyzed. Results: Seventy-eight patients with CSP were diagnosed by transvaginal ultrasonography in our hospital. The patients with CSP were diagnosed and treated according to Qilu Hospital classification: 29 cases of type I, 21 cases of type IIa, 6 cases of type IIb, 10 cases of type IIIa, 11 cases of type IIIb, and 1 case of type IIIc. There were no significant differences in age or time from the last cesarean section among the different types of CSP (P > 0.05). There were significant differences in menopause time, number of cesarean sections, and preoperative β-hCG levels among different types (P < 0.05). Seventy-four CSP patients had resumption of menses within 2 months after surgery, with a proportion of 94.87%, 3 CSP patients required a second operation, and 3 patients required intraoperative conversion to surgical methods, with an overall treatment success rate of 92.3% (72/78). Conclusion: For patients with CSP, according to the classification of Qilu Hospital, the operation obtained a better therapeutic effect, and no uterus was removed due to intraoperative massive hemorrhage. This classification is suitable for clinical use, simple and feasible, and can fully evaluate the patient’s condition. The recommended treatment has high success rate, with fewer complications. It is worthy of further clinical application and promotion.
Keywords:Cesarean Scar Pregnancy, Qilu Hospital Classification, Surgical Treatment
Copyright © 2021 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
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剖宫产术后瘢痕妊娠(Cesarean scar pregnancy, CSP)是剖宫产术后严重的远期并发症之一,是再次妊娠时受精卵着床于既往剖宫产术后的子宫切口瘢痕处、具有限时定义(早孕期 ≤ 12周)的一种特殊类型的异位妊娠。在临床上,CSP诊治不及时可在孕晚期形成凶险型前置胎盘、胎盘植入,有大出血、子宫破裂,周围的脏器损伤,严重者有子宫的切除、死亡的风险 [
近年来,随着我国二孩政策的开放以及较高的剖宫产率,CSP的发生率呈逐年升高的趋势。目前国内外对于CSP的诊断及治疗尚未有统一的标准和指南,如何安全、有效及个体化地诊治不同分型的CSP患者,以免造成不必要的并发症,已成为了临床上的重点关注。本研究回顾性分析了临沂市人民医院妇科依据齐鲁医院分型(实际的临床处理选择)进行诊治的78例CSP患者的临床资料,现报道如下。
