子宫切口瘢痕妊娠的诊断与治疗

目的讨论剖宫产术后子宫切口瘢痕妊娠的诊断及治疗方法。方法回顾性分析天津市中心妇产科医院2007年1月至2009年12月间收治的128例剖宫产术后子宫切口瘢痕妊娠患者的临床资料。其中98例清宫术前采用明胶海绵、甲氨喋呤(MTX)进行双侧子宫动脉选择性栓塞治疗,治疗后7 d内超声监护下进行清宫手术,观察术中出血量和术后伴发症状及血β2-HCG下降情况。30例给予MTX子宫妊娠部位注射后,择期超声下行清宫术。结果 98例介入治疗后7 d内给予清宫术,均使子宫切口处妊娠包块明显减小,术后血β2-HCG下降明显。30例超声提示包块血流不丰富,包块≤4 cm。切口瘢痕厚度4 mm,子宫浆膜层完整;血β2-HCG≤2000 mIU/L。给予MTX治疗后,在有介入治疗条件、超声下行清宫术,28例清宫顺利。2例清宫术时大出血,立即行介入治疗,治疗后第7天行清宫术,术后2个月包块消失,血β2-HCG降至正常。结论子宫切口瘢痕妊娠在清宫手术前进行双侧子宫动脉栓塞的辅助治疗,安全性好,并发症少,操作简单,可有效地控制切口妊娠清宫术中的出血量,保留了患者的生育功能。如超声提示包块血流不丰富、包块≤4 cm、血β-HCG≤2000 mIU/L、切口厚度4 mm,可给予MTX治疗,在有介入治疗条件、超声下行清宫术。     

甲氨喋呤单次肌内注射治疗异位妊娠效果观察

目的 探讨甲氨喋呤(MTX)单次肌内注射治疗异位妊娠的效果.方法 回顾分析我院收治的43例异位妊娠患者,对其采用MTX单次肌内注射(50 mg/m2)治疗,不用四氢叶酸解毒方案治疗.定时监测血绒毛膜促性腺激素β亚单位(β-HCG)直至正常.结果 39例成功,成功率为90.7%.其成功率与治疗前腹痛症状的发生率及血β-HCG值间的差异有非常显著性(P＜0.01).结论 无腹痛症状、血β-HCG≤6 000 mIU/ml为MTX单次肌注治疗的适应症.早期诊断和严格选择病例是治疗成功的关键.     

血清β人绒毛膜促性腺激素联合孕酮和超声监测异位妊娠药物治疗作用的价值

目的:探讨血清β人绒毛膜促性腺激素(β-HCG)联合孕酮、超声在监测输卵管异位妊娠药物治疗作用中的价值.方法:回顾分析我院2005年1月至2008年6月应用甲氨蝶呤(MTX)加米非司酮(RU486)治疗的输卵管异位妊娠患者60例,以治疗前血清β-HCG值2 000mIU/mL为界分为2组,治疗后动态监测其血清β-HCG、孕酮下降速度,分析这些指标降至正常所需时间与治疗前β-HCG水平的相关性,同时采用经阴道彩色多普勒血流显像检查药物治疗前患者输卵管动脉血流信号.结果:β-HCG<2 000 mIU/mL组,药物治疗成功率为85.37%,而β-HCG≥2 000 mIU/mL组,药物治疗成功率为38.89%.药物治疗成功者血清β-HCG、孕酮水平越高,两者下降至正常所需时间也越长(P均<0.01),孕酮下降速度较血清B.HCG快(P<0.01).药物治疗成功组与失败组间患者治疗前输卵管动脉血流阻力指数(RI)差异有统计学意义(P<0.01).结论:输卵管异位妊娠患者血清β-HCG≥2 000 mIU/mL时,药物治疗成功率相对偏低,其药物治疗成功所需时间较长.药物治疗过程中,孕酮下降速度快于β-HCG,可作为药物疗效观察的重要指标,经阴道彩色多普勒血流显像监测输卵管动脉血流信号是选择药物治疗的重要参考指标.     

