| Objective:The clinical data of 299 patients with cesarean section scar pregnancy were collected to analyze effectiveness of ultrasound-guided uterine dilatation and curettage(D&C)in the treatment of CSP and the related risk factors for treatment failure.At the same time,the more instructive clinical classification was discussed to provide the basis for clinical rational diagnosis and treatment.Methods:The clinical data of 299 patients with CSP who were treated with ultrasound-guided D&C as the initial strategy admitted to The Affiliated Hospital of Qingdao University from January 2015 to June 2020 were retrospectively analyzed.The patients were classified according to the Classification of Chinese Medical Association in 2016.According to whether pretreatment with uterine artery embolization(UAE)was performed or not,the patients were divided into UAE group(26 cases)and D&C group(273 cases).The D&C group was divided into successful group(249 cases)and failed group(24 cases)according to the treatment results.Failure was defined as changing surgical procedures or receiving supplementary therapy.The patients in the D&C group were classified according to the Practical Clinical Classification in 2019.Analyze the clinical data of all patients,as well as surgery and follow-up related indicators.Comparing the effect of two treatment methods in patients with type II CSP;Univariate analysis and Logistic regression analysis were used to analyze the predictors of the failure,and ROC curve was used to assess the cut-off values of predictors.Results:1.There were no significant differences in days of menopause,age,pregnancy times,number of cesarean sections,miscarriage times,time interval from previous cesarean section,fetal heart beat,preoperative serum β-human chorionic gonadotropin(β-HCG)level,gestation sac diameters,blood flow grading,scar thickness,time for blood β-HCG value to normal and success rate between the UAE group and the D&C group(P > 0.05).There were statistically significant differences in the intraoperative blood loss,days of hospitalization and total hospitalization expenses(P < 0.05).There was no significant difference in treatment success rate between the two groups(P > 0.05).2.In the D & C group,there was no significance in age,days of menopause,pregnancy times,number of cesarean sections,miscarriage times,time interval from previous cesarean section,fetal heart beat between the successful group and the failed group(P > 0.05).There were statistically differences in clinical classification,scar thickness,β-HCG level,gestation sac diameters,blood flow grading,intraoperative blood loss,time for blood β-HCG value to normal,hospitalization days and expenses(P < 0.05).The gestation sac diameters,β-HCG level and blood flow grading in the successful group were significantly lower than those in the failed group,and the muscle scar thickness was significantly higher than those in the failed group.The success rate of D&C was higher in type I and type IIa,but lower in type IIb,the difference of success rate of each clinical classification was statistically significant(P < 0.01).3.Logistic regression analysis showed that the maximum diameter of the pregnancy sac > 2.8cm(OR = 5.841,95%CI: 2.051-16.634),muscle thickness of scar < 2.5mm(OR=13.058,95%CI = 4.005-42.576),and blood β-HCG value > 30000U/L(OR=6.311,95%CI = 1.883-21.151)were independent risk factors for D & C failure.ROC curve showed that the predictive value of treatment failure was best when the maximum diameter of pregnancy sac was 3.3 cm,the scar thickness was 2.4 mm,and the serumβ-HCG was 43720U/L.Conclusion:1.Type Ⅰ CSP is relatively stable and less risky.D&C can be used as the first choice for the treatment of type I CSP.For type III patients with scar thickness ≤1mm,D&C is not recommended.2.For patients with type IIa CSP,UAE is not routine before D&C,and the success rate of direct D&C is high.However,if the local blood flow is abundant and the risk of intraoperative bleeding is high,preoperative preventive UAE can also be considered.3.For patients with type IIb CSP with thin muscle layer at scar and large gestation sac diameters,If the patient requires,D&C can be carefully performed in the operating room or under laparoscopic supervision under the premise of full disclosure of risks,and timely vaginal or laparoscopic lesion removal can be performed if necessary.4.The diameter of gestational sac,the thickness of the muscle layer at the scar and the blood β-HCG value are the risk factors for the failure of direct D&C;early detection and timely treatment are the keys to the successful of D&C. |
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