目的 探讨剖宫产术后子宫瘢痕部位妊娠(CSP)的临床表现、诊断依据、治疗方法和卫生经济学特点.方法 回顾性分析复旦大学附属妇产科医院2005年1月至2008年12月收治的96例CSP患者的临床资料,按不同治疗方法分为A组33例,行甲氨蝶呤(MTX)50 mg/m2静脉滴注,其中18例MTX静脉治疗后5～10 d内行清宫术(MTX+清宫);15例先行清宫术,术后每48小时复查1次血人绒毛膜促性腺激素β亚单位(β-hCG)水平,3次均下降不足30%者,再用MTX 50 mg/m2静脉滴注治疗(清宫+MTX).B组60例,行MTX双侧子宫动脉介入栓塞治疗,每侧子宫动脉注入MTX 100 mg,术后2 d内行清宫术.C组3例,行子宫病灶切除术.比较各组出血量(M)、病灶直径(-x±s)、治疗前血β-hCG水平(M)、病灶距子宫浆膜层≤3mm的例数、病灶血流阻力指数(RI)≤0.5的例数、治疗费用(-x±s)、住院时间(-x±s)的差异,并分析出血量与病灶直径和血β-hCG水平的相关性.结果 (1)临床指标:出血量:A组MTX+清宫者为20 ml、清宫+MTX者为10 ml,B组为12 ml,C组为200ml,C组与A、B组比较,差异有统计学意义(P＜0.01);病灶直径:A组MTX+清宫者为(16±8)mm、清宫+MTX者为(23±15)mm,B组为(30±14)mm,显著高于A组MTX+清宫者,差异有统计学意义(P＜0.01),C组为(52±7)mm,3组分别比较,差异均有统计学意义(P＜0.01);治疗前血β-hCG水平:A组MTX+清宫者为21 592 U/L、清宫+MTX者为979 U/L,两者比较,差异有统计学意义(P＜0.05),B组为11 312 U/L,C组为101 U/L,C组与A、B组比较,差异均有统计学意义(P＜0.05);病灶血流RI0.5共28例,其中A组8例(24%,8/33)、B组18例(30%,18/60),C组2例(2/3),C组高于其他两组,差异有统计学意义(P＜0.05);病灶距子宫浆膜层≤3 mm共23例:A组2例(6%,2/33),B组21例(35%,21/60),C组0例,B组高于其他两组,差异也有统计学意义(P＜0.05);治疗费用:A组MTX+清宫者为(5578±3679)元、清宫+MTX者为(5346±2765)元,两者比较,差异无统计学意义(P＞0.05),B组为(7860±2104)元,C组为(5004±421)元,B组高于A、C组,差异有统计学意义(P＜0.05);住院时间:A组MTX+清宫者为(15±8)d、清宫+MTX者为(19±14)d,B组为(16±10)d,C组为(17±8)d,各组比较,差异均无统计学意义(P＞0.05).(2)相关性:出血量与子宫病灶直径(r=0.31,P＜0.05)以及治疗前血β-hCG水平(r=0.35,P＜0.05)均呈正相关关系.结论 MTX静脉治疗、动脉介入栓塞治疗和子宫病灶切除术用于治疗CSP,如应用恰当都能取得良好效果;病灶大、血β-hCG水平高、病灶距浆膜层近或子宫病灶血液供应丰富时,可选择MTX子宫动脉介入栓塞+清宫术治疗,但费用较高.
