胎盘植入临床分析——附11例报告

目的:探讨胎盘植入病例的特点和治疗方法。方法:回顾性分析1999.03-2009.04收治11例胎盘植入病例资料。结果:3例早期妊娠胎盘植入均有剖宫产手术史,停经后有不规则阴道流血史;其中1例早期妊娠胎盘植入虽经超声提示孕囊位于子宫下段但仍误诊行人工流产及清宫手术时大出血;3例晚期妊娠分娩人工剥离胎盘时表明胎盘与子宫壁无间隙,经手术后病理证实胎盘植入;4例中期妊娠清宫时牵拉组织物有阻力,经彩色多普勒超声检查明确诊断;1例中期妊娠剖宫取胎时示胎盘与子宫壁无间隙,经手术后病理证实胎盘植入;3例早期妊娠者通过彩色多普勒超声检查确诊。早期处理的2例均手术切除子宫,近5年的9例行保守性手术和/或药物保守治疗成功保留患者生育功能。结论:对有剖宫产手术史患者停经后阴道流血就诊时,有必要行彩色多普勒超声检查;彩色多普勒超声检查有助于诊断胎盘植入;保守性手术和保守治疗可有效地避免子宫切除;严格剖宫产指征及重视避孕可预防胎盘植入的发生。     

疤痕子宫妊娠的临床诊治

目的：探讨剖宫产后疤痕子宫再次妊娠的临床诊治措施。方法：通过对60例剖宫产后疤痕子宫再次妊娠患者的资料进行回顾性分析,总结此类患者的临床表现和治疗方案。结果：60例患者中有52例经阴道超声检查或彩色多普勒确诊,误诊8例,均误诊为宫内妊娠,误诊率13.33%。60例患者中采用氨甲蝶呤＋米非司酮局部用药50例,全身用药8例,2例切除子宫,58例患者保留了生育能力。结论：经阴道超声检查或彩色多普勒是早期诊断剖宫产后疤痕子宫再次妊娠的理想方法,氨甲蝶呤＋米非司酮是其保守治疗的首选用药。     

剖宫产后子宫切口妊娠绒毛植入11例临床分析

目的:探讨诊治剖宫产子宫切口妊娠绒毛植入的方法.方法:回顾性分析我院2000～2005年间收治的11例剖宫产子宫切口妊娠绒毛植入患者的临床资料.结果:彩色多普勒超声检查8例确诊(72.73%),2例误诊为滋养细胞肿瘤,1例误诊为假性动脉瘤并血栓形成;4例子宫前壁包块直径较小者保守治疗成功,余行手术治疗.结论:超声是诊断剖宫产子宫切口早期妊娠绒毛植入的主要方法;根据病灶大小、临床症状选择适当的治疗方案;在未明确诊断时切忌盲目清宫、引产等操作.     

剖宫产术后子宫瘢痕妊娠15例临床分析

目的:探讨剖宫产术后子宫瘢痕妊娠(CSP)早期诊断以及治疗方法。方法:回顾2005年1月至2010年12月间收治的15例剖宫产术后子宫瘢痕妊娠患者资料进行临床分析。结果:本文所有病例的临床表现无特殊性,但凡有剖宫产史的再次妊娠并出现阴道不规则流血即为警惕信号。所有病例均痊愈出院,未出现严重并发症;保留子宫的患者均恢复了正常月经。结论:剖宫产术后子宫瘢痕妊娠是一种发生少的剖宫产远期并发症,临床表现缺乏特殊性,常有误诊;对有剖宫产史的再次妊娠者应通过查体、阴道镜检查及阴道彩色超声波检查以排除本病;确诊后采用MTX加米非司可酮保守治疗或手术治疗。     

