| Objective: With the rising of the cesarean delivery rates and the introduced of our country' two-child policy,the incidence of Cesarean Scar Pregnancy has rising in recent decades.The true etiological factor of CSP has not yet been clear,and no guidelines for the management have been published up to now.Because of nonspecific presentation,may cause uterine rupture,heavy bleeding and even life-threatening if handled properly,and early diagnosis and effective treatment is particularly important.This paper defines conservative treatment as the treatment of patients with CSP,compare with laparotomy and hysterotomy,only need medical treatment or combine with uterine curettage and hysteroscopy will be cured and not through the abdominal operation process.This paper aims to explore: the clinical feature,early diagnostic methods and the appropriate treatment of CSP,firstly;to evaluate clinical effect of our hospital patients with CSP separately to accept two different conservative treatment scheme,secondly.To verify the conservative treatment is an economical,simple,reliable,fewer complications,and good treatment effect and can be popularized in clinical work.Methods:Retrospectively analyzing the clinical data of all cases with CSP disgnosed by transvaginal ultrasound in the bethune international peace hospital from Jun.2011 to Aug.2015.Gestational age,gravidity,parity,the number of previous cesarean sections,the time interval from the last cesarean section,type,chief complaint,the maximum diameter of pregnancy mass,thickness of the scar at the lower uterine segment,the level of serum ?-HCG and the methods of treatment of the patients are analyzed descriptively.Further explore the clinical features of CSP and the clinical effect of conservative treatment.The statistical data is dealed with SPSS 21.0.When the measurement datais data is normal distributionis was described by-x ±s,the data isnon-normal distribution was described by median description(range).If the data meet the normal distributiong and homogeneity of variance,the independent sample t text,Nonnormality is using Mann-Whitnet U test.Enumeration data were compared with fourfold table chi-square test(When n?40 but there is 1?T<5,with Continuity Correction,or the Fisher's Exact Test).a=0.05(bilateral)as the test level,P<0.05 was considered statistically significant.Results:There were 170 patients disgnosed by transvaginal ultrasound accepted at bethune international peace hospital from Jun.2011 to Aug.2015.11 patients were loss to follow up.There were 159 patients were confirmed to be CSP and obtain complete information finally.1 Clinical characteristics of CSP1.1 The general features of CSP.The study into the group of 159 patients,The average age of 159 patients was(32.26±4.05)years,the median times of gravidity was 4(range 2-11),the median parity was 2(range 1-3),there were90 women had undergone only one previous cesarean section,and 65 women had undergone cesarean section twice,and and 4 women had undergone cesarean section three times,The median time interval from the last cesarean section to the diagnosis of cesarean scar pregnancy was 4 years,ranged from 4months to 16 years.The average period of amenorrhea was(50.72±8.43)days,the median plasma ?-HCG was 21072(range 171.4-106957)mIU/ml,the median maximum diameter of pregnancy mass was 2.7(range 0.5-7.1)cm,the median thickness of the scar at the lower uterine segment was 0.3(range0-0.79)cm.1.2 The type of CSP The study into the group of 159 patients,?type: Scar of intrauterine pregnancy sac type survival,was 106(66.67%),?type: Scar pregnancy cyst in the muscle layer,was 16(10.06%),? type: The mass type or similar trophocyte disease type,was 37(23.27%).1.3 The clinical characteristics of CSP The chief complaint of 159 patients was a history of amenorrhea and vaginal bleeding,with or without abdominal pain,or vaginal bleeding after artificial abortion or suction curettage.Thewere 66 patients(41.51%)accompanied with painless vaginal bleeding,and 13patients(8.18%)with abdominal pain,3 patients(1.88%)with abdominal pain only,43 patients(27.04%)with vaginal bleeding after artificial abortion or suction curettage,34(21.38%)cases with asymptomatic.2 The methods for treatment of CSP 79 cases accept local MTX embryocides plus uterine curettage(as A group),59 cases accept local MTX embryocides plus hysteroscopy(as B group),the others included 7 patients undergone local MTX embryocides only,8 patients used of combined laparoscopy and hysteroscopy,1 patient undergone uterine artery embolization plus local MTX embryocides plus uterine curettage,3 for laparotomy,1 for hysterectomy,1for hysterotomy.We will compare two methods in clinical work: local MTX embryocides plus uterine curettage,local MTX embryocides plus hysteroscopy.2.1 The general features of two groups2.1.1 The gestational age,median gravidity,median parity,one previous cesarean section,twice previous cesarean section,three times previous cesarean section,the difference of two groups was not statistically significant(P>0.05);The time of interval from last cesarean section,The period of amenorrhea,The maximum diameter of pregnancy mass,the a thickness of the scar at the lower uterine segment,The average level of serum ?