子宫切口瘢痕妊娠不同治疗方法的疗效分析

目的探讨子宫切口瘢痕妊娠治疗方案的合理选择。方法回顾性分析收治的41例子宫切口瘢痕妊娠患者的诊治过程,根据治疗方法的不同分为3组。A组:单纯大剂量甲氨喋呤(MTX)化疗组(n=16):肌肉注射MTX;B组:子宫动脉栓塞术(UAE)+清宫术组(n=15):行UAE联合MTX灌注化疗及清宫术治疗;C组:子宫动脉栓塞UAE+清宫+子宫切口瘢痕妊娠病灶切除术(n=10):在子宫动脉栓塞UAE+清宫术后,立即经腹或腹腔镜下行子宫前壁病灶切除。比较各组治疗效果。结果 MTX组,UAE+清宫术组,UAE+清宫+病灶切除术组的治疗成功率分别为87.5%(14/16),86.67%(13/15),100%(10/10)。3组治疗成功率比较差异有统计学意义(P0.05)。3组患者的年龄、停经时间、孕囊大小和初始血β人绒毛膜促性腺激素(β-HCG)水平比较,差异均无统计学意义(P0.05)。3组患者的年龄、停经时间、孕囊大小和初始血β-HCG水平比较,差异均无统计学意义(P0.05)。3组患者住院时间、血β-HCG恢复正常时间和宫内包块消失时间比较,差异有统计学意义(P0.01)。UAE+清宫+病灶切除术组住院天数、术后血β-HCG转阴和包块消失的时间最短,差异显著。结论子宫动脉栓塞+清宫术+子宫切口瘢痕妊娠病灶切除术,治疗效果良好,并发症少,术后恢复快,推荐成为首选的治疗方案。     

腹腔镜下手术治疗外凸型子宫瘢痕妊娠的临床研究

目的探讨并分析腹腔镜手术治疗子宫瘢痕妊娠的适应证和疗效。方法该院2004年1月～2011年11月选择满足血β-HCG<20000mIU/mL的外凸型CSP患者共24例进行腹腔镜下瘢痕妊娠物切除+子宫修补术治疗,观察手术时间、术中出血量、术后血β-HCG下降时间、患者恢复正常月经时间及住院天数。结果 24例手术均成功,无手术并发症发生,手术平均时间63min,平均出血量62mL。所有患者术后2周内血β-HCG降为正常,术后4周内月经恢复正常,手术后平均住院天数6d(5～10d)。血β-HCG<10000mIU/mL的10例患者与血β-HCG10000～20000mIU/mL的14例患者相比,手术时间和术中出血量差异有显著性(P<0.05)。结论腹腔镜手术对于血β-HCG<20000mIU/mL的外凸型CSP患者是一种可行的治疗方法。尤其适用于血β-HCG<10000mIU/mL的外凸型CSP患者。腹腔镜手术治疗CSP具有出血少、操作时间短、血β-HCG下降迅速、住院时间短等优势,同时修复了子宫的形态保留了生育功能。     

剖宫产术后子宫切口瘢痕妊娠患者不同治疗方案的临床疗效观察

选取我院90例剖宫产术后子宫切口瘢痕妊娠患者,将其随机分为A、B、C三组各30例,三组使用不同的治疗方案,观察比较患者治疗前后的血β-HCG和血细胞水平,以及住院时间和血流量情况。结果 C组患者治疗后的血β-HCG水平明显优于其他两组(P<0.05),三组血细胞水平对比差异不大(P>0.05)。三组住院时间和血流量比较结果为A组>B组>C组。在治疗剖宫产术后子宫切口瘢痕妊娠时,采用宫腔镜下手术联合子宫动脉栓塞治疗的效果显著优于单纯使用药物治疗、药物联合清宫术治疗。     

甲氨蝶呤杀胚后宫腔镜治疗剖宫产术后子宫瘢痕妊娠

目的:探讨甲氨蝶呤杀胚后经宫腔镜治疗剖宫产术后子宫瘢痕妊娠的临床疗效。方法:回顾性分析2015年2月~2017年1月我院收治的30例子宫瘢痕妊娠患者临床资料。根据治疗方式分为试验组和对照组各15例。对照组予以清宫术,试验组予以宫腔镜手术+甲氨蝶呤。比较两组的临床疗效。结果:试验组手术7 d后血β-HCG降低程度显著高于对照组(P<0.05);治疗后,试验组β-HCG水平以及月经恢复时间、血β-HCG恢复正常时间显著低于对照组,总有效率高于对照组(P<0.05)。结论:子宫瘢痕妊娠患者采用甲氨蝶呤杀胚后经宫腔镜治疗,临床效果理想。     