剖宫产瘢痕妊娠39例临床诊疗分析

目的:总结剖宫产瘢痕妊娠(CSP)的临床特点,探讨CSP的早期正确诊断方法及恰当的治疗方法。方法:回顾性分析2002年1月至2009年2月我院收治的39例剖宫产瘢痕妊娠患者临床资料及临床诊疗经过。结果:患者的平均年龄是31.5±5.0岁,均有子宫下段剖宫产史。患者均有停经史,26例发生停经后阴道点滴到中度流血。28例误诊为正常早孕或难免流产而行人流或药流,2例阴道大出血急行剖腹探查术,术后病理确诊,其余患者由彩色超声多普勒确诊,依据血β-HCG值高低分组采用米非司酮加甲氨蝶呤全身和/或局部应用的个体化治疗,两例另行子宫动脉栓塞术。患者均痊愈出院,随诊血β-HCG值至正常。结论:剖宫产术后子宫瘢痕妊娠临床表现缺乏特异性,容易误诊,应当加强对本病的认识,结合病史、查体及辅助检查以期早期诊断,可根据患者血β-HCG值选取不同的治疗方案。     

不同途径彩色多普勒超声诊断剖宫产瘢痕妊娠44例比较分析

目的:探讨3种不同途径的彩色多普勒超声诊断方法对剖宫产瘢痕妊娠(CSP)诊断的准确性。方法:选择2009年1月至2013年12月,泰山医学院附属医院以及泰安市中心医院共收治经临床以及术后病理证实的CSP患者44例,根据彩色多普勒超声的不同途径分为经腹组(13例)、经阴道组(17例)、经腹联合经阴道组(14例),比较3组的诊断准确率和误诊率,以及误诊导致的误治情况。结果:1经腹组诊断准确8例(61.5%),误诊5例(38.5%);经阴道组诊断准确13例(76.5%),误诊4例(23.5%),经腹联合经阴道组诊断准确13例(92.9%),误诊1例(7.1%)。210例误诊患者中,经腹组误诊为稽留流产的3例患者以及经阴道组误诊为稽留流产的1例患者口服戊酸雌二醇后行负压吸引术时发生大出血,其中3例术后给予纱条填塞宫腔压迫方止血,另1例因出血难以控制中转开腹行局部病灶切除术加子宫修补术。经腹组误诊为宫颈妊娠的2例患者,经阴道组误诊为宫颈妊娠的3例患者以及经腹部联合阴道组误诊为宫颈妊娠的1例患者均行子宫动脉栓塞术并动脉内注射甲氨蝶呤,然后行负压吸引术,方治疗成功。结论:经腹联合经阴道彩色多普勒超声检查较经腹及经阴道彩色多普勒超声检查的诊断准确率高,而误诊率最低,推荐临床上选择经腹联合经阴道彩色多普勒超声检查作为诊断CSP检查方法。     

彩色多普勒超声对宫颈妊娠的诊断价值

目的:分析宫颈妊娠的超声声像图特征及彩色多普勒血流显像情况,探讨彩色多普勒超声对宫颈妊娠的诊断价值。方法:对43例可疑宫颈妊娠的患者应用彩色多普勒超声进行检查,将彩色多普勒超声诊断结果与病理诊断结果对照分析。结果:43例患者的彩色多普勒超声诊断宫颈妊娠有39例与病理诊断结果相符,诊断准确率为90.7%;4例病理诊断为不全流产。结论:彩色多普勒超声对宫颈妊娠的患者有极其重要的诊断价值,是目前早期诊断宫颈妊娠的首选检查方法。     

剖宫产瘢痕妊娠30例临床分析

目的探讨剖宫产瘢痕妊娠（cesarean scar pregnancy,CSP）的早期诊断、治疗方法与预后。方法回顾性分析30例CSP患者的临床表现、超声诊断、治疗方式及随访资料。结果 30例CSP患者中,29例（96.67%）经阴道超声检查诊断。30例患者中,I型18例,Ⅱ型12例。18例Ⅰ型患者中,15例直接超声引导下行清宫术治疗,其中1例清宫术中大出血,行经腹子宫局部病灶切除术＋子宫瘢痕修补术;3例行选择性子宫动脉栓塞术＋清宫术。12例Ⅱ型患者中,9例采用天花粉或甲氨蝶呤杀胚治疗;3例行阴式子宫局部病灶切除术＋子宫瘢痕修补术。30例患者均治疗成功,预后良好。结论剖宫产瘢痕妊娠的诊断依靠阴道超声检查,明确诊断后根据超声分型及临床表现选择合适的方式治疗。     

