探讨剖宫产瘢痕妊娠(CSP)个体化治疗的临床价值。

回顾性分析2010年3月至2013年2月余姚市人民医院收治61例CSP患者的临床资料，将病灶分为内生型(Ⅰ型)和外生型(Ⅱ型)，比较型别的差异性。根据血β-人绒毛膜促性腺激素(β-HCG)水平和病灶部位、大小、血供、表面肌层厚度及阴道流血情况，分别行甲氨蝶呤(MTX)＋甲酰四氢叶酸(CF)或子宫动脉化疗栓塞(UACE)杀灭胚胎、止血和预防出血；在宫腔镜或B超引导下，必要时＋腹腔镜监视下清宫术。根据杀灭胚胎治疗距清宫术的时间不同，分为≤7 d清宫和>7 d清宫两组，比较有关疗效指标。

Ⅰ型54例，Ⅱ型7例，Ⅱ型较Ⅰ型患者先期流产者多(为71%和11%，χ²＝11.445)、包块平均直径大[分别为(4.3±1.2)cm和(2.4±1.3)cm，t＝－3.612]、表面肌层薄[分别为(1.6±0.5)mm和(2.7±1.0)mm，t＝2.916]，差异均有统计学意义(P值均<0.05)。行UACE杀灭胚胎、止血54例，MTX＋CF方案治疗7例；宫腔镜引导下清宫44例，B超监视下清宫6例，宫腔镜引导＋腹腔镜监视下清宫7例，经腹病灶切除＋子宫修补术和UACE后病灶消失各2例。61例患者均治愈出院，无子宫切除病例。≤7 d清宫组的住院时间[(13±6) d]和血β-HCG转为正常水平时间[(18±7)d]短于>7 d清宫组[分别为(27±12)d和(31±11)d，t＝－5.862和t＝－5.486]，差异均有统计学意义(P均<0.01)。

根据病情选择个体化治疗方案能改善CSP患者的疗效和预后，病情严重者应行介入疗法；病灶超声分型对选择合理的手术方式有指导意义。

To explore the clinical value of individualized therapy for caesarean scar pregnancy (CSP).

A retrospective study was conducted in 61 patients with CSP in Yuyao People′s Hospital from March 2010 to February 2013. According to the growth pattern of nidus, the patients were divided into 2 groups, which were endogenic type (type I group) and exogenic type (type II group). And the differences of two groups were compared. According to the serum level of β-HCG, location, size, blood flow and surface myometrial thickness of nidus, and vaginal hemorrhage, the patients were treated respectively with methotrexate (MTX) and leucovorin (CF) or uterine artery chemoembolization (UACE), in order to kill embryo, stop and prevent hemorrhage. If all the above treatment failed, curettage was done using hysteroscope, ultrasound or laparoscope to guide. The curative effects of the lengths of time from killing embryo to curettage (≤7 days or >7 days) were compared.

There were 54 cases in type I group and 7 cases in type II group. In type I and type II group, the percentage of abortion were 11% and 71%, the average diameter of masses were (2.4±1.3) cm and (4.3±1.2) cm, and the myometrial thickness of nidus surface were (2.7±1.0)mm and (1.6±0.5)mm, respectively. Comparing the two groups, χ²=11.445, t=-3.612 and t=2.916; P value were all <0.05. Fifty-four cases were treated with UACE, and 7 cases with MTX plus CF. Forty-four cases were treated with curettage guided by hysteroscope, 6 cases guided by ultrasound and 7 cases guided by hysteroscope and laparoscopy; other 2 cases were managed by excising the nidus trans-abdominally, and the other 2 cases were cured with UACE treatment. Sixty-one cases were all cured without hysterectomy. The length of hospitalization time and β-HCG turning to negative in ≤7 days group were (13±6) days and (18±7) days, while in >7 days group were (27±12) days and (31±11) days, respectively. There were significant differences between the two groups (t=-5.862, -5.486, P value were all <0.05).

Individualized therapy according to the patient′s condition can improve the curative effect and prognosis in CSP patients; and the patients in serious condition should be treated with UACE. The classification of CSP by ultrasound is instructive in choosing a rational operation.