收集2020年1月至2020年12月在山东省临沂市人民医院妇科依据齐鲁医院分型进行诊治的CSP患者的病例资料,一共78例。患者的年龄21~43岁,平均(33.65 ± 4.54)岁;停经时间30~83天,平均(53.15 ± 11.46)天;剖宫产次数1~3次,平均(1.81 ± 0.60)次;距离上一次剖宫产时间1~18年,平均(4.76 ± 3.44)年;孕囊或包块平均直径大小4.33~61 mm,平均(25.86 ± 13.79) mm。纳入标准:1) 患者既往均有剖宫产的手术史;2) 患者具有停经史,尿妊娠试验为阳性,血清β人绒毛膜促性腺激素(β-HCG)水平升高;3) 患者术前的超声检查符合CSP的诊断;4) 依据齐鲁医院分型进行手术治疗;5) 患者均签署知情同意书,要求手术终止妊娠。排除标准:1) 有全身严重感染等其他的手术禁忌证;2) 孕周 > 12周。
齐鲁医院分型是其多年来对于CSP患者在临床上的实际处理选择。具体诊疗方案见表1。
最小前壁的肌层厚度 | 妊娠囊或包块平均直径 | 临床实际处理的手术方式 | |
---|---|---|---|
I型 | ≥3 mm | 无论大小 | 超声监视下吸宫术 ± 宫腔镜手术 |
II型 | 1~3 mm | a ≤ 3 cm | 超声监视下吸宫术 + 宫腔镜手术 |
b > 3 cm | 腹腔镜监视下吸宫术 + 宫腔镜手术 | ||
或经阴道前穹隆切开病灶清除术 | |||
必要时瘢痕缺陷修补或经阴手术 | |||
III型 | <1 mm | a ≤ 6 cm,活胚孕囊 | 腹腔镜下瘢痕妊娠病灶清除术 + 吸宫术 |
或经阴道前穹隆切开病灶清除术 | |||
b ≤ 6 cm,停育孕囊或混合性包块 | 腹腔镜下瘢痕妊娠病灶清除术 + 吸宫术 | ||
或经阴前穹隆切开病灶清除术 | |||
c > 6 cm,或伴有动静脉瘘 | 开腹手术或子宫动脉栓塞后腹腔镜手术 |
表1. 齐鲁医院分型CSP的实际临床处理
记录术中出血量、手术时间、住院天数、住院总费用、子宫动脉栓塞率,宫腔内球囊压迫、输血治疗、残留及二次手术情况,术后β-HCG下降水平及恢复正常时间,术后月经复潮时间及治疗成功率等指标。
采用SPSS 26.0软件对数据进行统计分析。计量资料:呈正态分布的指标用均数 ± 标准差( x ¯ ± s )表示,组间比较采用单因素方差分析;呈非正态分布的指标用中位数和四分位间距表示(IQR),组间比较采用Kruskal-Wallis H检验。计数资料用百分率(%)表示,组间比较采用卡方检验或Fisher确切概率法。P < 0.05为差异有统计学意义。
本研究纳入78例CSP患者,依据齐鲁医院分型对于CSP患者进行诊治:I型29例,IIa型21例,IIb型6例,IIIa型10例,IIIb型11例,IIIc型1例。在CSP不同分型中年龄、距离上一次剖宫产时间比较,差异均无统计学意义(P > 0.05)。不同分型中停经时间、剖宫产次数、术前β-HCG水平比较,差异有统计学意义(P < 0.05)。见表2。
I型 (n = 29) | IIa型 (n = 21) | IIb型 (n = 6) | IIIa 型 (n = 10) | IIIb型 (n = 11) | IIIc型 (n = 1) | P值 | |
---|---|---|---|---|---|---|---|
年龄(岁) | 33.59 ± 5.14 | 33.95 ± 4.03 | 34.33 ± 5.16 | 32.60 ± 5.06 | 33.91 ± 3.78 | 33 | 0.978 |
剖宫产次数(次) | 1.69 ± 0.60 | 2.05 ± 0.59 | 2.00 ± 0 | 1.80 ± 0.42 | 1.45 ± 0.69 | 3 | 0.021 |
距离上一次剖 宫产时间(年) | 4.69 ± 3.32 | 4.81 ± 3.71 | 6.33 ± 3.07 | 3.90 ± 3.07 | 5.09 ± 3.99 | 1 | 0.683 |
停经时间(天) | 50.59 ± 7.39 | 47.76 ± 9.36 | 56.83 ± 11.27 | 59.90 ± 10.46 | 61.45 ± 17.52 | 60 | 0.004 |
术前血β-HCG 水平(mIU/ml) | 38,046.38 ± 35,900.19 | 25,948.0 ± 20,254.63 | 80,143.00 ± 2001.11 | 49,715.03 ± 33,546.09 | 7864.69 ± 16,938.56 | 584.7 | 0.000 |
表2. CSP患者不同分型的一般资料比较( x ¯ ± s )