目的 探討剖宮產術後子宮瘢痕部位妊娠(CSP)的臨床錶現、診斷依據、治療方法和衛生經濟學特點.方法 迴顧性分析複旦大學附屬婦產科醫院2005年1月至2008年12月收治的96例CSP患者的臨床資料,按不同治療方法分為A組33例,行甲氨蝶呤(MTX)50 mg/m2靜脈滴註,其中18例MTX靜脈治療後5～10 d內行清宮術(MTX+清宮);15例先行清宮術,術後每48小時複查1次血人絨毛膜促性腺激素β亞單位(β-hCG)水平,3次均下降不足30%者,再用MTX 50 mg/m2靜脈滴註治療(清宮+MTX).B組60例,行MTX雙側子宮動脈介入栓塞治療,每側子宮動脈註入MTX 100 mg,術後2 d內行清宮術.C組3例,行子宮病竈切除術.比較各組齣血量(M)、病竈直徑(-x±s)、治療前血β-hCG水平(M)、病竈距子宮漿膜層≤3mm的例數、病竈血流阻力指數(RI)≤0.5的例數、治療費用(-x±s)、住院時間(-x±s)的差異,併分析齣血量與病竈直徑和血β-hCG水平的相關性.結果 (1)臨床指標:齣血量:A組MTX+清宮者為20 ml、清宮+MTX者為10 ml,B組為12 ml,C組為200ml,C組與A、B組比較,差異有統計學意義(P＜0.01);病竈直徑:A組MTX+清宮者為(16±8)mm、清宮+MTX者為(23±15)mm,B組為(30±14)mm,顯著高于A組MTX+清宮者,差異有統計學意義(P＜0.01),C組為(52±7)mm,3組分彆比較,差異均有統計學意義(P＜0.01);治療前血β-hCG水平:A組MTX+清宮者為21 592 U/L、清宮+MTX者為979 U/L,兩者比較,差異有統計學意義(P＜0.05),B組為11 312 U/L,C組為101 U/L,C組與A、B組比較,差異均有統計學意義(P＜0.05);病竈血流RI0.5共28例,其中A組8例(24%,8/33)、B組18例(30%,18/60),C組2例(2/3),C組高于其他兩組,差異有統計學意義(P＜0.05);病竈距子宮漿膜層≤3 mm共23例:A組2例(6%,2/33),B組21例(35%,21/60),C組0例,B組高于其他兩組,差異也有統計學意義(P＜0.05);治療費用:A組MTX+清宮者為(5578±3679)元、清宮+MTX者為(5346±2765)元,兩者比較,差異無統計學意義(P＞0.05),B組為(7860±2104)元,C組為(5004±421)元,B組高于A、C組,差異有統計學意義(P＜0.05);住院時間:A組MTX+清宮者為(15±8)d、清宮+MTX者為(19±14)d,B組為(16±10)d,C組為(17±8)d,各組比較,差異均無統計學意義(P＞0.05).(2)相關性:齣血量與子宮病竈直徑(r=0.31,P＜0.05)以及治療前血β-hCG水平(r=0.35,P＜0.05)均呈正相關關繫.結論 MTX靜脈治療、動脈介入栓塞治療和子宮病竈切除術用于治療CSP,如應用恰噹都能取得良好效果;病竈大、血β-hCG水平高、病竈距漿膜層近或子宮病竈血液供應豐富時,可選擇MTX子宮動脈介入栓塞+清宮術治療,但費用較高.
목적 탐토부궁산술후자궁반흔부위임신(CSP)적림상표현、진단의거、치료방법화위생경제학특점.방법 회고성분석복단대학부속부산과의원2005년1월지2008년12월수치적96례CSP환자적림상자료,안불동치료방법분위A조33례,행갑안접령(MTX)50 mg/m2정맥적주,기중18례MTX정맥치료후5～10 d내행청궁술(MTX+청궁);15례선행청궁술,술후매48소시복사1차혈인융모막촉성선격소β아단위(β-hCG)수평,3차균하강불족30%자,재용MTX 50 mg/m2정맥적주치료(청궁+MTX).B조60례,행MTX쌍측자궁동맥개입전새치료,매측자궁동맥주입MTX 100 mg,술후2 d내행청궁술.C조3례,행자궁병조절제술.비교각조출혈량(M)、병조직경(-x±s)、치료전혈β-hCG수평(M)、병조거자궁장막층≤3mm적례수、병조혈류조력지수(RI)≤0.5적례수、치료비용(-x±s)、주원시간(-x±s)적차이,병분석출혈량여병조직경화혈β-hCG수평적상관성.결과 (1)림상지표:출혈량:A조MTX+청궁자위20 ml、청궁+MTX자위10 ml,B조위12 ml,C조위200ml,C조여A、B조비교,차이유통계학의의(P＜0.01);병조직경:A조MTX+청궁자위(16±8)mm、청궁+MTX자위(23±15)mm,B조위(30±14)mm,현저고우A조MTX+청궁자,차이유통계학의의(P＜0.01),C조위(52±7)mm,3조분별비교,차이균유통계학의의(P＜0.01);치료전혈β-hCG수평:A조MTX+청궁자위21 592 U/L、청궁+MTX자위979 U/L,량자비교,차이유통계학의의(P＜0.05),B조위11 312 U/L,C조위101 U/L,C조여A、B조비교,차이균유통계학의의(P＜0.05);병조혈류RI0.5공28례,기중A조8례(24%,8/33)、B조18례(30%,18/60),C조2례(2/3),C조고우기타량조,차이유통계학의의(P＜0.05);병조거자궁장막층≤3 mm공23례:A조2례(6%,2/33),B조21례(35%,21/60),C조0례,B조고우기타량조,차이야유통계학의의(P＜0.05);치료비용:A조MTX+청궁자위(5578±3679)원、청궁+MTX자위(5346±2765)원,량자비교,차이무통계학의의(P＞0.05),B조위(7860±2104)원,C조위(5004±421)원,B조고우A、C조,차이유통계학의의(P＜0.05);주원시간:A조MTX+청궁자위(15±8)d、청궁+MTX자위(19±14)d,B조위(16±10)d,C조위(17±8)d,각조비교,차이균무통계학의의(P＞0.05).(2)상관성:출혈량여자궁병조직경(r=0.31,P＜0.05)이급치료전혈β-hCG수평(r=0.35,P＜0.05)균정정상관관계.결론 MTX정맥치료、동맥개입전새치료화자궁병조절제술용우치료CSP,여응용흡당도능취득량호효과;병조대、혈β-hCG수평고、병조거장막층근혹자궁병조혈액공응봉부시,가선택MTX자궁동맥개입전새+청궁술치료,단비용교고.
