子宫动脉化疗栓塞后清宫术与开腹病灶清除术治疗瘢痕妊娠的疗效比较

目的比较子宫动脉化疗栓塞后清宫术与开腹病灶清除术治疗瘢痕妊娠的临床疗效。 方法回顾性分析2009年1月至2012年1月北京协和医院收治的瘢痕妊娠（cesarean scar pregnancy, CSP）患者77例，分为两组：A组22例，直接行开腹瘢痕妊娠病灶清除术，B组55例，UACE后24~72小时行清宫术。比较两组患者的术中出血量、手术时间、血β-hCG降至正常时间、住院时间、并发症、是否需要二次治疗和术后月经情况等数据之间的差异。 结果两组患者均不需子宫切除术。A组有1例术中发生大出血，急诊行子宫动脉栓塞，二次治疗率为5%；B组清宫术中子宫瘢痕处穿孔行修补术1例、出血活跃转行开腹瘢痕病灶清除术1例、清宫后血β-hCG下降不满意3例，其中加用MTX治疗2例，再次清宫1例；二次治疗率为9%。两组患者手术时间有显著性差异[A组(114.45±34.32) min，B组(35.35±20.21) min，P<0.01]；术中出血量比较：[A组（186.53±43.30）ml显著多于B组（52.36±28.04）ml，P <0.01]；两组患者β-hCG下降至正常时间有显著性差异[A组(15.32±3.21)天，B组(24.11±7.32)天，P <0.01]。住院时间两组差异显著[(19.34±5.72)天VS (13.46±4.87)天，P <0.01]。所有患者均在术后半年内恢复正常月经周期。 结论子宫动脉化疗栓塞后清宫和开腹子宫瘢痕病灶清除治疗剖宫产瘢痕妊娠均安全有效。子宫动脉化疗栓塞后清宫术创伤小、手术时间短、术中出血量少、住院时间短，且对于急诊大出血的患者尤为适用。

Treatment of cesarean scar pregnancy: Comparison between dilation and curettage after uterine artery chemoembolization with laparotomy lesion excision

ObjectiveCompare the clinical outcomes of dilation and curettage (D&C) after uterine artery chemoembolization (UACE) and laparotomy lesion excision for treatment of cesarean scar pregnancy. Methods77 Patients with cesarean scar pregnancy between January 2009 and January 2012 were enrolled for retrospective analyses. The patients were divided into two groups: 22 patients in group A treated by laparotomy lesion excision; group B included 55 patients, who received UACE 24-72 hours before D&C. The main outcome measures were operation time, blood loss, time for β-human chorionic gonadotrophin (β-hCG) to decline to normal values, the duration of hospital stay, rate of secondary treatment, complications and menstrual situation after operation. ResultsNone of the 77 patients received hysterectomy. In group A, 1 patient had to receive uterine artery embolization due to massive hemorrhage. The rate of secondary treatment was 5% in group A. In group B, 1 patient received perforation repair, 1 received laparotomy lesion excision due to active bleeding. Theβ-hCG level persisted in 3 patients, 2 of them received MTX injection and 1 received D&C again. The rate of secondary treatment was 9% in group B. The operation time in group B was less than that in group A (35.35±20.21) min versus (114.45±34.32) min, P <0.01). The mean blood loss in group B was lower than that in group A (52.36±28.04) ml versus (186.53±43.30)ml, P<0.01). The average time for β-hCG to decline to normal had significant different between two groups (15.32±3.21)d in group A versus (24.11±7.32) d in group B, P <0.01). The duration of hospital stay of group B was less than that of group A(13.46±4.87) days versus (19.34±5.72) days, P<0.01). All patients regained normal menstruation within half a year. ConclusionsD&C after UACE and laparotomy lesion excision are both safe and effective treatments for CSP. D&C after UACE is minimally invasive, with less operation time, less duration of hospital stay and less blood loss in operation. Especially, UACE could provide remarkable clinic outcomes for the patients with acute vaginal bleeding.