剖宫产瘢痕妊娠临床病例分析

发布时间：2018-09-16 21:59

【摘要】：目的:回顾性研究剖宫产瘢痕妊娠的相关因素,为剖宫产瘢痕妊娠的预防提供理论依据,同时分析剖宫产瘢痕妊娠不同治疗方案的优缺点及其以后的妊娠结局,为临床治疗剖宫产瘢痕妊娠的选择提供理论支持。方法:本研究收集我院2008年1月至2016年2月因剖宫产瘢痕妊娠(I型及II型)住院治疗并取得良好治疗效果的患者共92人作为研究对象。按照不同治疗方案患者分为保守治疗组、B超或宫腔镜下清宫组及子宫动脉超选择性栓塞术术后清宫组,分别统计三种不同治疗方案患者平均住院天数、治疗花费、血HCG转阴时间,选择性价比最高的治疗方案。挑选有生育要求的患者,随访其正常性生活未避孕1年的妊娠结局,包括正常妊娠、再次异位妊娠及不孕。同时电话随访患者填写危险因素调查表,并随机挑选同期剖宫产后再次正常妊娠妇女100例作为危险因素调查对照组。数据使用spss19.0软件分析,计量资料采用均数及标准差表示;计数资料采用卡方检验或连续校正卡方检验统计处理,剖宫产瘢痕妊娠相关单因素分析使用卡方检验,多因素统计依据logistic回归检验剖宫产瘢痕妊娠发病的危险因素。结果:1.剖宫产瘢痕妊娠发病年龄主要集中在30-39岁,共62人。2.剖宫产瘢痕妊娠相关单因素统计分析:有统计学意义(P0.05)的有人工流产史、前置胎盘、人工剥离胎盘、前次剖宫产胎先露的部位、盆腔炎性疾病、盆腹腔手术史,无统计学意义(P0.05)的有民族、吸烟、酗酒、月经紊乱、子宫肌瘤、宫腔粘连、子宫内膜息肉、胎盘早剥、剖宫产的次数、距前次剖宫产的时间、异位妊娠史、卵巢肿瘤、辅助生殖技术、宫内节育器及口服避孕药。3.多因素统计分析:人工流产史、前次剖宫产胎先露的部位、前置胎盘、人工剥离胎盘是剖宫产瘢痕妊娠的独立危险因素,其OR值为4.953、3.257、2.826、2.729。4.治疗前血HCG:保守治疗组11891.47±8164.16MIU/ml、B超或宫腔镜下清宫组29150.09±9953.03MIU/ml、子宫动脉超选择性栓塞术术后清宫组32986.72±10987.21MIU/ml,F=37.848,P0.05,三组间有差别,行两两比较后,保守治疗分别与B超或宫腔镜下清宫组和子宫动脉超选择性栓塞术术后清宫组有差异,但尚不能认为B超或宫腔镜下清宫组和子宫动脉超选择性栓塞术术后清宫组有差异。5.三组间治疗前病灶直径、病灶距子宫浆膜层的距离无统计学差异(P0.05)。6.三组间住院天数无统计学差异(P0.05)。7.花费:保守治疗组4191.80±428.14元、B超或宫腔镜下清宫组7363.2±1522.46元、子宫动脉超选择性栓塞术术后清宫组12930.06±1172.72元,F=297.88,P0.05,三组间有差别,两两比较后,三组间平均花费均有差别。8.血HCG转阴时间:保守治疗组29.40±5.75天、B超或宫腔镜下清宫组21.57±8.28天、子宫动脉超选择性栓塞术术后清宫组23.00±4.04天,F=15.711,P0.05,认为三组间有差别,两两比较后,认为保守治疗组分别与B超或宫腔镜下清宫组和子宫动脉超选择性栓塞术术后清宫组有差别,但尚不能认为B超或宫腔镜下清宫组和子宫动脉超选择性栓塞术术后清宫组有差别。9.有生育要求的患者中,保守治疗组、B超或宫腔镜下清宫组、子宫动脉超选择性栓塞术术后清宫组的正常妊娠率分别为:70.59%、40.91%、70.00%;再次异位妊娠的发生率分别为:11.76%、4.55%、20.00%;不孕率分别为:17.65%、54.55%、10.00%。三组间正常妊娠及再次异位妊娠率差异无统计学意义,但在不孕率上,B超或宫腔镜下清宫组不孕率高于其他两组。结论:1.剖宫产瘢痕妊娠发病年龄主要集中在30-39岁,对于该年龄段有剖宫产史的急腹症患者,需警惕剖宫产瘢痕妊娠的发生。2.剖宫产瘢痕妊娠的发生与人工流产史、前置胎盘、人工剥离胎盘、前次剖宫产胎先露的部位、盆腔炎性疾病、盆腹腔手术史有关。3.保守治疗性价比最高。4.有生育要求、血HCG较高且病情较重的患者,可选择子宫动脉超选择性栓塞术术后清宫。
[Abstract]:Objective: To retrospectively study the related factors of cesarean scar pregnancy, and to provide theoretical basis for the prevention of cesarean scar pregnancy. At the same time, to analyze the advantages and disadvantages of different treatment schemes for cesarean scar pregnancy and their subsequent pregnancy outcomes. Ninety-two patients with cesarean scar pregnancy (type I and type II) who were hospitalized from January 1, 2006 to February 26, 2016 and received good results were divided into conservative treatment group, ultrasonic or hysteroscopic uterine clearance group and uterine artery superselective embolization group. The average hospitalization days, treatment costs, blood HCG negative time, and the most selective treatment regimen were selected. The patients with fertility requirements were followed up for 1 year without contraception, including normal pregnancy, recurrent ectopic pregnancy and infertility. 100 normal pregnant women after cesarean section were selected as the control group. The data were analyzed by SPSS 19.0 software, and the measurement data were expressed by mean and standard deviation. The counting data were analyzed by chi-square test or continuous correction chi-square test. The single factor analysis related to cesarean scar pregnancy was performed by chi-square test and multi-factor system. Results: 1. The incidence of cesarean scar pregnancy was mainly concentrated in the age of 30-39 years, a total of 62 people. 2. Single factor statistical analysis of cesarean scar pregnancy: there were statistically significant (P 0.05) history of induced abortion, placenta previa, artificial stripping placenta, cesarean section placenta previa. There were no significant differences in the position of exposure, pelvic inflammatory disease, history of pelvic and abdominal surgery (P 0.05), smoking, alcoholism, menstrual disorders, uterine fibroids, uterine adhesion, endometrial polyps, placental abruption, the number of cesarean section, the time before cesarean section, ectopic pregnancy, ovarian tumors, assisted reproductive technology, intrauterine device and oral contraception. 