Objective To investigate the clinical manifestation, diagnosis, therapies and medical economics of cesarean scar pregnancy (CSP). Methods From Jan. 2005 to Dec. 2008, 96 patients with CSP treated in Obstetrics and Gynecology Hospital of Fudan University were studied retrospectively. Those cases were divided into 3 groups. Thirty-three patients were treated with methotrexate (MTX) 50 mg/m2 intravenously guttae in group A. Among that 18 cases were treated with MTX, after 5 - 10 days they underwent dilation and curettage of uterus; 15 cases were given by dilation and curettage first if the level of serum human chorionic gonadotrophin-β(β-hCG) descent less than 30% in every 48 hours for 3 times after curettage, then MTX (50 mg/m2) intravenously guttae. Sixty patients were treated with MTX 100 mg bilateral uterine artery injection and embolization in group B. After 2 days, they underwent curettage.Group C: 3 patients were treated with laparotomy lesion excision. The following clinical parameters were compared, including blood loss( M), lesion diameter (-x±s), blood β-hCG level (M)before treatment, the number of cases with myometrial thickness anterior to the CSP ≤3 mm, the resistant index (RI) ≤0. 5,expense(-x ± s), hospital days(-x ±s) in those 3 groups. The correlation of blood loss with lesion diameter and blood β-hCG level was studied. Results ( 1 ) Clinical manifestation: bleeding loss were 20 ml in MTX +curettage of group A, 10 ml in curettage + MTX of group A, 12 ml in group B and 200 ml in group C. The volume of bleeding loss in group C was significantly higher than those in group A or group B ( P ＜ 0. 01 ).The lesion diameter were ( 23 ± 15 ) mm in curettage + MTX of group A and ( 30 ± 14 ) mm of group B ,which were higher than ( 16 ± 8 ) mm of MTX + curettage of group A (P ＜ 0. 01 ). The lesion diameter of (52 ± 7 )mm in group C were significantly bigger than those in the other groups ( P ＜ 0. 01 ). The level of blood β-hCG levels were 21 592 U/L in MTX + curettage of group A, 979 U/L in curettage + MTX of group A,which reach statistical difference ( P ＜0. 05). The level of blood β-hCG levels were 11 312 U/L in group B and 101 U/L in group C. Among 28 cases with Rl≤0. 5,there was 8 cases in group A (24% ,8/33),18 cases in group B ( 30%, 18/60) and 2 cases in group C (2/3). Among 23 cases with myometrial thickness anterior to the CSP ≤ 3 mm, there was 21 cases in group B (35%, 21/60 ), which were significantly higher than 2 in group A (6%, 2/33 ) and none in group C ( P ＜ 0. 05 ). The expense were ( 5578 ± 3679) yuan in MTX + curettage of group A and (5346 ± 2765 ) yuan in curettage + MTX of group,which did not reach statistical difference (P＞0. 05). The expense were (7860 ±2104) yuan in group B,which were significantly higher than those in group A and (5004 ± 421 ) yuan in group C (P ＜ 0. 05 ). The hospital days were ( 15 ±8) days and ( 19 ± 14) days of group A, ( 16 ± 10) days in group B and ( 17 ±8)days in group C, there was no significant difference among those treatments ( P ＞ 0. 05 ). (2) Correlatin:there was positive correlation between bleeding loss and lesion diameter( r = 0. 31, P ＜ 0. 05 ) or blood β-hCG level ( r = 0. 35, P ＜ 0. 05). Conclusions MTX intravenously guttae, MTX uterine artery injection and embolization, and laparotomy lesion excision were all properly used in treatment of CSP. MTX uterine artery injection and embolization was recommended for those with big lesion, high β-hCG level, less myometrial thickness anterior to the CSP or plentiful blood supply of the lesion but the expense might be high.
