孕周≥10周剖宫产瘢痕妊娠65例临床分析

发布时间：2018-06-24 03:36

本文选题：剖宫产瘢痕妊娠(csp) + B超引导下刮宫术　；参考：《浙江大学》2017年硕士论文

【摘要】：目的分析孕周≥10周的剖宫产瘢痕妊娠采用不同治疗方法的预后情况,为临床诊治提供一些参考和依据。方法通过对浙江大学医学院附属妇产科医院2013年1月至2016年收治的CSP病例中孕周≥10周的患者的临床资料进行整理,并做回顾性的分析。按治疗方法分组:A组:单纯B超引导下刮宫术13例。B组:行双侧子宫动脉栓塞后超声引导下刮宫术40例。C组:行双侧子宫动脉栓塞后宫腔镜手术(C组)5例。D组:行双侧子宫动脉栓塞后再行极困难剖宫取胎+病灶去除+瘢痕修补术(D组)7例。通过比较4组的临床数据、影像学表现以及社会经济学指标,分析CSP预后的相关因素及治疗效果。结果A组:患者治疗前血HCG为(32039.48±27590.85)IU/L,孕周为11周,术中出血(64.89±120.93)ml,住院时间为(5.42±1.87)天,住院费用(3999.94±2596.60)元。B组:患者治疗前血HCG为(48516.45±49472.93)IU/L,孕周为11周,术中出血(199.25±378.346)ml,住院时间为(7.58±1.85)天,住院费用(13912.34±581.08)元。C组:患者治疗前血HCG为(18009.61±72461.76)IU/L,孕周为11周,术中出血(38.60±43.70)ml,住院时间为(7.80±1.64)天,住院费用(12441.38±4556.71)元。D组:患者治疗前血HCG为(84020.43±72461.76)IU/L,孕周为12周,术中出血(1657.14±624.827)ml,住院时间为(11.00±3.65)天,住院费用(25675.10±5639.96)元。4组的孕次、产次、剖宫产次,上次剖宫产距本次妊娠时间,术前血HCG值的一般临床数据比较均无统计学意义(P0.05)。A、B、C组孕周小于D组(孕周取中位数),差异有统计学意义(P0.05)。疤痕处肌层厚度A组大于B、D组,差异有统计学意义(P0.05)。A、B、C组的病灶体积小于D组,差异有统计学意义(P0.05)。从4组的术中出血来比较,D组高于A、B、C组,差异有统计学意义(P0.05)。A组的住院时间小于B组,B、C组的住院时间小于D组,差异均有统计学意义(P0.05)。住院费用A组低于B、C组,B、C组低于D组,差异均有统计学意义(P0.05)。多因素回归分析提示孕周,病灶大小与CSP(孕周≥10周)预后相关。本研究收集的65例病例均在门诊或住院后经阴道B超检查诊断为CSP且孕患者的孕周≥10周,行B超检查观察孕囊或包块与宫腔、子宫前壁剖宫产瘢痕处的位置关系,并观测孕囊大小,形态与瘢痕处肌层厚度以及局部血流情况,超声图像表现为:子宫前壁剖宫产瘢痕处可见孕囊或不均质团块,部分可见胎心搏动,周边可见星点状血流或血流丰富,且子宫前壁剖宫产瘢痕处肌层较薄,部分未见肌层。结论临床治疗中可根据患者孕周以及影像学检查提示的病灶大小,病灶周边血流丰富程度等综合考虑来决定治疗方案,根据不同患者的情况,我们的治疗应该做到个体化。但CSP的早发现以及早处理是合理治疗的关键。对于孕周≥10周的CSP患者,胚囊长度不大于6cm且剖宫产瘢痕处肌层最薄处不小于0.1cm,病灶处血流不丰富的患者可选择直接行B超引导下刮宫术(备栓塞);胚囊长度不大于6cm,最薄处肌层厚度不小于0.1cm,病灶周围血流较丰富的病人行双侧子宫动脉栓塞后超声引导下刮宫术;病灶为团块状,最薄处肌层厚度不小于0.1cm的患者行双侧子宫动脉栓塞后再行宫腔镜手术;病灶体积较大,且周围血流丰富,最薄处肌层小于0.1cm者行双侧子宫动脉栓塞后剖宫取胎术+病灶去除+瘢痕修补术。
[Abstract]:Objective to analyze the prognosis of cicatricial pregnancy for cesarean section with more than 10 weeks of pregnancy, and to provide some reference and basis for clinical diagnosis and treatment. Methods the clinical data of the patients who were treated in CSP cases of the affiliated obstetrics and Gynecology Hospital of Zhejiang University from January 2013 to 2016 were reviewed and reviewed, and the retrospective analysis was done. Group A: group A: group.B with simple B ultrasound guided curettage: 40 cases of.C after bilateral uterine artery embolization by ultrasound guided curettage: 5 cases in group.D after bilateral uterine artery embolization (group C): after bilateral uterine artery embolization, a very difficult cesarean section with the removal of the lesion + scar repair (D group) was performed (group D). By comparing 4 groups of clinical data, imaging performance and socioeconomic indicators, the related factors and therapeutic effects of CSP prognosis were analyzed. Results A group: before treatment, the blood HCG was (32039.48 + 27590.85) IU/L, pregnancy week was 11 weeks, intraoperative bleeding (64.89 + 120.93) ml, (5.42 + 1.87) days in hospital, and hospital expenses (3999.94 + 2596.60) yuan.B group: Before treatment, the blood HCG was (48516.45 + 49472.93) IU/L, pregnancy week was 11 weeks, intraoperative bleeding (199.25 + 378.346) ml, hospitalization time (7.58 + 1.85) days, hospitalization expenses (13912.34 + 581.08) yuan.C group: the blood HCG before treatment was (18009.61 + 72461.76) IU/L, pregnancy week was 11 