三种不同药物方案保守治疗异位妊娠的疗效观察

目的探讨不同方案保守治疗异位妊娠(EP)的疗效。方法回顾性分析该院2012年6月至2014年6月经药物保守治疗的198例EP患者的病历资料,根据治疗方案分为A组(39例)单用甲氨蝶呤(MTX),B组(92例)MTX联合米非司酮用药,C组(67例)采用MTX 8日疗法,观察各组治愈率、人绒毛膜促性腺激素β亚单位(β-HCG)下降至正常水平时间等,比较3种方案的疗效,以及不同血β-HCG水平对3种方案的影响。结果3组治愈率比较差异有统计学意义(P0.05),最高为C组(86.57%),B组次之(84.78%),A组最低(66.67%)。3组患者中β-HCG水平为1 500~3 000mIU/mL者及大于3 000mIU/mL者治愈率比较,差异均有统计学意义(P0.05)。结论单用MTX保守治疗EP效果欠佳,推荐选用联合方案或8日疗法,较高β-HCG水平患者采用8日疗法疗效最好。     

不同方法治疗剖宫产术后子宫瘢痕处妊娠的效果

目的:评价不同治疗方法治疗剖宫产术后瘢痕处妊娠的效果.方法:回顾分析2005年1月至2011年12月期间收治的剖宫产瘢痕处妊娠病例共32例,评价不同治疗方式及其治疗效果.结果:18例甲氨蝶呤(MTX)联合米非司酮药物保守治疗,其中4例单纯药物治疗成功,14例药物保守治疗后行清宫术.10例行米非司酮+子宫动脉(MTX)灌注栓塞术(UAE)+择期清宫术;2例瘢痕处妊娠病灶切除术+瘢痕缺陷修补术;2例患者子宫切除术.32例患者均治愈出院.结论:剖宫产术后子宫瘢痕处妊娠治疗应采用个体化治疗方案,其中米非司酮+子宫动脉(MTX)灌注栓塞术(UAE)+择期清宫术方案是一种适合各种类型子宫瘢痕处妊娠的安全、有效的治疗方法.     

宫腔镜联合子宫动脉栓塞终止剖宫产术后子宫瘢痕妊娠的疗效与安全性观察

目的探讨剖宫产术后子宫瘢痕妊娠使用宫腔镜联合子宫动脉栓塞终止妊娠的临床价值。方法选择我院在2018年1月～2019年1月剖宫产术后子宫瘢痕妊娠需要终止妊娠治疗的74例患者作为研究对象,采取随机排列表法将其分成对照组和观察组各37例。对照组患者采用甲氨蝶呤药物治疗,观察组患者采用宫腔镜联合子宫动脉栓塞协同治疗。比较两组住院时间、病灶消失时间、血β-HCG指标正常时间、月经恢复时间以及不良反应率。结果观察组住院时间以及病灶消失时间均短于对照组(P0.05);观察组血β-HCG指标正常时间短于对照组(P0.05);观察组不良反应率为2.70%,低于对照组的27.03%(P0.05),两组月经恢复时间比较无明显差异(P0.05)。结论剖宫产术后子宫瘢痕妊娠使用宫腔镜联合子宫动脉栓塞协同治疗终止妊娠效果显著,可缩短住院时间,促进子宫功能早日恢复,并且不良反应较小,安全性高,值得临床广泛推行。     

Cesarean Scar Pregnancy

A cesarean scar (ectopic) pregnancy occurs when a pregnancy implants on a cesarean scar. This condition is an uncommon but potentially devastating occurrence. The incidence is increasing as cesarean deliveries become more common. Early recognition of the salient sonographic findings is critical because a delay can lead to increased maternal morbidity and mortality. Magnetic resonance imaging is a valuable troubleshooting tool when sonography is equivocal or inconclusive before therapy or intervention. Early diagnosis by sonography directs therapy and improves outcomes by allowing preservation of the uterus and future fertility. We review the imaging features, differential diagnosis, complications, and treatment of cesarean scar pregnancies in the first trimester.     

