發(fā)布時(shí)間：2018-06-24 03:36

  本文選題：剖宮產(chǎn)瘢痕妊娠(csp) + B超引導(dǎo)下刮宮術(shù)��； 參考：《浙江大學(xué)》2017年碩士論文

【摘要】：目的分析孕周≥10周的剖宮產(chǎn)瘢痕妊娠采用不同治療方法的預(yù)后情況,為臨床診治提供一些參考和依據(jù)。方法通過對(duì)浙江大學(xué)醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院2013年1月至2016年收治的CSP病例中孕周≥10周的患者的臨床資料進(jìn)行整理,并做回顧性的分析。按治療方法分組:A組:單純B超引導(dǎo)下刮宮術(shù)13例。B組:行雙側(cè)子宮動(dòng)脈栓塞后超聲引導(dǎo)下刮宮術(shù)40例。C組:行雙側(cè)子宮動(dòng)脈栓塞后宮腔鏡手術(shù)(C組)5例。D組:行雙側(cè)子宮動(dòng)脈栓塞后再行極困難剖宮取胎+病灶去除+瘢痕修補(bǔ)術(shù)(D組)7例。通過比較4組的臨床數(shù)據(jù)、影像學(xué)表現(xiàn)以及社會(huì)經(jīng)濟(jì)學(xué)指標(biāo),分析CSP預(yù)后的相關(guān)因素及治療效果。結(jié)果A組:患者治療前血HCG為(32039.48±27590.85)IU/L,孕周為11周,術(shù)中出血(64.89±120.93)ml,住院時(shí)間為(5.42±1.87)天,住院費(fèi)用(3999.94±2596.60)元。B組:患者治療前血HCG為(48516.45±49472.93)IU/L,孕周為11周,術(shù)中出血(199.25±378.346)ml,住院時(shí)間為(7.58±1.85)天,住院費(fèi)用(13912.34±581.08)元。C組:患者治療前血HCG為(18009.61±72461.76)IU/L,孕周為11周,術(shù)中出血(38.60±43.70)ml,住院時(shí)間為(7.80±1.64)天,住院費(fèi)用(12441.38±4556.71)元。D組:患者治療前血HCG為(84020.43±72461.76)IU/L,孕周為12周,術(shù)中出血(1657.14±624.827)ml,住院時(shí)間為(11.00±3.65)天,住院費(fèi)用(25675.10±5639.96)元。4組的孕次、產(chǎn)次、剖宮產(chǎn)次,上次剖宮產(chǎn)距本次妊娠時(shí)間,術(shù)前血HCG值的一般臨床數(shù)據(jù)比較均無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。A、B、C組孕周小于D組(孕周取中位數(shù)),差異有統(tǒng)計(jì)學(xué)意義(P0.05)。疤痕處肌層厚度A組大于B、D組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。A、B、C組的病灶體積小于D組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。從4組的術(shù)中出血來(lái)比較,D組高于A、B、C組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。A組的住院時(shí)間小于B組,B、C組的住院時(shí)間小于D組,差異均有統(tǒng)計(jì)學(xué)意義(P0.05)。住院費(fèi)用A組低于B、C組,B、C組低于D組,差異均有統(tǒng)計(jì)學(xué)意義(P0.05)。多因素回歸分析提示孕周,病灶大小與CSP(孕周≥10周)預(yù)后相關(guān)。本研究收集的65例病例均在門診或住院后經(jīng)陰道B超檢查診斷為CSP且孕患者的孕周≥10周,行B超檢查觀察孕囊或包塊與宮腔、子宮前壁剖宮產(chǎn)瘢痕處的位置關(guān)系,并觀測(cè)孕囊大小,形態(tài)與瘢痕處肌層厚度以及局部血流情況,超聲圖像表現(xiàn)為:子宮前壁剖宮產(chǎn)瘢痕處可見孕囊或不均質(zhì)團(tuán)塊,部分可見胎心搏動(dòng),周邊可見星點(diǎn)狀血流或血流豐富,且子宮前壁剖宮產(chǎn)瘢痕處肌層較薄,部分未見肌層。結(jié)論臨床治療中可根據(jù)患者孕周以及影像學(xué)檢查提示的病灶大小,病灶周邊血流豐富程度等綜合考慮來(lái)決定治療方案,根據(jù)不同患者的情況,我們的治療應(yīng)該做到個(gè)體化。但CSP的早發(fā)現(xiàn)以及早處理是合理治療的關(guān)鍵。對(duì)于孕周≥10周的CSP患者,胚囊長(zhǎng)度不大于6cm且剖宮產(chǎn)瘢痕處肌層最薄處不小于0.1cm,病灶處血流不豐富的患者可選擇直接行B超引導(dǎo)下刮宮術(shù)(備栓塞);胚囊長(zhǎng)度不大于6cm,最薄處肌層厚度不小于0.1cm,病灶周圍血流較豐富的病人行雙側(cè)子宮動(dòng)脈栓塞后超聲引導(dǎo)下刮宮術(shù);病灶為團(tuán)塊狀,最薄處肌層厚度不小于0.1cm的患者行雙側(cè)子宮動(dòng)脈栓塞后再行宮腔鏡手術(shù);病灶體積較大,且周圍血流豐富,最薄處肌層小于0.1cm者行雙側(cè)子宮動(dòng)脈栓塞后剖宮取胎術(shù)+病灶去除+瘢痕修補(bǔ)術(shù)。
[Abstract]:Objective to analyze the prognosis of cicatricial pregnancy for cesarean section with more than 10 weeks of pregnancy, and to provide some reference and basis for clinical diagnosis and treatment. Methods the clinical data of the patients who were treated in CSP cases of the affiliated obstetrics and Gynecology Hospital of Zhejiang University from January 2013 to 2016 were reviewed and reviewed, and the retrospective analysis was done. Group A: group A: group.B with simple B ultrasound guided curettage: 40 cases of.C after bilateral uterine artery embolization by ultrasound guided curettage: 5 cases in group.D after bilateral uterine artery embolization (group C): after bilateral uterine artery embolization, a very difficult cesarean section with the removal of the lesion + scar repair (D group) was performed (group D). By comparing 4 groups of clinical data, imaging performance and socioeconomic indicators, the related factors and therapeutic effects of CSP prognosis were analyzed. Results A group: before treatment, the blood HCG was (32039.48 + 27590.85) IU/L, pregnancy week was 11 weeks, intraoperative bleeding (64.89 + 120.93) ml, (5.42 + 1.87) days in hospital, and