weeks, intraoperative hemorrhage (38.60 +) ml, hospitalization time, hospitalization expenses (12441.38 + 4556.71).D group: before treatment, blood HCG was (84020.43 + 72461.76) IU/L, pregnancy week was 12 weeks, intraoperative bleeding (1657.14 + 624.827) ml, hospitalization time (11 + 3.65) days, hospitalization expenses (25675.10 + 5639.96) yuan.4 group pregnancy, birth, cesarean section, last cesarean section of pregnancy time, preoperative blood HCG value general clinical data There was no statistical significance (P0.05).A, B, and group C was less than group D (median of gestational age), the difference was statistically significant (P0.05). The muscular layer thickness in the scar A group was larger than B, D group, the difference was statistically significant (P0.05).A, and there was a significant difference between the 4 groups. The time of hospitalization in group.A was less than that of group B, and the time of hospitalization in group.A was less than that of group B, and the time of hospitalization in group C was less than that of group D (P0.05). The hospitalization expense A group was lower than B, C group, B, and C group was lower than that of the group. 65 cases of the cases were diagnosed as CSP and the pregnancy weeks were more than 10 weeks after the outpatient or hospitalization. The relationship between the gestational sac or the caesarean section of the anterior uterine wall and the size of the gestation sac, the thickness of the scar and the local blood flow were observed by B ultrasonic examination. The cicatricial caesarean section of the anterior uterine wall can be seen in the gestation sac or inhomogeneous mass, part of the fetal heart pulsation, the peripheral blood flow or the rich blood flow, and the myometrium in the cesarean section of the anterior uterine wall is thinner, and the myometrium is not found in the section. According to the situation of different patients, our treatment should be individualized. However, our treatment should be individualized according to the situation of different patients. But early detection and early treatment of CSP are the key to rational treatment. The length of the embryo sac is not more than 6cm and the thickness of the myometrium in the cesarean scar is not less than 0.1cm for the CSP patients with the gestational weeks more than 10 weeks. The rich patients can choose the direct B ultrasound guided curettage (curettage); the length of the embryo sac is not more than 6cm, the thinnest of the muscularis thickness is not less than 0.1cm, and the patients with rich peripheral blood flow are guided by ultrasound guided curettage after bilateral uterine artery embolization; the lesion is a lump, and the thinner thickness of the muscle layer is not less than 0.1cm. After transcatheter arterial embolization, hysteroscopy was performed. The lesion volume was large, and the surrounding blood flow was rich, and the thinnest muscle layer was less than 0.1cm. After bilateral uterine artery embolization, the caesarean operation + lesion removal + scar repair operation was performed.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R714.22

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