两种不同方法治疗停经<7周的Ⅱ型和Ⅲ型剖宫产术后子宫瘢痕妊娠的安全性比较
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摘要
目的比较2种不同方法治疗停经<7周的Ⅱ型和Ⅲ型剖宫产术后子宫瘢痕妊娠(CSP)的安全性。方法收集海军机关门诊部2010年3月至2017年3月不同方法治疗停经<7周的Ⅱ型和Ⅲ型CSP患者的临床资料89例,并进行回顾性分析。根据治疗方法的不同分为甲氨蝶呤组(43例)和子宫动脉栓塞组(46例)。甲氨蝶呤组采取甲氨蝶呤治疗后超声监视下清宫,子宫动脉栓塞组采取甲氨蝶呤联合子宫动脉明胶海绵颗粒栓塞治疗后超声监视下清宫。对2组术中出血量、住院时间、住院费用、并发症发生率等指标进行比较。结果甲氨蝶呤组和子宫动脉栓塞组患者清宫手术中出血量中位数分别为6.0(2.0～50.0)、6.0(3.0～48.0),2组比较差异无统计学意义(P=0.737);甲氨蝶呤组和子宫动脉栓塞组住院时间中位数分别为4.0、8.0 d,2组比较差异具有统计学意义(P<0.01);甲氨蝶呤组、子宫动脉栓塞组住院费用中位数分别为5 667.9元、11 087.3元,2组比较差异具有统计学意义(P<0.01);子宫动脉栓塞组CSP患者术后发热33例(33/46,71.7%)、腹痛25例(25/46,54.3%);过敏1例(1/46,2.1%),但甲氨蝶呤组未发生不良反应;10个可能影响术中出血量的因素中,只有胎囊平均径线这一因素差异有统计学意义(P<0.05),二元logistic回归分析,2组之间的术中出血量差异无统计学意义(P>0.05)。结论与子宫动脉栓塞组治疗方法比较,甲氨蝶呤治疗后超声(监视下)清宫术治疗停经<7周的Ⅱ型和Ⅲ型CSP无增加出血的风险、无并发症、住院时间短、费用低,值得临床推广。
Objective To compare the safety of 2 different methods for the treatment of uterine scar pregnancy(CSP) after typeⅡ and type Ⅲ cesarean delivery for menopause over 7 weeks.Methods Clinical medical data of 89 cases of type Ⅱand type Ⅲ CSP treated with different methods in Navy Institutional Clinic from March 2010 to March 2017 for menopause over 7 weeks were collected and a retrospective analysis was made in the study. According to different treatment methods, the patients were divided into the methotrexate group(n=43) and the uterine artery embolization group(n=46). The methotrexate group was treated with methotrexate and monitored with ultrasonography, while the uterine arterial embolization group was treated with methotrexate combined with uterine artery gelatin sponge embolization, and hysterectomy was performed under ultrasonography. The amount of blood loss, length of hospital stay, hospitalization costs, and rate of complications were compared between the 2 groups.Results The median hemorrhage during hysterectomy in the methotrexate and the uterine arterial embolization groups were respectively 6.0(2.0-50.0) and 6.0(3.0-48.0). There was statistical significance, when comparisons were made between the 2 groups(P=0.737). The median length of hospital stay in the methotrexate and the uterine arterial embolization groups were respectively 4.0 and 8.0 days. There was also statistical significance, when comparisons were made between the 2 groups(P<0.01). The median hospitalization costs for the 2 groups were respectively 5 667.9 yuan and 11 087.3 yuan, there was no statistical significance between the 2 groups(P<0.01). In the CSP patients of the uterine arterial embolization group, there were 33 cases of postoperative fever(33/46), accounting for 71.7%, 25 cases of abdominal pain(25/46), accounting for 54.3% and one case of allergy(1/46), accounting for 2.1%. However, in the methotrexate group, there was no case of adverse reactions. Of the 10 factors that might affect the intraoperative blood loss, only the factor of average diameter of the fetal sac was found to be statistically significant(P<0.05). Binary logistic regression analysis indicated that no statistical significance could be found in intraoperative blood loss, when comparisons were made between the 2 groups(P>0.05).Conclusion Compared with the treatment method of the uterine artery embolization group, the treatment of CSP patients with hysterectomy under ultrasonography of typeⅡ and type Ⅲ with menopause over 7 weeks displayed such advantages as less surgical risk, fewer complications, shorter hospitalization stay and lower cost. Therefore, it is worth further clinical promotion.