剖宫产瘢痕妊娠的诊断及处理

目的:探讨剖宫产瘢痕妊娠的发病机制、早期诊断以及恰当的治疗方法。方法:回顾分析1994年1月至2006年5月北京协和医院收治的25例剖宫产瘢痕妊娠患者的临床资料,包括:患者的发病年龄,孕产次,发病至剖宫产术的间隔时间,首发症状,发病部位,诊断过程,辅助检查、治疗方法,经过及结局。结果:剖宫产瘢痕妊娠占同期异位妊娠的1.1%,与同期正常妊娠数之比为1:1368。25例患者的平均年龄31.4岁,92%的患者仅有一次剖宫产手术史,发病至末次剖宫产术的间隔时间为4月至15年,最常见的临床表现为停经和阴道流血,其中11例发生阴道大出血。16例(64%)患者分别误诊为宫内早孕(14例)和滋养细胞肿瘤(2例)而给予相应处理,仅9例治疗前确诊。通过剖宫产病史,妇科检查和超声、磁共振等辅助检查综合分析可作出诊断。治疗方法包括全子宫切除和保守性治疗(全身或孕囊内甲氨蝶呤注射和保守性手术)。25例患者均治愈出院。结论:剖宫产瘢痕妊娠较少见,临床易误诊,对有剖宫产手术史的患者应结合妇科检查及辅助检查以早期诊断,强调根据患者情况予以个体化治疗,可获得较好疗效。     

剖宫产术后子宫瘢痕妊娠20例临床治疗分析

目的探讨剖宫产术后瘢痕妊娠的临床特点、早期诊断及治疗方法。方法对煤炭总医院2010年4月至2014年4月收治的20例剖宫产术后子宫瘢痕妊娠(cesarean scar pregnancy,CSP)患者的临床资料进行回顾性分析。结果超声确诊19例,1例B超可疑葡萄胎清宫后确诊瘢痕妊娠。4例单纯行清宫术;13例甲氨蝶呤+米非司酮治疗后行清宫术;1例清宫+米非司酮;2例阴道大出血患者行子宫动脉栓塞止血,其中1例行清宫术,另1例行清宫后结合MRI检查明确病灶与膀胱的关系,行开腹子宫瘢痕妊娠病灶切除术加子宫修补术。结论有剖宫产史的妇女因停经就诊时,要常规行超声检查,结合MRI检查可进一步明确诊断。子宫动脉栓塞可以迅速止血,药物加清宫可作为治疗子宫瘢痕妊娠的主要方法,必要时行子宫瘢痕病灶切除加子宫修补等治疗措施。     

Treatment of viable cesarean scar ectopic pregnancy with suction curettage.

OBJECTIVE: Pregnancy in previous cesarean scar is the rarest form of ectopic pregnancy. All reported cases in the literature that were treated with uterine curettage either become unsuccessful or complicated. We aimed to present a case of cesarean scar ectopic pregnancy that was successfully treated with suction curettage without any additional therapy. CASE: A 32-year-old asymptomatic woman, gravida 2, para 1 was referred to our hospital with the possible diagnosis of cervical ectopic pregnancy. Transvaginal and transabdominal sonographic examination revealed the diagnosis of viable ectopic pregnancy in a previous cesarean scar. Suction curettage with carman canulles was performed under transabdominal ultrasonographic guidance. beta-hCG decreased progressively postoperatively. CONCLUSION: Suction curettage under ultrasonography guidance can be used in termination of selected cases (early diagnosed, without symptoms that necessitates emergency intervention) of cesarean scar pregnancy.     

