两种经阴道手术治疗I、II型剖宫产瘢痕妊娠 疗效的临床分析

Clinical Analysis of Two Transvaginal Surgical Approaches for Type I and II Cesarean Scar Pregnancy

摘要: 目的：比较两种经阴道手术方式对于治疗I型、II型剖宫产瘢痕妊娠(CSP)的临床疗效。方法：回顾分析2013年12月至2023年12月我院收治的142例CSP患者的临床资料，按手术方式分为：I型穹隆切开组(26例)与I型宫腔镜组(27例)；II型穹隆切开组(42例)与II型宫腔镜组(47例)。比较两组的手术指标(手术时间、术中出血量、血β-hCG降至正常时间、住院费用、住院时间)及随访指标(术后1月超声、月经变化、再次妊娠情况)。结果：I型CSP中，宫腔镜组出血量、手术时间、住院时间及费用均低于穹隆切开组(P < 0.05)，术后子宫剖宫产瘢痕憩室(CSD)的改善率低于阴道前穹隆切开组(P < 0.01)，穹隆切开组患者术后再次妊娠，孕囊着床位置正常的发生率高于宫腔镜组(P < 0.05)；II型CSP患者中，宫腔镜组出血量、住院时间及费用亦低于穹隆切开组(P < 0.05)，但CSD改善率仍低于穹隆切开组(P < 0.01)。结论：两种术式均适用于CSP治疗。没有生育要求且希望创伤最小、恢复快的I型、II型CSP患者，推荐行电吸人流 + 宫腔镜检查；对有生育需求者或患者有修复子宫剖宫产瘢痕憩室的意愿时，建议行经阴道前穹隆切开病灶切除 + 子宫修补术。

Abstract: Objective: To compare the clinical efficacy of two different transvaginal surgical approaches for the treatment of Type I and Type II cesarean scar pregnancy (CSP). Methods: A retrospective analysis was conducted on the clinical data of 142 CSP patients admitted to our hospital from December 2013 to December 2023. Patients were divided into groups based on the surgical method and CSP type: Type I Fornix Incision Group (26 cases), Type I Hysteroscopy Group (27 cases); Type II Fornix Incision Group (42 cases), and Type II Hysteroscopy Group (47 cases). Surgical indicators (operation time, intraoperative blood loss, time for serum β-hCG to return to normal, hospitalization cost, length of hospital stay) and follow-up indicators (ultrasound at 1-month post-surgery, menstrual changes, subsequent pregnancy status) were compared between the groups. Results: For Type I CSP, the hysteroscopy group showed significantly lower blood loss, operation time, length of stay, and hospitalization costs compared to the fornix incision group (P < 0.05). However, the rate of improvement in post-operative uterine cesarean scar diverticulum (CSD) was lower than in the anterior vaginal fornix incision group (P < 0.01). Patients in the fornix incision group who achieved subsequent pregnancy had a higher rate of normal gestational sac implantation location compared to the hysteroscopy group (P < 0.05). For Type II CSP patients, the hysteroscopy group also demonstrated significantly lower blood loss, length of stay, and hospitalization costs compared to the fornix incision group (P < 0.05), but the CSD improvement rate remained significantly lower than that of the fornix incision group (P < 0.01). Conclusion: Both surgical techniques are suitable for treating CSP. For Type I or Type II CSP patients without future fertility desires who prioritize minimal trauma and rapid recovery, vacuum aspiration combined with hysteroscopy is recommended. For patients with fertility desires or those wishing to repair the uterine cesarean scar diverticulum, transvaginal anterior fornix lesion excision combined with uterine repair is advised.