剖宫产术后子宫瘢痕妊娠中期妊娠引产的诊治评价  

Evaluation of the diagnosis and treatment of cesarean scar pregnancy induced in the second trimester:a national multicenter retrospective study

作　　者：白桂芹[1] 陈蔚琳[2] 黄向华[3] 赵绍杰 赵淑萍[5] 陈秀娟[6] 陈素文[7] 杨华[8] 卢霞[9] 刘冠媛[10] 陈琼华[11] 张林爱 金力[2] Bai Guiqin;Chen Weilin;Huang Xianghua;Zhao Shaojie;Zhao Shuping;Chen Xiujuan;Chen Suwen;Yang Hua;Lu Xia;Liu Guanyuan;Chen Qionghua;Zhang Lin'ai;Jin Li(Department of Obstetrics and Gynecology,the First Affiliated Hospital,Xi'an Jiaotong University,Xi'an 710061,China;Department of Obstetrics and Gynecology,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences,Beijing 100730,China;Department of Obstetrics and Gynecology,the Second Hospital of Hebei Medical University,Shijiazhuang 050000,China;Department of Gynecology,Wuxi Maternal and Child Health Hospital,Nanjing Medical University,Wuxi 214001,China;Department of Gynecology,Qingdao Women and Children's Hospital,Qingdao University,Qingdao 266034,China;Department of Gynecology,Fujian Provincial Maternity and Children's Hospital,Fuzhou 350000,China;Department of Family Planning,Beijing Obstetrics and Gynecology Hospital,Capital Medical University,Beijing 100026,China;Department of Family Planning,Tianjin Central Hospital of Gynecology Obstetrics,Tianjin 300052,China;Department of Obstetrics and Gynecology,the Sixth Affiliated Hospital of Xinjiang Medical University,Urumqi 830002,China;Department of Obstetrics and Gynecology,Bejing Chaoyang Hospital,Capital Medical University,Beijing 100020,China;Department of Obstetrics and Gynecology,the First Affiliated Hospital of Xiamen University,Xiamen 361003,Chian;Department of Family Planning,Children's Hospital of Shanxi,Women Health Center of Shanxi,Taiyuan)

机构地区：[1]西安交通大学第一附属医院妇产科,710061 [2]中国医学科学院北京协和医院妇产科,100730 [3]河北医科大学附属第二医院妇产科,石家庄050000 [4]南京医科大学附属无锡妇幼保健院妇科,214001 [5]青岛大学附属青岛妇女儿童医院妇科中心,266034 [6]福建省妇幼保健院妇科,福州350000 [7]首都医科大学附属北京妇产医院计划生育科,100026 [8]天津市中心妇产科医院计划生育科,300052 [9]新疆医科大学附属第六医院妇产科,乌鲁木齐830002 [10]首都医科大学附属北京朝阳医院妇产科,100020 [11]厦门大学附属第一医院妇产科,361003 [12]山西省儿童医院山西省妇幼保健院计划生育科,太原030013

出　　处：《中华妇产科杂志》2021年第8期545-553,共9页Chinese Journal of Obstetrics and Gynecology

基　　金：国家自然科学基金(81771615);陕西省重点科技创新团队(2019TD-031)。

摘　　要：目的研究剖宫产术后子宫瘢痕妊娠中期妊娠引产的诊治情况和发生不良妊娠结局的危险因素。方法采用全国多中心回顾性研究方法,选取12家三级甲等医院因各种原因引产的中孕期剖宫产术后子宫瘢痕妊娠的单胎孕妇154例,观察其妊娠结局并采用logistic回归分析发生严重不良结局的危险因素;评价引产前超声和MRI检查在预测胎盘植入及严重不良结局中的作用;比较子宫动脉栓塞术(UAE)对有、无胎盘植入孕妇预防引产中出血的作用。结果154例孕妇中,胎盘植入发生率为42.2%(65/154),产后出血≥1000 ml的发生率39.0%(60/154),子宫切除率为14.9%(23/154),子宫破裂发生率为0.6%(1/154)。产后出血≥1000 ml且切除子宫的危险因素仅为胎盘植入(P<0.01)。产次每增加1次,中孕期剖宫产术后子宫瘢痕妊娠发生胎盘植入的风险是产次未增加者的2.385倍(95%CI为1.046~5.439;P=0.039);随着引产前超声测量的子宫瘢痕厚度的增加,中孕期剖宫产术后子宫瘢痕妊娠发生胎盘植入的风险降低(OR=0.033,95%CI为0.001~0.762;P=0.033)。超声且MRI检查提示胎盘植入孕妇的产后出血量及子宫切除率与单纯超声检查或单纯MRI检查提示胎盘植入者无显著差异(P均>0.05)。合并胎盘植入的孕妇中,行UAE者产后出血量(中位数为1300 ml)和子宫切除率[34%(16/47)]与未行UAE者差异均无统计学意义(P均>0.05);而在未合并胎盘植入的孕妇中,行UAE者产后出血量低于未行UAE者(中位数分别为100、600 ml;P<0.01),但子宫切除率无明显差异[分别为2%(1/56)、9%(3/33);P>0.05]。结论(1)剖宫产术后子宫瘢痕妊娠中期妊娠引产中胎盘植入是产后出血≥1000 ml且切除子宫的唯一危险因素;多次分娩以及超声测量的子宫瘢痕厚度是发生胎盘植入的危险因素。(2)使用超声、MRI检查预测中孕期剖宫产术后子宫瘢痕妊娠发生胎盘植入的技术有待于提高。(3)UAE预防剖宫产术后子宫Objective To study the risk factors of adverse pregnancy outcomes for induced abortion of cesarean scar pregnancy in midtrimester.Methods A national multicenter retrospective study was conducted.A total of 154 singletons pregnant women with cesarean scar pregnancy during the second trimester induced abortion by various reasons in 12 tertiary A hospitals were selected,their pregnant outcomes were observed and the risk factors of serious adverse outcomes were analyzed with univariate and multivariate logstic regression;the role of ultrasound and MRI in predicting placenta accreta and severe adverse outcomes was evaluated,the effectiveness of uterine artery embolization(UAE)in preventing hemorrhage in pregnant women with and without placenta accreta was compared.Results Among 154 subjects,the rate of placenta accreta was 42.2%(65/154),the rate of postpartum hemorrhage≥1000 ml was 39.0%(60/154),the rate of hysterectomy was 14.9%(23/154),the rate of uterine rupture was 0.6%(1/154).The risk factor of postpartum hemorrhage≥1000 ml and hysterectomy was placenta accreta(P<0.01).For each increase in the number of parity,the risk of placenta accreta increased 2.385 times(95%CI:1.046-5.439;P=0.039);and the risk of placenta accreta decreased with increasing ultrasound measurement of scar myometrium thickness(OR=0.033,95%CI:0.001-0.762;P=0.033).The amount of postpartum hemorrhage and hysterectomy rate in the group with placenta accreta diagnosed by ultrasound combined with MRI were not significantly different from those in the group with placenta accreta diagnosed by ultrasound only or MRI only(all P>0.05).For pregnant women with placenta accreta,there were no significant difference in the amount of bleeding and hysterectomy rate between the UAE group[median:1300 ml;34%(16/47)]and the non-embolization group(all P>0.05);in pregnant women without placenta accreta,the amount of bleeding in the UAE group was lower than that in the non-embolization group(median:100 vs 600 ml;P<0.01),but there was no significant difference in hy

关 键 词：妊娠 异位 剖宫产术 妊娠中期 引产 侵入性胎盘 产后出血 回顾性研究 

分 类 号：R719.3[医药卫生—妇产科学]