hospital expenses (3999.94 + 2596.60) yuan.B group: Before treatment, the blood HCG was (48516.45 + 49472.93) IU/L, pregnancy week was 11 weeks, intraoperative bleeding (199.25 + 378.346) ml, hospitalization time (7.58 + 1.85) days, hospitalization expenses (13912.34 + 581.08) yuan.C group: the blood HCG before treatment was (18009.61 + 72461.76) IU/L, pregnancy week was 11 weeks, intraoperative hemorrhage (38.60 +) ml, hospitalization time, hospitalization expenses (12441.38 + 4556.71).D group: before treatment, blood HCG was (84020.43 + 72461.76) IU/L, pregnancy week was 12 weeks, intraoperative bleeding (1657.14 + 624.827) ml, hospitalization time (11 + 3.65) days, hospitalization expenses (25675.10 + 5639.96) yuan.4 group pregnancy, birth, cesarean section, last cesarean section of pregnancy time, preoperative blood HCG value general clinical data There was no statistical significance (P0.05).A, B, and group C was less than group D (median of gestational age), the difference was statistically significant (P0.05). The muscular layer thickness in the scar A group was larger than B, D group, the difference was statistically significant (P0.05).A, and there was a significant difference between the 4 groups. The time of hospitalization in group.A was less than that of group B, and the time of hospitalization in group.A was less than that of group B, and the time of hospitalization in group C was less than that of group D (P0.05). The hospitalization expense A group was lower than B, C group, B, and C group was lower than that of the group. 65 cases of the cases were diagnosed as CSP and the pregnancy weeks were more than 10 weeks after the outpatient or hospitalization. The relationship between the gestational sac or the caesarean section of the anterior uterine wall and the size of the gestation sac, the thickness of the scar and the local blood flow were observed by B ultrasonic examination. The cicatricial caesarean section of the anterior uterine wall can be seen in the gestation sac or inhomogeneous mass, part of the fetal heart pulsation, the peripheral blood flow or the rich blood flow, and the myometrium in the cesarean section of the anterior uterine wall is thinner, and the myometrium is not found in the section. According to the situation of different patients, our treatment should be individualized. However, our treatment should be individualized according to the situation of different patients. But early detection and early treatment of CSP are the key to rational treatment. The length of the embryo sac is not more than 6cm and the thickness of the myometrium in the cesarean scar is not less than 0.1cm for the CSP patients with the gestational weeks more than 10 weeks. The rich patients can choose the direct B ultrasound guided curettage (curettage); the length of the embryo sac is not more than 6cm, the thinnest of the muscularis thickness is not less than 0.1cm, and the patients with rich peripheral blood flow are guided by ultrasound guided curettage after bilateral uterine artery embolization; the lesion is a lump, and the thinner thickness of the muscle layer is not less than 0.1cm. After transcatheter arterial embolization, hysteroscopy was performed. The lesion volume was large, and the surrounding blood flow was rich, and the thinnest muscle layer was less than 0.1cm. After bilateral uterine artery embolization, the caesarean operation + lesion removal + scar repair operation was performed.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R714.22

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