中华妇产科杂志
中華婦產科雜誌
중화부산과잡지
CHINESE JOUNAL OF OBSTETRICS AND GYNECOLOGY
2014年
1期
10-13
,共4页
李源%向阳%万希润%冯凤芝%任彤
李源%嚮暘%萬希潤%馮鳳芝%任彤
리원%향양%만희윤%풍봉지%임동
妊娠,异位%瘢痕%腹腔镜检查%剖宫产术%手术后并发症%诊断,鉴别%妊娠滋养细胞肿瘤
妊娠,異位%瘢痕%腹腔鏡檢查%剖宮產術%手術後併髮癥%診斷,鑒彆%妊娠滋養細胞腫瘤
임신,이위%반흔%복강경검사%부궁산술%수술후병발증%진단,감별%임신자양세포종류
Pregnancy,ectopic%Cicatrix%Laparoscopy%Cesarean section%Postoperative complications%Diagnosis,differential%Gestational trophoblastic neoplasms
目的 探讨包块型剖宫产术后子宫瘢痕妊娠(CSP)的临床特点、鉴别诊断及治疗方式.方法 回顾性分析2005年至2012年北京协和医院妇产科收治的39例包块型CSP患者的临床资料,其中14例在外院误诊为滋养细胞肿瘤,并有4例接受了不同药物[甲氨蝶呤(MTX)、顺铂、氟尿嘧啶、放线菌素D]的化疗；6例外院未明确诊断,但可疑为滋养细胞肿瘤.按不同治疗方式将39例患者分为MTX治疗组(3例),行MTX 50 mg/m2单次肌内注射或50 mg病灶局部注射；清宫组(16例),行清宫术；腹腔镜组(15例),行腹腔镜CSP病灶切除术(包括2例清宫术治疗失败患者)；开腹组(6例),开腹行CSP病灶切除术(包括1例MTX治疗失败患者)；子宫切除组(4例),开腹行子宫全切除术(包括2例清宫术治疗失败患者).分析其临床特征和治疗结局.结果 (1)临床特征:患者平均年龄(33±5)岁,其中两次剖宫产史者5例；CSP距末次剖宫产中位时间为4年.39例患者中,35例患者表现为药物流产(5例)、人工流产手术(9例)或清宫术(21例)后持续阴道出血或β-hCG持续异常.B超表现为子宫前壁下段可见囊实性或实性混合回声包块,周边可探及丰富的高速低阻血流频谱.(2)治疗结局:39例患者中,20例患者曾被疑诊或误诊为滋养细胞肿瘤.MTX治疗组3例患者中2例成功；清宫组16例患者中,8例在子宫动脉栓塞后B超监视下清宫,6例成功,8例在腹腔镜或宫腔镜下清宫,5例成功；腹腔镜组15例患者均行腹腔镜CSP病灶切除术,均治疗成功；开腹组6例患者均行开腹CSP病灶切除术,均治疗成功；子宫切除组4例患者均行开腹子宫全切除术,均治疗成功.(3)住院时间及手术时间:腹腔镜组平均住院时间为(3.5±1.6)d,平均手术时间为(54±16) min;开腹组平均住院时间为(9.7±5.8)d,平均手术时间为(87 ±15) min;两组住院时间及手术时间比较,差异均有统计学意义(P＜0.05).结论 包块型CSP多为孕囊型CSP清宫不全或不全流产后残留妊娠组织继续生长而成,超声图像容易与滋养细胞肿瘤混淆导致误诊.应当根据患者具体情况采用个体化治疗方案,腹腔镜CSP病灶切除术在保留患者生育功能的同时,具有成功率高、安全性高及住院时间短的优点,可作为包块型CSP治疗的首选.
目的 探討包塊型剖宮產術後子宮瘢痕妊娠(CSP)的臨床特點、鑒彆診斷及治療方式.方法 迴顧性分析2005年至2012年北京協和醫院婦產科收治的39例包塊型CSP患者的臨床資料,其中14例在外院誤診為滋養細胞腫瘤,併有4例接受瞭不同藥物[甲氨蝶呤(MTX)、順鉑、氟尿嘧啶、放線菌素D]的化療；6例外院未明確診斷,但可疑為滋養細胞腫瘤.按不同治療方式將39例患者分為MTX治療組(3例),行MTX 50 mg/m2單次肌內註射或50 mg病竈跼部註射；清宮組(16例),行清宮術；腹腔鏡組(15例),行腹腔鏡CSP病竈切除術(包括2例清宮術治療失敗患者)；開腹組(6例),開腹行CSP病竈切除術(包括1例MTX治療失敗患者)；子宮切除組(4例),開腹行子宮全切除術(包括2例清宮術治療失敗患者).分析其臨床特徵和治療結跼.結果 (1)臨床特徵:患者平均年齡(33±5)歲,其中兩次剖宮產史者5例；CSP距末次剖宮產中位時間為4年.39例患者中,35例患者錶現為藥物流產(5例)、人工流產手術(9例)或清宮術(21例)後持續陰道齣血或β-hCG持續異常.B超錶現為子宮前壁下段可見囊實性或實性混閤迴聲包塊,週邊可探及豐富的高速低阻血流頻譜.(2)治療結跼:39例患者中,20例患者曾被疑診或誤診為滋養細胞腫瘤.MTX治療組3例患者中2例成功；清宮組16例患者中,8例在子宮動脈栓塞後B超鑑視下清宮,6例成功,8例在腹腔鏡或宮腔鏡下清宮,5例成功；腹腔鏡組15例患者均行腹腔鏡CSP病竈切除術,均治療成功；開腹組6例患者均行開腹CSP病竈切除術,均治療成功；子宮切除組4例患者均行開腹子宮全切除術,均治療成功.(3)住院時間及手術時間:腹腔鏡組平均住院時間為(3.5±1.6)d,平均手術時間為(54±16) min;開腹組平均住院時間為(9.7±5.8)d,平均手術時間為(87 ±15) min;兩組住院時間及手術時間比較,差異均有統計學意義(P＜0.05).結論 包塊型CSP多為孕囊型CSP清宮不全或不全流產後殘留妊娠組織繼續生長而成,超聲圖像容易與滋養細胞腫瘤混淆導緻誤診.應噹根據患者具體情況採用箇體化治療方案,腹腔鏡CSP病竈切除術在保留患者生育功能的同時,具有成功率高、安全性高及住院時間短的優點,可作為包塊型CSP治療的首選.
