可逆性子宫动脉结扎术在Ⅱ型及Ⅲ型子宫瘢痕处妊娠中的应用研究

Study on the application of reversible uterine artery ligation in type Ⅱ and Ⅲ cesarean scar pregnancy

摘要

目的 探讨腹腔镜下可逆性子宫动脉结扎用于Ⅱ型及Ⅲ型子宫瘢痕处妊娠(CSP)的可行性和安全性。方法 回顾性分析2020年1月至2022年12月期间,在宁波市妇女儿童医院接受手术治疗的Ⅱ型或Ⅲ型子宫瘢痕处妊娠病例,选择其中行宫腹腔镜联合手术,且术中行可逆性子宫动脉结扎术的28例作为研究对象.术中首先行腹腔镜下可逆性子宫动脉结扎术,然后再行瘢痕处妊娠物清除、瘢痕组织切除和修复手术.分析比较Ⅱ型与Ⅲ型患者的手术时间、术中出血量、并发症等围手术期情况,以及术后24小时血清人绒毛膜促性腺激素(β-hCG)下降情况、再次妊娠情况等手术结局。结果 本研究CSP患者年龄(35.03±5.51)岁,停经时间平均(54.48±15.34)天,治疗前血清β-hCG平均(114148.69±80957.08)mIU/mL;分型情况为Ⅱ型19例,Ⅲ型9例,两组一般临床资料比较差异无统计学意义(P>0.05).28例患者中27例顺利完成手术,术中平均出血量(174.19±145.48)mL,手术时间(136.30±39.56)min,术后24小时血清β-hCG下降(62.44±14.80)%;1例患者尽管已行子宫动脉结扎,但在宫腔镜下行妊娠物清除时,仍然出现阴道持续大量流血,经宫腔球囊填塞后出血停止,共出血1200mL;所有患者均未出现膀胱损伤等严重并发症;Ⅲ型CSP患者术中出血量、手术时间大于Ⅱ型患者,差异有统计学意义(t值分别为2.243、3.381,P<0.05),其余手术指标差异无统计学意义(P>0.05).经平均(26.71±9.28)个月的随访,8例有再生育意愿的患者中,有2例再次妊娠,其中1例患者足月剖宫产,1例患者再次发生子宫瘢痕处妊娠。结论 腹腔镜下可逆性子宫动脉结扎术用于Ⅱ型及Ⅲ型子宫瘢痕处妊娠安全有效,可作为子宫动脉栓塞的一种替代方法,但对于β-hCG高、包块大、胎心阳性、影像学检查提示胎盘植入者需慎重.

Abstract

Objective To investigate the feasibility and safety of laparoscopic reversible uterine artery ligation for type Ⅱ or Ⅲ cesarean scar pregnancy (CSP). Methods A retrospective analysis was performed for the type Ⅱ or Ⅲ cesarean scar pregnancy cases treated with surgery at Ningbo Women and Children's Hospital from January 2020 to December 2022, and 28 cases of type Ⅱ or Ⅲ cesarean scar undergoing intraoperative laparoscopic surgery and reversible uterine artery ligation were selected as the study subjects. During the operation, laparoscopic reversible uterine artery ligation was performed first, followed by scar removal of the scarred pregnancy, excision and repair of scar tissue. The operation time, intraoperative blood loss, complications and other perioperative conditions, as well as the decrease in serum human chorionic gonadotropin (β-hCG) 24 hours after operation and the recurrence of pregnancy in patients with type Ⅱ and type Ⅲ were analyzed and compared. Results In this study, the average age of CSP patients was 35.03±5.51 years, the average duration of menstruation was 54.48±15.34 days, and the average serum β-hCG level before treatment was 114148.69±80957.08 mIU/mL. There were 19 cases of type Ⅱ and 9 cases of type Ⅲ. There was no significant difference in general clinical data between the two groups (P>0.05). Among the 28 patients, 27 patients successfully completed the operation, with an average intraoperative blood loss was 174.19±145.48 mL, the operation time was 136.30±39.56 min, and the serum β-hCG decreased by 62.44±14.80% 24 hours after the operation. In one patient, despite uterine artery ligation, there was continuous heavy vaginal bleeding during hysteroscopic removal of the pregnancy product, and the bleeding stopped after balloon tamponade, with a total bleeding of 1200 mL. None of the patients had serious complications such as bladder injury. There was a statistically significant difference in the intraoperative blood loss and operation time of type Ⅲ CSP patients compared with type Ⅱ patients (t=2.243, 3.381, P<0.05), but there was no significant difference in other surgical indexes (P>0.05). After an average follow-up of 26.71±9.28 months, two of the eight patients with reproductive intention were pregnant again, including one patient with full-term cesarean section and one patient had a recurrent pregnancy in the uterine scar again. Conclusion Laparoscopic reversible uterine artery ligation is safe and effective for type Ⅱ or Ⅲ cesarean scar pregnancy and can be used as an alternative to uterine artery embolization. However, it should be cautious for patients with high β-hCG level, large mass, positive fetal heartbeat, and placenta accreta on imaging.

关键词

子宫动脉结扎 / 子宫瘢痕处妊娠 / 可逆性 / 腹腔镜

Key words

uterine artery ligation / cesarean scar pregnancy / reversibility / laparoscopy

参考文献

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基金资助

宁波市妇科疾病临床医学研究中心(2024L002)