| ObjectiveTo observe the pregnancy outcome of cesarean scar pregnancy with expectant management,evalute the pregnancy risk and explore the natural courses about different types of CSP patients with expectant management.MethodsTo review and analyze the clinical data of 40 CSP patients in Henan Provincial People’s Hospital from January 2015 to January 2020.Of the 40 patients,38 were single pregnancy,2 were twin pregnancy,of which 29 were type Ⅰ(including one twin pregnancy,dichorionic diamnionic twin pregnancy),8 were type Ⅱ(including one twin pregnancy,dichorionic diamnionic twin pregnancy)and 3 were type Ⅲ.All patients were diagnosed with cesarean scar pregnancy in first trimester by color Doppler ultrasound,and They were classified into three types according to the same ultrasound classification criteria:CSPI type,CSPⅡ type,CSPⅢ type;the 40 patients were divided into low risk group(29 patients,type CSPⅠ)and high risk group(11 patients,type CSPⅡ and type Ⅲ).Basic information about patients(e.g.age,pregnancy,delivery,cesarean section,distance from last cesarean section,duration of pregnancy,abortion,etc.)and clinical outcomes(placenta location and implantation,uterine rupture or hysterectomy,gestational weeks of delivery,weight of newborn,amount of bleeding during delivery,5 min Apgar of newborn,maternal and neonatal survival)were collected by consulting electronic medical records and telephone return visits.The study data are analyzed by SPSS22.0 statistical software,the metrological data are expressed by x±s,the classified data by frequency,the non-normal distribution by Mann-Whitney U test,and the classified data by χ2 test.P<0.05 was considered statistically significant.To evaluate the risk and pregnancy outcome of cesarean scar pregnancy with different types with expectant managementTo search the published chinese and english literature of cesarean scar pregnancy with expectant management from January 2005 to December 2019 through Embase、The Cochrane Library、pubmed full-text database,China national knowledge infrastructure(CNKI),China science and technology journal database(VIP)and wanfang database,and search the references manually.selected studies according to inclusion and exclusion criteria.Extract relevant data about basic information and pregnancy outcome information of patients and evaluate and analyze the clinical outcome indicators.RevMan5.3 statistical software was used to systematically evaluate the inclusion literature.Heterogeneity tests were performed on the studies with different types of CSP patients,when I2≤50%且 P>0.05 was considered to have homogeneity,the combined analysis between the results of the study used a fixed effect model,and the forest map was drawn for pregnancy outcome indicators.Result33 of 40 CSP patients with expectant management successfully had newborns in the third trimester,including type Ⅰ 26,type Ⅱ 6,type Ⅲ 1.7 patients lost embryos and fetuses in the first and second trimester:2 cases of embryo termination(type Ⅰ、type Ⅱ)in the first trimester,1 case terminated pregnancy due to premature rupture of membranes(type Ⅰ)in the second trimester,1 patientunderwent exploratory laparotomy due to uterine rupture(type Ⅲ)in the second trimester,3 patients terminated pregnancy due to vaginal bleeding,including 2 of 3 cases were in the second trimester(type Ⅰ,type Ⅱ),and 1 of 3 cases was in the second trimester(type Ⅲ).Additionally,1 case of hysterectomy due to postpartum hemorrhage(typeⅢ,pregnancy 28+2 weeks,the newborn is alive).There were no statistically significant about the difference in age,pregnancy,delivery,cesarean section,gestational week of delivery,5 min Apgar score of newborn and birth weight of low-risk group(type Ⅰ)and high-risk group(type Ⅱ、type Ⅲ)(P>0.05).There was no statistically significant difference in the volume of postpartum hemorrhage between the two groups(1576.9±959.3)ml、(3214.3±3095.9)ml,(P>0.05).According to the condition of operation and the pathology of placenta after operation,compared with placental penetration in the third trimester,the difference was statistically significant(P<0.05),33 cases showed different degree of placenta accreta,no maternal death,all newborns survivedThis study systematically evaluated the clinical outcome indicators of 175 patients in 16 literatures,excluding 1 case that had not yet delivered,The rate of the remaining 174 CSP with expectant management successfully having newborns was 77.0%(134/174),174 cases underwent cesarean section,The range of bleeding volume was 300～13000 ml.72 cases of 174 patients underwent hysterectomy(41.4%,72/174).2 neonatal deaths(1.1%,2/174),both two neonates died of premature delivery,low birth weight infants.A pregnant woman died 10 days postpartum(0.6%,1/174)due to postpartum hemorrhage,secondary renal failure,respiratory failure,DIC.Of these,5 documents describe the pregnancy outcome of 77 CSP patients with different types in detail.The difference was statistically significant(P<0.05),the low-risk group had lower expected rate of placenta accreta than the high-risk group.However,There was no significant difference about hysterectomy rate between the low-risk group and the high-risk group(p>0.05).The results showed that CSP low-risk group had higher expected rate than the high-risk group(P<0.05).After one article was excluded from the heterogeneity test,the outcome indexes of having alive borns in the remaining 4 articles were analyzed.Meta-analysis results showed that CSP low-risk group with expectant management had higher delivery rate than high-risk group,and the difference was statistically significant(P<0.05)Conclusion1.The patients of Cesarean scar pregnancy with expectant management has a certain rate of live delivery,but also has a high risk of massive bleeding,hysterectomy,and so on.2.The patients with type Ⅰ and type Ⅱ who have strong desire of pregnancy can continue pregnancy.But the CSP patients with type Ⅲ have the risk of uterine rupture in the second trimester and hysterectomy due to massive bleeding,the treatment method should be carefully selected. |
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