목적 탐토포괴형부궁산술후자궁반흔임신(CSP)적림상특점、감별진단급치료방식.방법 회고성분석2005년지2012년북경협화의원부산과수치적39례포괴형CSP환자적림상자료,기중14례재외원오진위자양세포종류,병유4례접수료불동약물[갑안접령(MTX)、순박、불뇨밀정、방선균소D]적화료；6예외원미명학진단,단가의위자양세포종류.안불동치료방식장39례환자분위MTX치료조(3례),행MTX 50 mg/m2단차기내주사혹50 mg병조국부주사；청궁조(16례),행청궁술；복강경조(15례),행복강경CSP병조절제술(포괄2례청궁술치료실패환자)；개복조(6례),개복행CSP병조절제술(포괄1례MTX치료실패환자)；자궁절제조(4례),개복행자궁전절제술(포괄2례청궁술치료실패환자).분석기림상특정화치료결국.결과 (1)림상특정:환자평균년령(33±5)세,기중량차부궁산사자5례；CSP거말차부궁산중위시간위4년.39례환자중,35례환자표현위약물유산(5례)、인공유산수술(9례)혹청궁술(21례)후지속음도출혈혹β-hCG지속이상.B초표현위자궁전벽하단가견낭실성혹실성혼합회성포괴,주변가탐급봉부적고속저조혈류빈보.(2)치료결국:39례환자중,20례환자증피의진혹오진위자양세포종류.MTX치료조3례환자중2례성공；청궁조16례환자중,8례재자궁동맥전새후B초감시하청궁,6례성공,8례재복강경혹궁강경하청궁,5례성공；복강경조15례환자균행복강경CSP병조절제술,균치료성공；개복조6례환자균행개복CSP병조절제술,균치료성공；자궁절제조4례환자균행개복자궁전절제술,균치료성공.(3)주원시간급수술시간:복강경조평균주원시간위(3.5±1.6)d,평균수술시간위(54±16) min;개복조평균주원시간위(9.7±5.8)d,평균수술시간위(87 ±15) min;량조주원시간급수술시간비교,차이균유통계학의의(P＜0.05).결론 포괴형CSP다위잉낭형CSP청궁불전혹불전유산후잔류임신조직계속생장이성,초성도상용역여자양세포종류혼효도치오진.응당근거환자구체정황채용개체화치료방안,복강경CSP병조절제술재보류환자생육공능적동시,구유성공솔고、안전성고급주원시간단적우점,가작위포괴형CSP치료적수선.
Objective To study the clinical features,differential diagnosis and treatment of caesarean scar pregnancy (CSP) with sonographic mass.Methods A retrospective analysis was performed on 39 patients of CSP with sonographic mass undergoing treatment in Peking Union Medical College Hospital from 2005 to 2012.14 cases with misdiagnosis of gestational trophoblastic neoplasm,among 4 cases were administered by chemotherapy with methotrexate (MTX),cisplatin,fluorouracil (5-FU) and dactinomycin.According to treatment methods,39 cases were divided into five groups: 3 cases in methotrexate,16 cases in dilation and curettage,15 cases in excision of CSP lesion via laparoscopy,6 cases in excision of CSP lesion via laparotomy,and 4 cases in transabdominal hysterectomy (TAH).Results (1)Clinical characteristics: the mean age was (33 ± 5) years old.Five patients had undergone two prior caesarean sections.The median interval from the last caesarean delivery to CSP was 4 years.Thirty-five cases presented vaginal bleeding or abnormal serum β-hCG level from 5 cases with medical abortion,9 cases with artificial abortion and 21 cases with dilation and curettage.The sonography showed cystic-solid or solid mass with mixed echoes in the lower segment of anterior uterine wall,surrounded by peritrophoblastic vasculature.(2) Treatment outcome: diagnosis of gestational trophoblastic neoplasm was suspected or made in 20 patients,four of whom were even treated by chemotherapy.MTX therapy was given to 3 patients,2 of whom were cured.Dilation and curettages were given to 16 patients,11 of whom were cured.8 patients underwent curettage with sonographic guidance after uterine artery embolism,and 8 patients with laparoscopic or hysteroscopic guidance.All of 15 patients underwent excision of CSP lesion via laparoscopy were cured.4 patients were treated by TAH.(3) Time of in hospital and operation:in laparoscopy group,the average hospitalization days were (3.5 ± 1.6) days,the average operation duration was (54 ± 16)minutes.In laparotomy group,the average hospitalization days were (9.7 ± 5.8) days,and the average surgical duration was (87 ± 15) minutes.It reached significant difference (P ＜ 0.05).Conclusions CSP with sonographic mass was the consequence of continued growth of residual pregnancy mass after incomplete abortion or curettage of CSP with gestation sac.The similar sonographic image might lead to misdiagnosis.Individual therapy was recommended.Excision of CSP lesion via laparoscopy might be the primary option for its advantages in differential diagnosis,caesarean scar defect repair and successful ratio.