Cesarean scar pregnancy; Diagnosis and management between 2003 and 2015 in a single center

Objectives

We aimed to evaluate diagnosis and management of an ectopic pregnancy developing in a previous cesarean scar.

剖宫产瘢痕妊娠27例诊治分析

目的探讨剖宫产瘢痕妊娠(CSP)的合理诊治方法。 方法回顾性分析2005年1月至2011年9月中山大学孙逸仙纪念医院收治的27例CSP患者的临床资料,对其病史、临床表现、辅助检查、诊断、处理及结局等进行总结分析。外院转入组与我院首次接诊组患者的孕次、产次、距末次剖宫产时间、停经天数、入院时HCG值的比较应用t检验,两组的开腹手术比例、包块型比例的比较应用卡方检验。 结果27例患者中外院转入者13例,均在外院行药流或清宫术后,因反复阴道流血或突发性大量阴道流血转入我院;首次就诊我院者14例。我院首次接诊组与外院转入组比较,停经天数(57.1±17.8)d与(83.5±28.4)d,t＝2.910;开腹手术比例(1例与7例),χ²＝7.050;超声表现为包块型的比例(1例与13例),χ²＝23.280;P值均<0.05。27例中行宫腔镜电切术7例,其中2例因术中出血较多,转为开腹手术。开腹行病灶切除加修补术8例,行清宫术9例,其中单纯行清宫2例,2例术中出现大出血而紧急子宫动脉化疗栓塞术(UACE),其他5例则用甲氨蝶呤(MTX)治疗或UACE后行清宫术。行UACE 14例,其中13例UACE联合清宫术或宫腔镜或术后MTX治疗。单纯MTX药物治疗2例。27例均治愈,无子宫切除病例。 结论剖宫产瘢痕妊娠较少见,临床容易误诊,治疗应根据患者血HCG水平、病灶大小、部位、表面肌层厚度、血流、阴道流血情况等进行综合评价,选择个体化治疗方案,必要时几种治疗方法联合应用。     

Pitfalls in Ultrasound Diagnosis of Cesarean Scar Pregnancy

Cesarean scar pregnancy (CSP) is a rare kind of ectopic pregnancy implanted in the previous cesarean scar and has an increasing incidence over the past 30 years. As the suspicion is low, the diagnosis may be delayed or misinterpreted in ultrasound, leading to treatment strategies that might end up in uterine rupture or hysterectomy. The objective here is to review the ultrasound findings in CSP with varied presentations. Transabdominal and transvaginal sonography combined with color Doppler is a reliable tool for the diagnosis of CSP. When the gestational sac is seen in lower part of the uterine cavity, differentiation between threatened miscarriage, cervical pregnancy and CSP could be difficult. Not all cases of CSP present with typical ultrasound findings and a high index of suspicion is needed for diagnosis in these cases. An attempted curettage or MTP pill taken in an undiagnosed CSP often alters the typical findings. The possibility of CSP should also be considered in cases presenting with abnormal uterine bleeding and have a prior history of cesarean section. With lack of awareness about this condition, the diagnosis can often be missed either with MRI or in ultrasound. Correct interpretation and timely diagnosis save the mother from life-threatening complications and also preserves future fertility.     

