不同方法治疗子宫切口瘢痕妊娠的临床效果分析

发布时间：2019-02-17 20:47

【摘要】：背景和目的剖宫产后子宫切口瘢痕妊娠（cesarean scar pregnancy, CSP）是指有剖宫产史的女性再次妊娠时，胚胎着床于前次剖宫产子宫切口部位，是一种罕见的异位妊娠。因其无特殊临床特征，故容易被误诊或漏诊，常常因不恰当的清宫而导致不可抑制的子宫大出血，严重者可能危及生命。以往因该疾病发病稀疏，人们对其认识不足，多数大出血患者最终以切除子宫的方式挽救生命，从而丧失了生育能力。近些年来，随着剖宫产率的不断增高，CSP的发病率也呈逐步上升趋势，人们对该疾病的认识也在不断加深。越来越多的报道分析研究了该病的病因、机制以及治疗方法。但CSP的确切病因至今仍尚不明确，虽然随着超声技术的提高和各种治疗方法的改进，保留生育能力的各项治疗措施已经基本代替了子宫切除术，但各地报道的治疗经验和结果各不相同，目前仍缺乏统一有效地的治疗方法。为探求CSP的最佳治疗方案，本研究回顾性分析了近5年来收治的113例CSP患者的临床资料，以期能为临床医师在CSP治疗的方案选择上提供初步的临床依据。资料与方法 1.一般资料收集郑州大学第一附属医院及焦作市妇幼保健院2008年5月至2013年5月收治住院的CSP患者113例为研究对象，其中孕囊型44例，团块型67例，中孕型2例。除2例中孕型CSP外，余111例CSP患者分别以不同类型不同治疗方式分组进行分析对比，其中局部注射甲氨蝶呤（methotrexate，MTX）组35例、全身应用MTX组35例，介入组31例，手术组10例。因治疗不满意而改变治疗方式后，有3例最初采用局部应用MTX方案的患者更改方案，其中有1例改为介入治疗，2例改为手术治疗；有6例最初全身应用MTX治疗的患者和3例最初介入治疗的患者改为手术治疗。 2.研究方法对研究对象的病例资料进行回顾性分析对比，监测治疗后一周血人绒毛膜促性腺激素（human chorionic gonadotropin，，HCG）变化情况及其转阴时间，观察治疗期间阴道出血情况及不良反应、治疗后包块超声影像变化，分析住院天数、住院费用及治愈率。 3.统计学分析用SPSS13.0统计软件对数据进行分析，计量资料以x±s表示，率的比较采用χ2检验，P0.05为差异有统计学意义。结果 1.手术治疗血HCG下降最快，住院时间、包块消失时间及HCG转阴时间最短，介入栓塞治疗次之，均与MTX全身治疗相比差异明显（P0.05） 2.局部应用MTX对孕囊型的疗效明显优于团块型（P0.05） 3.介入栓塞治疗费用最高（P0.05）结论 1.CSP的治疗应实行个体化治疗 2.孕囊穿刺局部MTX注药可作为孕囊型患者治疗的首选方法 3.介入栓塞治疗可作为团块型患者的治疗首选 4.对于保守治疗无效者可改为手术子宫病灶切除+修复术 5.对于病灶较大，子宫局部肌层菲薄，病灶明显突向膀胱者，应考虑直接手术治疗
[Abstract]:Background and objective (cesarean scar pregnancy, CSP) is a rare ectopic pregnancy when a woman with a history of cesarean section is pregnant again, the embryo is implanted in the site of the uterine incision of the previous cesarean section. Because it has no special clinical characteristics, it is easy to be misdiagnosed or missed diagnosis, often due to the improper Qing Palace and lead to irrepressible uterine bleeding, serious may endanger life. In the past, because of the sparse disease, people do not know enough about it. Most patients with massive bleeding eventually save their lives by removing the uterus, thus losing their fertility. In recent years, with the increasing rate of cesarean section, the incidence of CSP is also gradually rising, and people's understanding of the disease is also deepening. More and more reports have analyzed the etiology, mechanism and treatment of the disease. However, the exact cause of CSP is still unclear, although with the improvement of ultrasound technology and various treatments, fertility retention treatment has basically replaced hysterectomy. However, the reported treatment experience and results are different, and there is still a lack of unified and effective treatment methods. In order to explore the best treatment scheme for CSP, the clinical data of 113 patients with CSP admitted in our hospital in recent 5 years were retrospectively analyzed in order to provide a preliminary clinical basis for clinicians to choose the treatment regimen for CSP. Data and methods 1. General data were collected from 113 CSP patients admitted to the first affiliated Hospital of Zhengzhou University and Jiaozuo Maternal and Child Health Hospital from May 2008 to May 2013. 44 cases of gestational sac type, 67 cases of mass type and 2 cases of middle pregnancy type were studied. In addition to 2 cases of pregnancy type CSP, the remaining 111 cases of CSP were divided into three groups: local injection of methotrexate (methotrexate,MTX) group (35 cases), systemic application of MTX group (35 cases), interventional group (31 cases), and operation group (10 cases). After the treatment was changed because of unsatisfactory treatment, there were 3 patients who were treated with local MTX regimen at first, including 1 patient undergoing interventional therapy and 2 patients undergoing surgical treatment. Surgical treatment was performed in 6 patients with initial systemic MTX therapy and 3 patients with initial interventional therapy. 2. Methods the data of the patients were retrospectively analyzed and compared to monitor the changes of serum human chorionic gonadotropin (human chorionic gonadotropin,HCG) and the time of turning negative one week after treatment. The bleeding and adverse reactions of vagina during the treatment period were observed. The changes of ultrasonic images of the mass after treatment were observed, and the days of hospitalization, the cost of hospitalization and the cure rate were analyzed. 3. Statistical analysis using SPSS13.0 statistical software to analyze the data, the measurement data expressed as x 卤s, the rate of comparison using 蠂 2 test, P0.05 as the difference was statistically significant. Result 1. The decrease of blood HCG was the fastest, the time of hospitalization, the time of mass disappearance and the time of HCG turning negative was the shortest in surgical treatment, the second was interventional embolization, which was significantly different from that of MTX (P0.05). The effect of local application of MTX on gestational sac type was significantly better than that on mass type (P0.05) 3. The cost of interventional embolization is the highest (P0.05) conclusion the treatment of 1.CSP should be individualized 2. Local MTX injection can be used as the first choice for the treatment of gestational sac type patients. Interventional embolization can be used as the first choice for mass type patients. For patients with ineffective conservative treatment, surgical hysterectomy and repair of uterine lesions can be replaced by 5. 5%. Direct surgical treatment should be considered for those with larger lesions, thin local myometrium and obvious focus to bladder.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R714.2

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