-HCG,the difference of two groups was not statistically significant(P>0.05).2.1.2 The clinical presentations of two groups: with vaginal bleeding were 41(51.9%)and 25(42.4%);with the accompanying abdominal pain were 12(15.2%)and 7(11.9%),the difference of two groups was not statistically significant(P>0.05).2.2 The comparison of two groups of treatment2.2.1 The success rates of two groups: the cases of the success were 71(89.9%)and 56(94.9%)respectively,the difference of two groups was not statistically significant(P>0.05).2.2.2 The comparison of two groups of serum ?-HCG decline rate after treatment,the time of serum ?-HCG recovery normal,the time of CSP massclearance1)The serum ?-HCG decline rate 2 days postoperative were 90.14% and91.34% respectively,the difference of two groups was not statistically significant(P>0.05).2)the time of serum ?-HCG recovery normal were 24.99±7.89 and21.05±8.12 respectively,the difference of two groups was statistically significant(P<0.05).3)the time of CSP mass clearance were 20.59±12.03 and 16.80±9.79 respectively,the difference of two groups was not statistically significant(P<0.05).The number of cases of mass clearance after 2-3 days,A group(n=79)has 10 cases(12.7%)and B group(n=48)has 7 cases(14.6%),the difference of two groups was not statistically significant(x2=0.095,P>0.05).2.2.3 The comparison of two groups of intraoperative blood loss,the total hospitalization days,the hospitalization expenses1)the median blood loss were 60(10-500)ml and 55(10-600)ml respectively,the difference of two groups was statistically significant(P<0.05).2)the median total hospitalization days were 9(6-21)and 8(4-22)respectively,the difference of two groups was statistically significant(P<0.05).3)the average hospitalization expenses were 4810.02±1487.05 yuan and6055.52±2102 yuan,respectively,the difference of two groups was statistically significant(P<0.05).2.3 The teatment efficancy of two groups2.3.1 The local MTX embryocides plus uterine curettage group(A group):There 71 cases succeed,and 8 case failed in A group.The average maximum diameter of pregnancy mass were(2.55±0.89)cm and(3.24±1.56)cm respectively,the difference of sucess cases and failed cases was not statistically significant(P>0.05);the average thickness of the scar were(0.31±0.09)cm and(0.32±0.04)cm respectively,the difference of sucess cases and failed cases was not statistically significant(P>0.05);the median level ofserum ?-HCG were 17597(261-101076)mIU/ml and 4853.5(1545-100973)mIU/ml respectively,the difference of sucess cases and failed cases was not statistically significant(P>0.05).It is said that this three indicators had no obvious impact on A group.2.3.2 The local MTX embryocides plus hysteroscopy group(B group): There56 cases succeed,and 3 case failed in A group.The average maximum diameter of pregnancy mass were(2.59±0.98)cm and(4.73±0.15)cm respectively,the difference of sucess cases and failed cases was statistically significant(P<0.05);the average thickness of the scar were(0.37±0.19)cm and(0.13±0.15)cm respectively,the difference of sucess cases and failed cases was statistically significant(P<0.05);the median level of serum ?-HCG were24237(171.4-106957)mIU/ml and(64557.67±12580.75)mIU/ml respectively,the difference of sucess cases and failed cases was statistically significant(P<0.05).It is said that the maximum diameter of pregnancy mass and the thickness of the scar and the level of serum ?-HCG all had affected the curative effect of the B group.2.3.3 The comparison of two groups of success rate with different typeThe success rate of two groups of ? type was 90.3% and 97.3%,respectively,the difference of two groups was not statistically significant(P>0.05);The success rate of two groups of ? type was 85.7% and 83.3%,respectively,the difference of two groups was not statistically significant(P>0.05);The success rate of two groups of ? type was 90.0% and 93.8%,respectively,the difference of two groups was not statistically significant(P>0.05).Prompt the different type and the success rate of A group,B group has no obvious correlation.Conclusions:1 The local MTX embryocides plus uterine curettage and the local MTX embryocides plus hysteroscopy group of two conservative treatment have significant effects on the treatment of CSP.Compare with laparoscopy,laparotomy and hysterotomy,simple to operate,convenient and high economic benefits,especially fits in the basic level hospital.2 Compare with local MTX embryocides plus uterine curettage,the local MTX embryocides plus hysteroscopy can completely clean all villi tissure during the hysteroscopy under direct vision,the time of serum ?-HCG recovery normal is short,the mass absorbed quickly,ruduce the risk of persistent scar pregnancy,can be popularized in clinical application.3 All CSP patients composite the pregnant mass is big,the thickness of the scar is thin and the level of serum ?-HCG is high,the success rate of conservative treatment is low. |
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