3. Multivariate statistical analysis: The history of induced abortion, the location of anterior cesarean section, placenta previa and artificially stripped placenta were the independent risk factors of cesarean scar pregnancy. The OR value was 4.953, 3.257, 2.826, 2.729.4. The blood HCG before treatment was 11891.47 [8164.16MIU/ml] in the conservative treatment group, 29150.09 [9953.03MIU/ml] in the ultrasound or hysteroscopy group. After superselective uterine artery embolization, the uterine clearance group was 32986.72 + 10987.21 MIU/ml, F = 37.848, P 0.05. There were differences among the three groups. After two-to-two comparisons, the conservative treatment was different from the B ultrasound or hysteroscopic uterine clearance group and the uterine artery clearance group after superselective uterine artery embolization. There was no significant difference in the diameter of lesions and the distance between lesions and the serosa between the three groups (P 0.05). 6. There was no significant difference in the length of hospital stay among the three groups (P 0.05). 7. Cost: 4191.80 428.14 yuan in the conservative treatment group, 7363.2 1522.46 yuan in the B ultrasound or hysteroscopic clearance group, and 7363.2 1522.46 yuan in the uterine artery superselective treatment group. After sex embolization, the clear uterus group was 12930.06+1172.72 yuan, F=297.88, P 0.05, there were differences among the three groups. After two comparisons, the average cost between the three groups was different. 8. Blood HCG negative time: conservative treatment group 29.40+5.75 days, B ultrasound or hysteroscopy clear uterus group 21.57+8.28 days, uterine artery superselective embolization clear uterus group 23.00+4.04 days, F=15.711, P = 15.711, P 0.05, that there are differences between the three groups, after two comparisons, that conservative treatment group and B ultrasound or hysteroscopy uterine clearance group and uterine artery superselective embolization after uterine clearance group were different, but can not be considered B ultrasound or hysteroscopy uterine clearance group and uterine artery superselective embolization after uterine clearance group have differences. 9. fertility requirements of patients In the conservative treatment group, the normal pregnancy rates were 70.59%, 40.91% and 70.00% in the B ultrasound or hysteroscopy group, respectively; the recurrence rates of ectopic pregnancy were 11.76%, 4.55% and 20.00%, and the infertility rates were 17.65%, 54.55% and 10.00% respectively. Conclusion: 1. The incidence of cesarean scar pregnancy is mainly concentrated in 30-39 years old. For the patients with acute abdomen who have a history of cesarean section, it is necessary to be alert to the occurrence of cesarean scar pregnancy. 2. The occurrence of cesarean scar pregnancy and induced abortion. History, placenta previa, artificially stripped placenta, placenta previa site of cesarean section, pelvic inflammatory disease, history of pelvic and abdominal surgery related. 3. Conservative treatment of the highest cost-effectiveness. 4. Fertility requirements, blood HCG higher and severely ill patients, can choose uterine artery superselective embolization after uterine clearance.
【学位授予单位】：宁夏医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R714.22

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