Objective To compare the safety of 2 different methods for the treatment of uterine scar pregnancy(CSP) after typeⅡ and type Ⅲ cesarean delivery for menopause over 7 weeks.Methods Clinical medical data of 89 cases of type Ⅱand type Ⅲ CSP treated with different methods in Navy Institutional Clinic from March 2010 to March 2017 for menopause over 7 weeks were collected and a retrospective analysis was made in the study. According to different treatment methods, the patients were divided into the methotrexate group(n=43) and the uterine artery embolization group(n=46). The methotrexate group was treated with methotrexate and monitored with ultrasonography, while the uterine arterial embolization group was treated with methotrexate combined with uterine artery gelatin sponge embolization, and hysterectomy was performed under ultrasonography. The amount of blood loss, length of hospital stay, hospitalization costs, and rate of complications were compared between the 2 groups.Results The median hemorrhage during hysterectomy in the methotrexate and the uterine arterial embolization groups were respectively 6.0(2.0-50.0) and 6.0(3.0-48.0). There was statistical significance, when comparisons were made between the 2 groups(P=0.737). The median length of hospital stay in the methotrexate and the uterine arterial embolization groups were respectively 4.0 and 8.0 days. There was also statistical significance, when comparisons were made between the 2 groups(P<0.01). The median hospitalization costs for the 2 groups were respectively 5 667.9 yuan and 11 087.3 yuan, there was no statistical significance between the 2 groups(P<0.01). In the CSP patients of the uterine arterial embolization group, there were 33 cases of postoperative fever(33/46), accounting for 71.7%, 25 cases of abdominal pain(25/46), accounting for 54.3% and one case of allergy(1/46), accounting for 2.1%. However, in the methotrexate group, there was no case of adverse reactions. Of the 10 factors that might affect the intraoperative blood loss, only the factor of average diameter of the fetal sac was found to be statistically significant(P<0.05). Binary logistic regression analysis indicated that no statistical significance could be found in intraoperative blood loss, when comparisons were made between the 2 groups(P>0.05).Conclusion Compared with the treatment method of the uterine artery embolization group, the treatment of CSP patients with hysterectomy under ultrasonography of typeⅡ and type Ⅲ with menopause over 7 weeks displayed such advantages as less surgical risk, fewer complications, shorter hospitalization stay and lower cost. Therefore, it is worth further clinical promotion.
引文
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[4] 袁岩,戴晴,蔡胜,等.超声对剖宫产瘢痕妊娠的诊断价值 [J].中华超声影像学杂志,2010,19(4):321-324.DOI:10.3760/ cma.j.issn.1004-4477.2010.04.018.
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[7] Liu S,Sun J,Cai B,et al.Management of cesarean scar pregnancy using ultrasound-guided dilation and curettage [J].J Minim Invasive Gynecol,2016,23(5):707-711.DOI:10.1016/j.jmig.2016.01.012.
[8] 中华医学会妇产科学分会计划生育学组.剖宫产术后子宫瘢痕妊娠诊治专家共识(2016)[J].中华妇产科杂志,2016,51(8):568-572.DOI:10.3760/cma.j.issn.0529-567x.2016.08.003.
[9] Yang H,Li S,Ma Z,et al.Therapeutic effects of uterine artery embolisation (UAE) and methotrexate (MTX) conservative therapy used in treatment of cesarean scar pregnancy[J].Arch Gynecol Obstet,2016,293(4):819-823.DOI:10.1007/ s00404-015-3881-0.
[10] Li C,Li C,Feng D,et al.Transcatheter arterial chemo-embolization versus systemic methotrexate for the management of cesarean scar pregnancy[J].Int J Gynaecol Obstet,2011,113(3):178-182.DOI:10.1016/j.ijgo.2010.11.027.
[11] Shen L,Tan A,Zhu H,et al.Bilateral uterine artery chemoembolization with methotrexate for cesarean scar pregnancy[J].Am J Obstet Gynecol,2012,207(5):386.e1-6.DOI:10.1016/j.ajog.2012.09.012.
[12] Le A,Shan L,Xiao T,et al.Transvaginal surgical treatment of cesarean scar ectopic pregnancy[J].Arch Gynecol Obstet,2013,287(4):791-796.DOI:10.1007/s00404-012-2617-7.
[13] Yela DA,Marchiani N.Conservative management of ectopic pregnancy in cesarean scar:case report[J].Rev Bras Ginecol Obstet,2013,35(5):233-237.
[14] Li N,Zhu F,Fu S,et al.Transvaginal ultrasound-guided embryo aspiration plus local administration of low-dose methotrexate for caesarean scar pregnancy[J].Ultrasound Med Biol,2012,38(2):209-213.DOI:10.1016/j.ultrasmedbio.2011.10.012.
[15] Lian F,Wang Y,Chen W,et al.Uterine artery embolization combined with local methotrexate and systemic methotrexate for treatment of cesarean scar pregnancy with different ultrasonographic pattern[J].Cardiovasc Intervent Radiol,2012,35(2):286-291.DOI:10.1007/s00270-011-0097-y.
[16] Seow KM,Wang PH,Huang LW,et al.Transvaginal sono-guided aspiration of gestational sac concurrent with a local methotrexate injection for the treatment of unruptured cesarean scar pregnancy[J].Arch Gynecol Obstet,2013,288 (2):361-366.DOI:10.1007/s00404-013-2765-4.
[17] Wang G,Liu X,Bi F,et al.Evaluation of the efficacy of laparoscopic resection for the management of exogenous cesarean scar pregnancy[J].Fertil Steril,2014,101(5):1501-1507.DOI:10.1016/j.fertnstert.2014.01.045.
