| Objective:Cesarean scar pregnancy(CSP)is a late complication of cesarean section.There is a potential risk of serious complications such as placenta accrete,uterine rupture,massive bleeding,and even death.Although various approaches were used to treat CSP,there is no accepted guideline.Hysteroscopy,as a minimally invasive treatment,has received more attention in the treatment of CSP in recent years.However,the efficacy and safety of the treatment are controversial and there are short of large sample clinical studies.CSP patients are more common in early pregnancy,especially within 10 weeks of gestation.In this article,521 CSPs were retrospectively analyzed to investigate the efficacy and safety of hysteroscopy for CSP patients within 10 weeks of gestation,and provide reference for the proper choice of the therapeutic regime.Methods:PatientsTotally 521 patients with cesarean scar pregnancy(CSP)treated with hysteroscopy or dilation and curettage(D&C)at Woman's Hospital,School of Medicine,Zhejiang University,from Jan 1.2018 to Jun 30.2019 were recruited.Patients were divided into hysteroscopy group(group A)and D&C group(group B)according to treatment methods.According to whether uterine artery embolization(UAE)was used before operation,the study group was divided into A1 group(hysteroscopy group under ultrasound-guided),A2 group(hysteroscopy combined with UAE group under ultrasound-guided),and the control group was further divided into group B1(D&C group under ultrasound-guided)and group B2(D&C combined with UAE group under ultrasound-guided).The number of patients in each group was 112(group A1),47(group A2),263(group B1)and 99(group B2),respectively.Observation content(1)General information:age,gestational age,gravidity,parity,number of cesarean sections,time interval from previous cesarean section;(2)Clinical symptoms:Whether there was vaginal bleeding and/or abdominal pain before operation;(3)Preoperative examination:Hemoglobin concentration,serum?-h CG level,the ultrasound type,and the blood flow signals around the sac;(4)Success rate of operation:A successful outcome was defined as the resolution of serum?-h CG,disappearance of gestational mass,with no need surgery or medication remedy.If there was an uncontrollable bleeding or uterine perforation during the operation which needs to be converted to abdominal operation,or the decline of serum?-h CG was not satisfied(the decline of blood?-h CG was less than 15%per week,or fluctuate at a level,those who need remedial treatment combined with the clinical conditions)or the persistence of gestational mass which needs remedial treatment,the operation was deemed as failure.(5)Efficacy indicators:(1)The decline percentage of serum?-h CG level;(2)Time for resolution of serum?-h CG;(3)Time for absorption of gestational mass;(4)The duration of vaginal bleeding after the operation.(6)Safety indicators:(1)Intraoperative blood loss;(2)Postoperative infection rate;(3)Uterine perforation rate;(4)Hysterectomy rate;(5)Blood transfusion rate;(6)Whether the menses returned(with or without amenorrhea caused by adhesion of cervix and uterine cavity);(7)Specific complications of hysteroscopic surgery:mainly including hyperhy-dration syndrome,gas embolism,etc;(8)Serious complications caused by UAE:mainly including bladder necrosis,ureteral injury,pulmonary embolism,etc.(7)Other indicators:(1)Hospital stay;(2)Hospitalization expenses.Statistical analysisAll data analyses were conducted with SPSS software(version 20.0;SPSS).Quantitative data of each group were firstly analyzed for normal distribution(Kol Mogorov-Smirnov One-Sample Test)and homogeneity of variance test(Levene's Test).If variables fit assumptions of normality and homogeneity of variance,the independent samples t test was used.The results were given as mean±standard deviation(`x±s).If not,a nonparametric test was used(the Mann–Whitney U test).Group results were expressed as median,minimum,and maximum.Chi-square test(?~2 Test)was used for categorical variables,and the results of each group were expressed as percentages and numbers.P values<0.05 were considered statistically significant.Results:General information(1)Group A1and group B1:There were no differences in patients'age,gestational age,gravidity,parity,number of cesarean sections,time interval from previous cesarean section between the two groups(P>0.05).(2)Group A2 and group B2:There were no differences in patients'age,gestational age,gravidity,parity,number of cesarean sections,time interval from previous cesarean section between the two groups(P>0.05).Clinical symptoms(1)Group A1and group B1:There was no significant difference between the two groups in whether there were vaginal bleeding,abdominal pain,vaginal bleeding with abdominal pain,and absence of the above symptoms before operation(P>0.05).(2)Group A2 and group B2:There was no significant difference between the two groups in whether there were vaginal bleeding,abdominal pain,vaginal bleeding with abdominal pain,and absence of the above symptoms before operation(P>0.05).Preoperative examination(1)Group A1 and group B1:(1)There were no differences in preoperative hemoglobin concentration,serum?