回归性分析菏泽市剖宫产瘢痕妊娠的危险因素

目的:分析剖宫产瘢痕妊娠的危险因素。方法:回顾性分析本院2015年1月至2019年12月收治的42例子宫瘢痕妊娠患者,与通过计算机以2∶1的比例随机分配到对照组的84例非瘢痕妊娠患者的临床资料。比较两组患者的妊娠年龄、孕周、妊娠次数、剖宫产次数、流产次数等情况,探究发生瘢痕妊娠的潜在危险因素。结果:瘢痕妊娠患者妊娠次数、剖宫产次数、流产次数、剖宫产后流产史以及宫腔手术史明显多于对照组,当前怀孕和上一次怀孕之间的时间间隔明显小于对照组,P<0.05,差异具有统计学意义。两组患者妊娠年龄、孕周、胎次、上次剖宫产时机、手术方式及手术指征无明显差异,P>0.05。Logistic回归分析表明妊娠次数、剖宫产次数、流产次数增加、剖宫产后流产史、宫腔手术史以及当前怀孕和上一次怀孕之间的时间间隔较短会增加瘢痕妊娠的发生风险。结论:增加瘢痕妊娠发生风险的主要危险因素包括:妊娠次数、剖宫产次数、流产次数增加,剖宫产后流产史、宫腔手术史以及当前怀孕和最后一次怀孕之间的间隔较短。     

First-trimester diagnosis of cesarean scar ectopic pregnancy

Once considered extremely rare, implantation of a pregnancy within the scar of a previous cesarean section is becoming more common. In fact, its incidence is now higher than that of cervical ectopic pregnancies. We identified 5 cases of ectopic pregnancy implanted in a prior cesarean section scar at our institution since 2004. We outline the criteria for the first-trimester sonographic diagnosis of cesarean scar ectopic pregnancy, including a new sign of lower uterine segment ballooning, which has previously not been reported. Clinicians must have a heightened awareness of this serious and potentially fatal pregnancy complication.     

超声在诊断及治疗剖宫产切口部位妊娠中的临床价值

目的探讨剖宫产切171部位妊娠的临床诊断和治疗方法。方法回顾性分析29例患者的临床资料。结果17例未行超声检查即采取人工流产或刮宫术，9例术中或术后阴道大量流血；本病初诊误诊率高达82．8％（24／29），B超诊断率62．1％（18／29）；28例保守治疗成功（96．6％），1例行子宫次全切除术（3．4％）。结论超声在诊断和治疗子宫切口妊娠中具重要意义。     

彩色多普勒超声对子宫下段切口处早期胚胎着床的诊断价值

目的探讨子宫下段剖腹产切口处早期胚胎着床的灰阶超声及彩色多普勒超声的特征. 方法 28例子宫下段剖腹产切口处早期妊娠的患者均行超声检查,记录各病例的二维图像及收缩期峰值血流速度和血流阻力指数.结果子宫下段剖腹产切口处早期胚胎着床的二维图像具有特征性表现,部分病例彩色多普勒频谱表现为高速低阻特征.结论彩色多普勒超声是无创性诊断子宫下段切口处早期妊娠的可靠方法.     

When a cesarean section scar is more than an innocent bystander in a subsequent pregnancy: Ultrasound to the rescue

Over the years, cesarean section has played a pivotal role in reducing maternal and perinatal morbidity and mortality. With the rising trend of this surgery, a substantial number of pregnant women have a cesarean section scar. The scar can serve as the abode of grave conditions in subsequent pregnancies, namely cesarean scar pregnancy, morbidly adherent placenta, and scar dehiscence. Sonography has emerged as a robust tool for the diagnosis of these potentially life‐threatening conditions. This review highlights the key sonographic features of various complications that can occur at the cesarean scar site in subsequent pregnancies. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45 :319–327, 2017;     

First-trimester treatment of cesarean scar pregnancy using a cervical ripening—double-balloon catheter: A case report

Cesarean scar pregnancies are relatively rare. In the first trimester, if the decision is made to terminate the pregnancy, it should be done as soon as possible to avoid complications. We report a successful termination of a live, 6 weeks and 4 days cesarean scar pregnancy using a double-balloon cervical ripening catheter in a patient with two previous cesarean deliveries.     

