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目的:探讨剖宫产术后子宫瘢痕妊娠(caesarean scar pregnancy,CSP)的个体化治疗方法及其疗效。方法:选择2012年1月—2016年12月安徽医科大学第二附属医院收治的62例确诊为CSP的患者,根据临床类型分为2组,结合发病特点及患者意愿分别采用个体化的治疗方案。第1组(内生型)包括:方法 1(5例):保守治疗,即米非司酮+氨甲喋呤或子宫动脉栓塞术治疗;方法 2(26例):经宫腔镜病灶清除术(术中超声或腹腔镜监视);方法 3(11例):超声监视下清宫术;第2组(外生型)包括:方法4(6例):经腹腔镜病灶切除术+子宫瘢痕修补术;方法 5(11例)经阴道病灶切除术+子宫瘢痕修补术;方法 6(4例)经腹病灶切除+子宫瘢痕修补术(其中1例为经腹腔镜手术后并发盆腔血肿急诊转开腹手术)。术前对β-人绒毛膜促性腺激素(β-human chorionic gonadotrophin,β-HCG)>3 000 U/m L的患者予药物治疗或子宫动脉栓塞术。结果:6种治疗方法均有效。在第1组中,与方法 2、3比较,方法 1组住院时间、β-HCG恢复正常的时间、月经复潮时间均明显延长,差异有统计学意义(P均<0.01),而方法2、3之间,差异均无统计学意义(P均>0.05);3种治疗方法中均有月经量减少病例出现,差异无统计学意义;在术中出血方面,和方法 2比,方法 3术中出血明显减少,差异有统计学意义(P<0.01)。在第2组中,方法 5术中出血明显减少,与其他两种方法相比,差异均有统计学意义(P均<0.01),而在住院时间、手术时间、β-HCG恢复正常的时间方面,3种方法相比差异均无统计学意义(P>0.05)。结论:根据不同临床类型及发病特点选择不同方法治疗剖宫产术后子宫瘢痕处妊娠均取得预期效果,其中手术清除病灶周期短、术后恢复快、血β-HCG恢复正常的时间短,疗效确切。对于β-HCG较低、病灶较小且不愿手术的患者,保守治疗亦能够取得较好疗效。
Objective: To explore the individualized treatment of caesarean scar pregnancy (CSP) after cesarean section and its curative effect. Methods: Sixty-two patients diagnosed as CSP admitted to the Second Affiliated Hospital of Anhui Medical University from January 2012 to December 2016 were selected and divided into two groups according to their clinical characteristics. Individualized treatment plans . Group 1 (Endogenous) included: Method 1 (5): Conservative treatment with mifepristone + methotrexate or uterine artery embolization; Method 2 (26 cases): Hysteroscopic debridement Method 3 (11 cases): Obstetrics and Gynecology under ultrasound monitoring; Group 2 (Exo) including Method 4 (6 cases): Laparoscopic nephrectomy + uterine scar repair; Method 5 (11 cases) transvaginal focal resection plus uterine scar repair; Method 6 (4 cases) abdomen lesion resection + uterine scar repair (including 1 case of laparoscopic pelvic hematoma after emergency surgery to open laparotomy ). Preoperative chemotherapy or uterine artery embolization was performed in patients with β-human chorionic gonadotrophin (β-HCG)> 3 000 U / mL. Results: Six treatments were effective. In group 1, compared with methods 2 and 3, the duration of hospital stay, the time to normalization of β-HCG and the time of menstrual resuscitation were all significantly prolonged in method group 1 (P <0.01), while in method 2 , 3, the difference was not statistically significant (P all> 0.05); 3 kinds of treatment methods have reduced cases of menstrual flow, the difference was not statistically significant; in the intraoperative bleeding, compared with the method 2, method 3 Intraoperative bleeding was significantly reduced, the difference was statistically significant (P <0.01). In group 2, the bleeding of method 5 was significantly reduced, compared with the other two methods, the differences were statistically significant (P all <0.01), and in hospitalized time, operation time, β-HCG returned to normal time There was no significant difference between the three methods (P> 0.05). Conclusion: According to different clinical types and incidence characteristics, different methods were selected to treat pregnancy after uterine cesarean section pregnancy achieved the desired results, including surgery to clear the short period of the disease, postoperative recovery fast, blood β-HCG return to normal time is short, the effect exact. Conservative treatment can achieve better results in patients with lower β-HCG, lesser lesions and reluctance to operate.