影响剖宫产切口瘢痕妊娠患者子宫动脉栓塞术联合宫腔镜手术结局的危险因素分析

Analysis of risk factors affecting surgical outcomes of uterine artery embolization combined with hysteroscopy for cesarean scar pregnancy

摘要:

目的 探讨影响子宫动脉栓塞术（UAE）联合宫腔镜治疗剖宫产切口瘢痕妊娠（CSP）效果的危险因素。方法 回顾性分析2019年9月—2022年9月西昌市人民医院60例接受UAE联合宫腔镜手术治疗CSP患者的临床病历资料。根据手术是否成功分为观察组（一次手术成功，49例）与对照组（转开腹或腹腔镜手术或接受二次手术，11例），比较两组患者一般临床资料和相关病理指标。采用多因素一般Logistic回归模型分析CSP手术结局的影响因素。绘制受试者工作特征（ROC）曲线分析子宫瘢痕处组织厚度对手术结果的预测价值。结果 60例患者中，49例一次手术成功（81.67%），11例手术失败（18.33%）。对照组中有8例接受二次手术，2例转腹腔镜手术，1例开腹。观察组β-HCG水平低于对照组（P < 0.05），子宫瘢痕处组织厚度大于对照组（P < 0.05），滋养细胞浸润深度等级低于对照组（P <0.05）。子宫瘢痕处组织厚度厚［O^R =1.547（95%CI：1.124，2.129）］、滋养细胞浸润深度3级［O^R =1.154（95% CI：1.052，1.266）］均是手术失败的危险因素（P < 0.05）。ROC曲线结果显示，子宫瘢痕处组织厚度预测手术结果的敏感性为73.5%（95% CI：0.649，0.856），特异性为90.9%（95% CI：0.771，0.976），曲线下面积为0.870（95% CI：0.824，0.975）。子宫瘢痕组织厚度 ≥ 3.5 cm患者较子宫瘢痕组织厚度 <3.5 cm患者出血量少，并发症发生率低（P <0.05）。滋养细胞浸润1、2级患者术中出血量较滋养细胞浸润3级患者少，并发症发生率低（P < 0.05）。结论 滋养细胞浸润深度和子宫瘢痕处组织厚度是影响UAE联合宫腔镜治疗CSP手术结局的独立危险因素，UAE联合宫腔镜治疗适用于子宫瘢痕处组织厚度≥3.5 cm和滋养细胞未突破肌层者，对于子宫瘢痕处组织厚度<3.5 cm和滋养细胞浸润至浆膜层患者，建议考虑腹腔镜或开腹手术。

Abstract:

Objective To investigate risk factors affecting the efficacy of uterine artery embolization (UAE) combined with hysteroscopy for cesarean scar pregnancy (CSP).Methods Clinical data of 60 CSP patients receiving UAE combined with hysteroscopic surgery (September 2019-September 2022) were retrospectively analyzed. Patients were divided into observation group (primary procedure success, n = 49) and control group (conversion to laparotomy/laparoscopy or secondary surgery, n = 11). Demographic characteristics and pathological indicators were compared. Multivariate logistic regression analyzed influencing factors. Receiver operating characteristic (ROC) curves assessed uterine scar tissue thickness' predictive value.Results Among 60 patients, 49 achieved primary procedure success (81.67%), while 11 failed (18.33%: 8 required secondary surgery, 2 converted to laparoscopy, 1 to laparotomy). Observation group had lower β-hCG levels (P < 0.05), greater uterine scar tissue thickness (P < 0.05), and shallower trophoblastic infiltration depth (P < 0.05) versus control group. Increased uterine scar tissue thickness [O^R = 1.547 (95% CI:1.124, 2.129) ] and grade 3 trophoblastic infiltration [O^R = 1.154 (95% CI: 1.052, 1.266) ] were risk factors for surgical failure (P < 0.05). ROC analysis showed uterine scar tissue thickness predicted outcomes with sensitivity = 73.5% (95% CI: 0.649, 0.856), specificity = 90.9% (95% CI: 0.771, 0.976), AUC = 0.870 (95% CI:0.824, 0.975). Patients with scar thickness ≥ 3.5 cm had reduced blood loss and lower complication rates versus < 3.5 cm (P < 0.05). Patients with grade 1-2 trophoblastic infiltration had less blood loss and fewer complications versus grade 3 (P < 0.05).Conclusion Trophoblastic infiltration depth and uterine scar tissue thickness independently influence outcomes of UAE combined with hysteroscopy for CSP. This approach suits patients with scar thickness ≥ 3.5 cm without full-thickness myometrial invasion. For scar thickness < 3.5 cm or serosal layer infiltration, laparoscopic or open surgery is recommended.