CSP患者的不同分型中,住院天数、住院总费用、术中的出血量、手术时间、术前与术后首次复查血β-HCG下降水平比较,差异均有统计学意义(P < 0.05)。在CSP患者的不同分型中,术后血β-HCG恢复正常的时间比较,差异无统计学意义(P > 0.05)。见表3。依据齐鲁医院分型,CSP患者中I型有16例行超声监护下高风险吸宫术,8例行超声监护下高风险吸宫术 + 宫腔镜手术,3例行腹腔镜监测下高风险吸宫术 + 宫腔镜手术,2例行腹腔镜子宫瘢痕妊娠清除术 + 吸宫术 + 宫腔镜手术。是由于术中见宫腔镜检查宫腔前壁下段见一宽大、较深憩室,憩室左右侧角处见残留妊娠组织,憩室内活动性出血,等离子电切环予以电切,切除过程困难,妊娠组织与肌层致密粘连,分界不清,电凝出血点,予以宫颈注射稀释垂体后叶素6u,缩宫素10u静滴,同时按摩子宫,宫颈外口仍存在多量流血,台下与患者家属沟通术中情况后,遂中转了手术方式。IIa型有2例行超声监护下高风险吸宫术,4例行超声监护下高风险吸宫术 + 宫腔镜手术,8例行腹腔镜监测下高风险吸宫术 + 宫腔镜手术,7例行腹腔镜子宫瘢痕妊娠清除术 + 吸宫术 + 宫腔镜手术。中转手术方式是因为术中见患者阴道壁松弛,无法暴露宫颈,尝试宫腔镜检查,进镜宫颈暴露困难,无法钳夹,遂横行切开子宫前壁下段,见妊娠组织(羊水、胎盘及绒毛),予以吸引器吸出,并修剪瘢痕处组织,2/0倒刺线连续全层缝合切缘成形子宫,1/0可吸收线加固缝合浆肌层。IIb型中有1例行超声监护下高风险吸宫术 + 宫腔镜手术,2例行腹腔镜监测下高风险吸宫术 + 宫腔镜手术,3例行腹腔镜子宫瘢痕妊娠清除术 + 吸宫术 + 宫腔镜手术;IIIa型中有1例腹腔镜监测下高风险吸宫术 + 宫腔镜手术,9例腹腔镜子宫瘢痕妊娠清除术 + 吸宫术 + 宫腔镜手术。其中1例是药物流产失败后2月,术中见妊娠组织侵蚀至膀胱底,检查有活动性出血,2-0可吸收线缝扎膀胱底止血。术中失血多,予A型RH阳性去白浓缩红细胞3U,冰冻血浆600 ml。1例是吸宫后见瘢痕处明显凹陷,横行切开子宫下段约3 cm,见无明显妊娠组织残留,2/0倒刺线连续全层缝合加固成形子宫。1例是术中行宫腔镜检查,宫腔下段前壁偏左侧见一憩室,较深,见残留妊娠组织及活动性出血,切除困难,术中腹腔镜监测下见宫体前壁下段菲薄。遂宫腔下段至球囊压迫止血,考虑宫腔镜下无法完全切除妊娠组织,需行瘢痕切开术,患者合并残角子宫,告知保留有残角子宫,存在经期腹痛、残角子宫妊娠可能。要求切除残角子宫及左侧输卵管,并行瘢痕切开清除妊娠组织。IIIb型中有11例行腹腔镜子宫瘢痕妊娠清除术 + 吸宫术 + 宫腔镜手术。1例是人工流产术后7月,发现宫腔占位40天,遂行清宫术,术中出血多,输血4u悬浮红细胞,复查阴道彩超宫腔混合回声团块。1例术中出血多,输血去白悬浮红细胞4U,血浆390 ml。1例是5天前在外院行人工流产术,术中出血约700 ml,予子宫动脉栓塞,阴道流血较前减少。IIIc型中有1例行腹腔镜子宫瘢痕妊娠清除术 + 吸宫术 + 宫腔镜手术,本例是人工流产术后,经超声发现子宫瘢痕处包块,大小 < 6 cm,伴有动静脉瘘,患者一般情况稳定,拒绝开腹手术及子宫动脉栓塞治疗,遂行腹腔镜手术治疗。6例是人工流产术后、药物流产失败、子宫动脉栓塞治疗不佳收入我院,依据齐鲁医院分型进行诊治,其中5例是IIIb型,1例是IIIc型。对于CSP患者,依据齐鲁医院分型进行诊治,手术均获得了较好的治疗效果,无因术中大出血而切除子宫。术后血β-HCG恢复正常水平时间:I型(2.03 ± 1.02)周,IIa型(2.48 ± 2.32)周,IIb型(2.00 ± 0.63)周,IIIa型(2.10 ± 0.99)周,IIIb型(1.91 ± 1.38)周,IIIc型2周。74例CSP患者在术后2月内月经复潮,比例为94.87%,3例CSP患者需要二次手术,3例术中需要中转手术方式,总体治疗成功率为92.3% (72/78)。见表4。
分型 | I型 (n = 29) | IIa型 (n = 21) | IIb型 (n = 6) | IIIa型 (n = 10) | IIIb型 (n = 11) | IIIc型 (n = 1) | P值 |
---|---|---|---|---|---|---|---|
住院天数(d) | 2.45 ± 1.09 | 3.38 ± 0.97 | 4.50 ± 1.38 | 4.50 ± 0.71 | 5.00 ± 1.55 | 2 | 0.000 |
住院总费用(元) | 6733.08 ± 4915.00 | 14,635.90 ± 6000.63 | 15,640.55 ± 3613.75 | 18,159.03 ± 2662.84 | 19,849.76 ± 3703.84 | 18,624.06 | 0.000 |