29例剖宫产瘢痕妊娠诊断及治疗方式的探讨

目的探讨子宫下段剖宫产瘢痕妊娠的临床发病特点、诊断标准及其治疗策略的选择,为临床合理诊治提供依据。方法收集2007年1月至2010年6月华中科技大学同济医学院附属同济医院妇科病房收治的29例子宫下段剖宫产瘢痕妊娠患者的临床资料,分析其临床发病特点、诊断及其治疗过程。结果子宫下段剖宫产瘢痕妊娠发病率为1.43/1000次妊娠。29例患者均有停经,27例(93.10%)患者有不同程度的阴道出血,其中19例(65.52%)患者出血总量超过500ml,5例(17.24%)患者因失血过多致失血性休克,26例(89.66%)患者血β-hCG(14.03～200000U/L)水平升高。29例均由盆腔三维彩色多普勒超声检测诊断,诊断准确率100%。治疗方法中,药物治疗23例(成功3例,成功率10.34%),清宫术7例,双侧髂内动脉栓塞或结扎21例,剖宫产瘢痕妊娠病灶切除术18例。治疗后监测血β-hCG水平恢复正常时间为2～7周,平均(4.01±0.23)周,无严重不良反应。结论子宫下段剖宫产瘢痕妊娠的治疗方法多样化,其中甲氨蝶呤药物联合双侧髂内动脉结扎和剖宫产瘢痕妊娠病灶切除手术方法出血较少且疗效显著。应争取早期确诊,并及时选择合理的治疗方法。     

Cesarean scar ectopic pregnancies: etiology, diagnosis, and management

OBJECTIVE: To clarify the appropriate way to diagnose and treat an ectopic pregnancy in the uterine scar of a prior cesarean delivery. DATA SOURCES: Articles written in English that were published from January 1966 to August 2005 and quoted in the computerized database MEDLINE/PubMed retrieved by using the words "cesarean section," "cesarean delivery," "cesarean section scar pregnancy," and "ectopic pregnancy." Additional articles were obtained from reference lists of pertinent case reports and reviews. METHODS OF STUDY SELECTION: Fifty-nine articles that met the inclusion criteria provided data on the clinical presentation, diagnosis, and treatment modalities of 112 cases of cesarean delivery scar pregnancies. TABULATION, INTEGRATION, AND RESULTS: Review of the 112 cases revealed a considerable increase in the incidence of this condition over the last decade, with a current range of 1:1,800 to 1:2,216 normal pregnancies. More than half (52%) of the reported cases had only one prior cesarean delivery. The mean gestational age was 7.5 +/- 2.5 weeks, and the most frequent symptom was painless vaginal bleeding. Endovaginal ultrasonography was the diagnostic method in most cases, with a sensitivity of 84.6% (95% confidence interval 0.763-0.905). Expectant management of 6 patients resulted in uterine rupture that required hysterectomy in 3 patients. Dilation and curettage was associated with severe maternal morbidity. Wedge resection and repair of the implantation site via laparotomy or laparoscopy were successful in 11 of 12 patients. Simultaneous administration of systemic and intragestational methotrexate to 5 women, all with beta-hCG exceeding 10,000 milli-International Units/mL required no further treatment. CONCLUSION: Surgical treatment or combined systemic and intragestational methotrexate were both successful in the management of cesarean delivery scar pregnancy. Because subsequent pregnancies may be complicated by uterine rupture, the uterine scar should be evaluated before, as well as during, these pregnancies.     

剖宫产瘢痕妊娠治疗现状及进展

近年来对剖宫产瘢痕妊娠(CSP)的报道逐渐增多,也随之出现了各种不同的治疗方法,但在全球范围内仍无统一的治疗方案。药物治疗主要为甲氨蝶呤(MTX)的全身、局部及联合用药;介入治疗大大降低了常规治疗切除子宫的风险,是目前CSP患者大出血的首选止血措施;手术治疗主要包括清宫术、多种途径病灶切除的保守性手术及子宫切除术。虽然CSP的治疗方法已达31种之多,但仍然处于小样本研究,治疗方案的选择应遵循适合个体病情特点的个体化治疗原则。     

Hysteroscopic management of cesarean scar pregnancy after unsuccessful methotrexate treatment

Current management of cesarean scar pregnancy is conservative and consists of medical treatment with methotrexate (MTX). We present a report on a woman with this type of pregnancy who had continuous vaginal bleeding and persistent serum levels of beta human chorionic gonadotropin after undergoing curettage and MTX. Eventually, the remaining ectopic gestational tissue was removed by operative hysteroscopy.     

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.