-h CG level,the maximum diameter of the gestational sac,the presence of fetal heartbeat,and the blood flow signals around the sac between the two groups(P>0.05).(2)The proportion of type I patients in group A1 and group B1 were 11.6%and31.6%,respectively.The proportion of type I patients in group A1 was lower than that in group B1,and the difference was statistically significant(P<0.05).The proportion of type II patients in group A1 and group B1 were 59.8%and 55.5%,respectively.There was no significant difference between the groups(P>0.05).The proportion of type III patients in group A1 and group B1 were 28.6%and 12.9%respectively.The proportion of type III patients in group A1 was higher than that in group B1,and the difference was statistically significant(P<0.05).(2)Group A2 and group B2:(1)There were no differences in preoperative hemoglobin concentration,serum?-h CG level,the maximum diameter of the gestational sac,the presence of fetal heartbeat and ultrasound type between the two groups(P>0.05).(2)The blood flow signals around the gestational sac were rich in both groups.Success rate of operation(1)Group A1and group B1:The success rates of the two groups were 98.2%and 97.3%,respectively.The success rate of the A1 group was higher than that of the B1 group.There was no significant difference between the two groups(P>0.05).(2)Group A2 and group B2:The success rates of the two groups were 100.0%and 98.0%,respectively.The success rate of the A2 group was higher than that of the B2 group.There was no significant difference between the two groups(P>0.05).Efficacy indicators(1)Group A1 and group B1:(1)There were no differences in decline percentage of serum?-h CG level,the duration of vaginal bleeding after the operation between the two groups(P>0.05).(2)Comparing group A1 and group B1,the median time for resolution of serum?-h CG was 21days and 28 days.The time for resolution of serum?-h CG in A1 group was shorter than that in B1 group(P<0.01).(3)The time for the absorption of gestational mass was(11.63±16.98)days and(22.32±18.51)days,respectively(P<0.05).The time for the absorption of gestational mass in A1 group was shorter than that in B1 group(P<0.01).(2)Group A2 and group B2:There were no differences in decline percentage of serum?-h CG level,the median time for resolution of serum?-h CG,the time for the absorption of gestational mass,the duration of vaginal bleeding after the operation between the two groups(P>0.05).Safety indicators(1)Group A1 and group B1:(1)The median intraoperative blood loss of the two groups was 20 ml and 10 ml respectively.The intraoperative blood loss of group A1 was more than that of group B1,the difference was statistically significant(P<0.01).(2)There were no differences in the postoperative infection rate between the two groups(P>0.05).(3)There were no cases of uterine perforation,hysterectomy and blood transfusion in the two groups.(4)There were no cases of amenorrhea.No amenorrhea caused by adhesion of the cervix and uterine cavity.(5)All patients in group A1 had no special complications of hysteroscopy(hyperhydration syndrome,gas embolism,etc).(2)Group A2 and group B2:(1)There were no differences in the median intraoperative blood loss,postoperative infection rate between the two groups(P>0.05).(2)There were no cases of uterine perforation,hysterectomy,blood transfusion and serious complications caused by the UAE in the two groups;(3)There were no cases of amenorrhea.No amenorrhea caused by adhesion of the cervix and uterine cavity.(4)All patients in group A2 had no special complications of hysteroscopy(hyperhydration syndrome,gas embolism,etc).Other indicators(1)Group A1 and group B1:(1)The hospitalization time of group A1 and group B1 were 4.54±1.21 days and3.65±1.14 days,respectively.The difference was statistically significant(P<0.01).(2)The median hospitalization expenses of A1 group and B1 group were 5327.69yuan and 2874.10 yuan,respectively.The difference was statistically significant(P<0.01).(2)Group A2 and group B2:(1)The hospitalization time of group A2 and group B2 was 5.77±1.45 days and5.94±1.80 days respectively.There was no significant difference(P>0.05).(2)The median hospitalization expenses of group A2 and group B2 were 15118.85yuan and 12818.87 yuan,respectively.The difference was statistically significant(P<0.01).Conclusions:When meeting the inclusion and exclusion criteria for this study:(1)Hysteroscopic treatment of CSP was safe and effective.(2)In the absence of UAE,hysteroscopic treatment of CSP had a shorter time for resolution of serum?-h CG and the disappearance of gestational mass than D&C.When hospitalization costs were not considered,hysteroscopy may be preferred.(3)In combination with UAE,hysteroscopy and D&C had similar curative effect. |
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