Type ? Cesarean Scar Pregnancy Subtyping And Its Guiding Value In Clinical Management

Background and PurposeCesarean scar pregnancy(CSP)refers to an ectopic pregnancy where the fertilized egg is implanted in the scar of the previous cesarean section incision,only in early period of pregnancy(?12 weeks).In recent years,with the gradual increase in the rate of cesarean section and the implementation of the two-child policy in China,the incidence of CSP has increased significantly.However,the pathogenesis of the disease is still unclear,and there is no united diagnosis and treatment of the disease at home and abroad.If not handled properly,CSP could cause severe complications that are difficult to control during or after surgery,such as uterine rupture,and even hysterectomy and death.Based on the retrospective analysis of clinical data,this team proposed clinical practical classification(Qilu classification)of CSP,we gave patients different surgical treatments according to the clinical practical classification and achieved good clinical efficacy.Among all types,type ? CSP is the most difficult one in clinical management,prone to massive hemorrhage during or after surgery.This article aims to find the risk factors that cause massive hemorrhage in the management of CSP by retrospective analysis of cases of type ? CSP in practical clinical classification,subtype it for diagnosis and treatment,and discuss the appropriate methods.MethodsThis research collected and retrospectively analyzed 122 cases of type ? CSP who were hospitalized in Qilu Hospital of Shandong University from January 2013 to December 2019.All patients were diagnosed as CSP according to the criteria of the Family Planning Branch of the Chinese Medical Association,they also met the criteria of type ? CSP in clinical practical classification.The most dangerous situation in the diagnosis and treatment of CSP is intraoperative massive hemorrhage,which can endanger the patient's life in severe cases.Therefore,this study used the amount of intraoperative blood loss as an indicator.Possibly relevant clinical indicators,including:age,the time since last menstruation,number of cesarean sections,time since last cesarean section,size of gestational sac or mass measured by ultrasound,presence or absence of FHB,presence or absence of AVM,presence or absence treatment before admission(medical abortion or dilation and curettage);preoperative blood ?-HCG levels,we tried to find risk factors that may cause massive hemorrhage and subtype type ? CSP according to the presence or absence of risk factors for finding appropriate treatments.Results1.Risk factors of massive hemorrhage in type ? CSPThe results of single factor analysis showed that the rate of massive hemorrhage in type ? CSP surgery was related to the size of the gestational sac or the diameter of the mass.The larger the mass,the higher the risk of massive hemorrhage(P=0.000);it is also related to whether it is combined with arteriovenous malformation,the risk of massive hemorrhage increased significantly when combined with arteriovenous malformation(P=0.000),and there was no significant correlation with other clinical and laboratory parameters(P>0.05).Multivariate logistic regression analysis showed the size of the gestational sac or the diameter of the mass(P=0.029),and the existence of arteriovenous malformation were independent factors affecting the rate of massive hemorrhage(P=0.019).The receiver operating characteristic curve using the size of mass or the gestational sac to predict the rate of massive hemorrhage shows the area under the curve for the size of mass or the gestational sac is 0.876,P=0.000,95%CI:0.813-0.939.When the diameter of the sac or mass is 6cm,the sensitivity is 0.794,the specificity is 0.852.2.Type ? CSP subtypingAccording to the presence or absence of arteriovenous malformation,whether gestational sac or mass diameter is greater than 6cm,type ? CSP is subtyped.The gestational sac or mass is greater than 6cm in diameter and/or combined with arteriovenous malformation belongs to type ?B,otherwise it belongs to type ?A.This research retrospectively analyzed the intraoperative,postoperative and follow-up results of the two groups.The success of the operation was defined as no need to change the surgical method to complete the operation.The success rate of type ?B CSP was significantly lower than that of type ?A(P<0.05).Type ?B has longer operative time,longer postoperative hospital stay,higher total hospitalization cost,and more surgical massive hemorrhage than type ?A(P<0.05).Follow-up results showed that there were no statistically significant difference between type ?A and type ?B in the time of P-HCG reducing to normal,re-pregnancy rate,and change of menstrual blood loss(P>0.05).There were no patients unplanned re-admitted in the two groups.Conclusions1.Arteriovenous malformation and(or)gestational sac or mass greater than 6cm in diameter are risk factors for predicting rate of massive hemorrhage in type ? CSP.2.Subtype type ? CSP into ?A and ?B.Type ?B is more dangerous than type?A.3.Type ? CSP subtyping is beneficial to the selection of clinical surgical methods and has high clinical practical value.