Heterotopic Cesarean Scar Pregnancy

Heterotopic cesarean scar pregnancy is a rare, life‐threatening form of ectopic pregnancy. To provide information regarding the clinical manifestations, diagnosis, management, and prognosis of this condition, we reviewed all cases reported in the English literature. All literature on heterotopic cesarean scar pregnancy was retrieved by searching the PubMed database and tracking references of the relevant literature. Full texts were reviewed, and clinical manifestations, diagnostic methods, and the relationship between the treatment and prognosis were summarized. A total of 14 patients with heterotopic cesarean scar pregnancies were identified, including 6 spontaneous pregnancies and 8 following in vitro fertilization–embryo transfer. Gestational ages at diagnosis ranged from 5 weeks to 8 weeks 4 days. Only 5 cases presented with vaginal bleeding, and the others were asymptomatic. All 14 cases were diagnosed by transvaginal sonography. One patient with no future fertility requirements underwent pregnancy termination by methotrexate. Of the remaining 13 patients who desired to preserve their intrauterine gestations, 10 were treated by sonographically guided selective embryo reduction in situ (by embryo aspiration, drug injection, or both); 2 underwent laparoscopic and hysteroscopic excision of the ectopic pregnancy masses; and 1 was treated by expectant management. All operations were successful and maintained a living intrauterine gestation. Twelve cases resulted in live births by cesarean delivery (3 at term and 9 preterm). One patient underwent pregnancy termination at 12 weeks because of a fetal malformation confirmed by sonography. The possibility of heterotopic cesarean scar pregnancy after cesarean delivery should be considered, especially when pregnancy follows assisted reproductive technology. Transvaginal sonography is an important tool for diagnosis and management. Despite the many options, the best treatment for this condition remains unclear. Selective embryo reduction in situ with sonographic guidance is the main treatment modality and can result in a successful intrauterine gestation, albeit at high risk.     

Sonographically guided minimally invasive treatment of unusual ectopic pregnancies.

OBJECTIVE: To present our experience with sonographically guided treatment of unusual ectopic pregnancies, defined as heterotopic pregnancies and pregnancies occurring at ectopic locations other than the extracornual portion of the fallopian tube. METHODS: We retrieved and reviewed all cases of unusual ectopic pregnancies that underwent sonographically guided therapy at our institution. Twenty-seven cases were identified, from 1992 through 2003, including 18 cervical, 6 cornual, 1 tubal heterotopic, and 2 cesarean scar implantations. RESULTS: All of the cervical ectopic, cornual ectopic, and tubal heterotopic pregnancies were treated by sonographically guided injection of potassium chloride into the ectopic gestational sac or fetus. Guidance was via transvaginal sonography in all 18 cervical pregnancies, 3 of the 6 cornual pregnancies, and the tubal heterotopic pregnancy, and via transabdominal sonography in 3 cornual ectopic pregnancies. One of the cesarean scar pregnancies was treated by transvaginally guided potassium chloride injection, and the other was treated via transabdominally guided dilation and evacuation. Treatment was successful in 25 of the 27 patients, including all 23 patients with an ectopic pregnancy and no concomitant intrauterine pregnancy. Four patients had concomitant intrauterine and ectopic pregnancies (1 cervical, 2 cornual, and 1 tubal); in 3 the intrauterine fetuses resulted in live-born infants, and in the fourth the intrauterine pregnancy was electively terminated. Eight of the 27 patients had subsequent intrauterine pregnancies. CONCLUSIONS: Sonographically guided minimally invasive treatments of unusual ectopic pregnancies are safe and effective alternatives to surgical and systemic medical therapy. These treatments ablate the ectopic pregnancy, permit normal continuation of a concomitant intrauterine pregnancy, and preserve the uterus for subsequent pregnancies.     

剖宫产切口疤痕妊娠与宫颈妊娠的超声监测

目的:分析剖宫产切口疤痕妊娠与宫颈妊娠的超声声像变化特征,评价经阴道彩色多普勒超声在子宫下部异位妊娠诊治中的监测价值。方法:总结1995~2005年6月本院住院诊治的子宫下段剖宫产切口疤痕妊娠和宫颈妊娠病例,分析其彩色多普勒超声声像特征,追踪其临床转归及手术、病理结果。结果:剖宫产切口疤痕妊娠9例,宫颈妊娠5例,均由临床手术病理证实,根据经阴道彩色多普勒超声声像学特征分为4型:I型为胚胎存活型(5例),II型为胚胎停育有孕囊型(2例),III型为类滋养细胞疾病型(4例),IV型为绒毛退变型(3例)。I型全宫切除3例,保守治疗2例,II型2例均行全宫切除;III型全宫切除1例,经腹宫颈切开取绒毛术1例,余2例保守治疗;IV型均为保守治疗。结论:经阴道彩色多普勒超声对子宫下部异位妊娠能够提供较准确的定位定性诊断,正确的超声分型有助于临床选择合适的治疗方案,估计病程及转归。