术中出血量(ml) | 20.69 ± 36.27 | 29.76 ± 20.89 | 75.00 ± 50.10 | 222.00 ± 379.47 | 112.73 ± 229.74 | 100 | 0.026 |
手术时间(min) | 36.48 ± 25.07 | 68.43 ± 30.71 | 92.50 ± 29.11 | 102.40 ± 37.03 | 96.82 ± 23.90 | 105 | 0.000 |
术前与术后首次复 查血β-HCG下降 水平(mIU/ml) | 32,922.89 ± 29,829.63 | 31,087.15 ± 27,984.67 | 67,579.65 ± 7249.72 | 52,673.36 ± 26,028.52 | 6798.16 ± 15,105.06 | 536.50 | 0.000 |
术后血β-HCG 恢复正常时间(周) | 2.03 ± 1.02 | 2.48 ± 2.32 | 2.00 ± 0.63 | 2.10 ± 0.99 | 1.91 ± 1.38 | 2.00 | 0.912 |
宫腔内球囊压迫(n) | 1 | 2 | 0 | 2 | 0 | 0 | |
输血治疗(n) | 0 | 0 | 0 | 1 | 1 | 0 | |
二次手术(n) | 1 | 1 | 0 | 0 | 1 | 0 | |
中转手术(n) | 1 | 1 | 0 | 1 | 0 | 0 | |
子宫动脉栓塞(n) | 0 | 0 | 0 | 0 | 1 | 0 | |
术后2月内 月经复潮(n) | 27 | 20 | 6 | 9 | 11 | 1 | |
是否残留(n) | 1 | 0 | 0 | 0 | 1 | 0 | |
治疗成功率(%) | 93.1 | 90.5 | 100 | 90 | 90.1 | 100 |
表3. CSP不同分型中的手术治疗指标比较
分型 | I型 (n = 29) | IIa型 (n = 21) | IIb型 (n = 6) | IIIa型 (n = 10) | IIIb型 (n = 11) | IIIc型 (n = 1) | P |
---|---|---|---|---|---|---|---|
超声监护下高风险吸宫术(n) | 16 | 2 | 0 | 0 | 0 | 0 | 0.000 |
超声监护下高风险吸宫术 + 宫腔镜手术(n) | 8 | 4 | 1 | 0 | 0 | 0 | |
腹腔镜监测下高风险吸宫术 + 宫腔镜手术(n) | 3 | 8 | 2 | 1 | 0 | 0 | |
腹腔镜子宫瘢痕妊娠清除术 + 吸宫术 + 宫腔镜手术(n) | 2 | 7 | 3 | 9 | 11 | 1 |
表4. CSP患者不同分型治疗的手术方式
剖宫产术后子宫瘢痕妊娠是剖宫产术后一种远期的严重并发症,指孕囊、受精卵或胚胎着床于既往剖宫产术后的子宫切口瘢痕,是一种特殊类型的异位妊娠 [
目前临床上CSP分型有2000年的Vial分型 [
本研究分型是2019年康彦君等 [
Birch Petersen K等 [
本文纳入了我院78例CSP患者,依据齐鲁医院分型进行诊治,术前没有常规MTX预处理,术中无子宫切除术的病例,术后随诊2周患者的血清β-HCG水平基本恢复正常,94.87%在2月内月经复潮,总体治疗成功率为92.3%,在临床实际的应中有确切的可行性以及高成功率,此分型兼顾了孕囊或病灶的大小、分型直观易理解、可制定个体化的治疗策略,并且没有过分强调术前MTX或UAE的预处理的重要性,因此可以减少MTX引起的副反应和UAE对卵巢功能及子宫内膜等远期损害,减少严重并发症的发生和对患者的创伤,对于CSP患者的生育能力尽最大努力的保留。剖宫产术后子宫瘢痕处妊娠的诊疗原则:早诊断、早终止、早清除,能够改善患者的预后。本研究是依据齐鲁医院分型对CSP患者进行分型诊疗,未MTX预处理,手术治疗后均取得不错的治疗效果,此分型适用于临床,简便可行,能够对患者的病情充分的评估,推荐的治疗方案,成功率高,并发症少,值得进一步应用于临床及推广。
本研究不足是样本量小,更需要多中心、前瞻性对照研究进一步的综述证实,在对于CSP的治疗中可以得出统一明确的诊疗方案。
李冬梅,王苏荣,刘天凤. 齐鲁医院分型诊治78例子宫瘢痕妊娠的临床观察Clinical Observation of 78 Cases of Cesarean Scar Pregnancy Diagnosed and Treated by Typing in Qilu Hospital[J]. 临床医学进展, 2021, 11(06): 2730-2737. https://doi.org/10.12677/ACM.2021.116395