摘要
目的探究术前甲氨蝶呤(methotrexate,MTX)预处理时机对晚期(≥孕8 w)剖宫产瘢痕部位妊娠(caesarean scar pregnancy,CSP)患者卵巢功能的影响及治疗失败的影响因素分析。方法回顾性分析2018年2月至2023年10月于南充市中心医院进行术前MTX预处理后的晚期CSP患者315例。根据术前MTX预处理距手术时长分为4组:A组(术前1~4 d)71例、B组(术前5~7 d)117例、C组(术前8~10 d)67例、D组(术前11~14 d)60例。比较各组手术治疗成功率及手术相关指标(中转其他术式、失血过多、妊娠组织残留)、围术期临床指标、术后随访指标,及各组入院时及术后3个月子宫血流动力学指标[血流搏动指数(pulsatility index,PI)、阻力指数(resistance index,RI)]及卵巢功能[黄体生成素(luteinising hormone,LH)、卵泡刺激素(follicle stimulating hormone,FSH)、雌激素(estrogen,E2)]。采用广义估计方程(generalised estimating equatio,GEE)分析影响患者治疗结局的相关因素。结果A组、B组治疗成功率分别为92.96%、92.31%,明显高于C组、D组(77.61%、78.33%)(P<0.05);入院时,各组PI、RI水平比较无明显差异(P>0.05);术后3个月,各组PI、RI水平较入院时均明显升高(P<0.05),但组间比较无统计学意义(P>0.05)。各组术前血清β-hCG水平、术前血清β-hCG变化率、住院时长相比,差异有统计学意义(P<0.05),组间两两比较均存在明显差异(P<0.05)。各组LH、FSH、E2水平入院时<术后1个月<术后2个月<术后3个月(P<0.05);A组、B组术后1个月、术后2个月LH、E2水平均明显高于C组、D组(P<0.05),但术后3个月,各组患者LH、E2水平无明显差异(P>0.05)。由GEE方程分析结果,患者是否存在心管搏动、头臀长、孕囊平均径线、瘢痕肌层厚度、超声分型及血流分级均会对临床治疗结局产生显著影响(P<0.05)。结论术前MTX预处理不同时机对晚期CSP患者子宫及卵巢功能均无明显不良影响,但术前预处理时长≤7 d联合手术对晚期CSP患者进行治疗成功率较高,且患者住院时间较短,是联合治疗较为合适的时机;同时由于心管搏动、头臀长、孕囊平均径线、瘢痕肌层厚度、超声分型及血流分级等指标会对CSP患者联合治疗成功率产生影响,需在术前对CSP患者综合评估,以提升临床治疗效果。
Objective To investigate the effect of preoperative methotrexate(MTX)pretreatment timing on ovarian function in patients with late(≥8 w gestation)cesarean scar pregnancy(CSP)and to analyse the factors influencing treatment failure.Methods A retrospective analysis of 315 patients with late CSP who underwent treatment after preoperative MTX pretreatment at Nanchong Central Hospital from February 2018 to October 2023.According to the length of surgery to the preoperative MTX pretreatment was divided into 4 groups:71 cases in group A(1~4d preoperative),117 cases in group B(5~7d preoperative),67 cases in group C(8~10 d preoperative)and 60 cases in group D(11~14 d preoperative),comparison of the success rate of surgical treatment and surgery-related indicators(intermediate transfer to other surgical procedures,blood loss,pregnancy tissue retention),perioperative clinical indicators,postoperative follow-up indicators,and uterine haemodynamic indicators[pulsatility index(PI),resistance index(RI)]and ovarian function[luteinising hormone(LH),follicle stimulating hormone(FSH)and estrogen(E2)]at admission and 3 months postoperatively in each group.Generalised estimating equations(GEE)were used to analyze the relevant factors affecting patients'treatment outcomes.Results The clinical treatment success rates of patients in Groups A and B were 92.96%and 92.31%,respectively,which were significantly higher than Groups C and D(77.61%and 78.33%)(P<0.05);at the time of admission,there was no significant difference in the comparison of PI and RI levels between the groups(P>0.05);after 3 months postoperatively,PI and RI levels were significantly higher in all groups compared with those at the time of admission(P<0.05),but there was no significant difference in the comparison between the groups(P>0.05).There were significant differences in preoperative serumβ-hCG levels,preoperative serumβ-hCG change rate,and length of hospital stay in each group compared to each other(P<0.05),and there were significant differences in the two-by-two comparisons between the groups(P<0.05).The levels of LH,FSH and E2 in each group were at the time of admission<1 month postoperatively<2 months postoperatively<3 months postoperatively(P<0.05);the levels of LH and E2 in Groups A and B were significantly higher than those in Groups C and D at 1 month postoperatively and 2 months postoperatively(P<0.05),but there was no significant difference in the levels of LH and E2 in the patients of each group at 3 months postoperatively(P>0.05).As a result of the GEE equation analysis,the presence of cardiac tube beats,head and hip length,mean diameter of the gestational sac,thickness of the scarred muscle layer,ultrasound typing,and blood flow grading of the patients significantly affected the clinical outcome(P<0.05).Conclusions Different preoperative timing of MTX pretreatment had no significant adverse effects on uterine and ovarian function in patients with late CSP,however,the duration of preoperative preconditioning≤7 d combined with surgery for patients with late CSP has a higher success rate and shorter hospital stay,which is a more appropriate time for combined treatment;at the same time,as cardiac tube pulsation,head-rump length,mean diameter of the gestational sac,thickness of the scarred muscle layer,ultrasound typing and blood flow grading all have an impact on the success rate of combined treatment in patients with CSP,a comprehensive assessment of patients with CSP is needed preoperatively to enhance the clinical outcome.
作者
黄天豪
冉栩
王迪桥
张涵明
Huang Tianhao;Ran Xu;Wang Diqiao;Zhang Hanming(Department of Anesthesiology,Nanchong Central Hospital,Nanchong Sichuan 637000,P.R.China;Department of Obstetrics,Nanchong Central Hospital,Nanchong Sichuan 637000,P.R.China)
出处
《中国计划生育和妇产科》
2025年第2期82-88,97,共8页
Chinese Journal of Family Planning & Gynecotokology
关键词
剖宫产瘢痕部位妊娠
术前预处理
甲氨蝶呤
手术时机
卵巢功能
影响因素
caesarean scar pregnancy
preoperative pretreatment
methotrexate
timing of surgery
ovarian function
influencing factors