[18] Qian ZD,Huang LL,Zhu XM.Curettage or operative hysteroscopy in the treatment of cesarean scar pregnancy[J].Arch Gynecol Obstet,2015,292(5):1055-1061.DOI:10.1007/ s00404-015-3730-1.
[2] Ash A,Smith A,Maxwell D.Caesarean scar pregnancy[J].BJOG,2007,114(3):253-263.DOI:10.1111/j.1471-0528.2006.01237.x.
[3] Hoshino T,Kita M,Imai Y.Macroscopic appearance of a uterus with a cesarean scar pregnancy[J].Int J Gynaecol Obstet,2011,115(1):65-66.DOI:10.1016/j.ijgo.2011.06.007.
[4] 袁岩,戴晴,蔡胜,等.超声对剖宫产瘢痕妊娠的诊断价值 [J].中华超声影像学杂志,2010,19(4):321-324.DOI:10.3760/ cma.j.issn.1004-4477.2010.04.018.
[5] Timor-Tritsch IE,Cali G,Monteagudo A,et al.Foley balloon catheter to prevent or manage bleeding during treatment for cervical and cesarean scar pregnancy[J].Ultrasound Obstet Gynecol,2015,46(1):118-123.DOI:10.1002/uog.14708.
[6] Cheng LY,Wang CB,Chu LC,et al.Outcomes of primary surgical evacuation during the first trimester in different types of implantation in women with cesarean scar pregnancy[J].Fertil Steril,2014,102(4):1085-1090.e2.DOI:10.1016/j.fertnstert.2014.07.003.
[7] Liu S,Sun J,Cai B,et al.Management of cesarean scar pregnancy using ultrasound-guided dilation and curettage [J].J Minim Invasive Gynecol,2016,23(5):707-711.DOI:10.1016/j.jmig.2016.01.012.
[8] 中华医学会妇产科学分会计划生育学组.剖宫产术后子宫瘢痕妊娠诊治专家共识(2016)[J].中华妇产科杂志,2016,51(8):568-572.DOI:10.3760/cma.j.issn.0529-567x.2016.08.003.
[9] Yang H,Li S,Ma Z,et al.Therapeutic effects of uterine artery embolisation (UAE) and methotrexate (MTX) conservative therapy used in treatment of cesarean scar pregnancy[J].Arch Gynecol Obstet,2016,293(4):819-823.DOI:10.1007/ s00404-015-3881-0.
[10] Li C,Li C,Feng D,et al.Transcatheter arterial chemo-embolization versus systemic methotrexate for the management of cesarean scar pregnancy[J].Int J Gynaecol Obstet,2011,113(3):178-182.DOI:10.1016/j.ijgo.2010.11.027.
[11] Shen L,Tan A,Zhu H,et al.Bilateral uterine artery chemoembolization with methotrexate for cesarean scar pregnancy[J].Am J Obstet Gynecol,2012,207(5):386.e1-6.DOI:10.1016/j.ajog.2012.09.012.
[12] Le A,Shan L,Xiao T,et al.Transvaginal surgical treatment of cesarean scar ectopic pregnancy[J].Arch Gynecol Obstet,2013,287(4):791-796.DOI:10.1007/s00404-012-2617-7.
[13] Yela DA,Marchiani N.Conservative management of ectopic pregnancy in cesarean scar:case report[J].Rev Bras Ginecol Obstet,2013,35(5):233-237.
[14] Li N,Zhu F,Fu S,et al.Transvaginal ultrasound-guided embryo aspiration plus local administration of low-dose methotrexate for caesarean scar pregnancy[J].Ultrasound Med Biol,2012,38(2):209-213.DOI:10.1016/j.ultrasmedbio.2011.10.012.
[15] Lian F,Wang Y,Chen W,et al.Uterine artery embolization combined with local methotrexate and systemic methotrexate for treatment of cesarean scar pregnancy with different ultrasonographic pattern[J].Cardiovasc Intervent Radiol,2012,35(2):286-291.DOI:10.1007/s00270-011-0097-y.
[16] Seow KM,Wang PH,Huang LW,et al.Transvaginal sono-guided aspiration of gestational sac concurrent with a local methotrexate injection for the treatment of unruptured cesarean scar pregnancy[J].Arch Gynecol Obstet,2013,288 (2):361-366.DOI:10.1007/s00404-013-2765-4.
[17] Wang G,Liu X,Bi F,et al.Evaluation of the efficacy of laparoscopic resection for the management of exogenous cesarean scar pregnancy[J].Fertil Steril,2014,101(5):1501-1507.DOI:10.1016/j.fertnstert.2014.01.045.
[18] Qian ZD,Huang LL,Zhu XM.Curettage or operative hysteroscopy in the treatment of cesarean scar pregnancy[J].Arch Gynecol Obstet,2015,292(5):1055-1061.DOI:10.1007/ s00404-015-3730-1.