Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
Department of Public Health, Tzu Chi University, Hualien, Taiwan.
PLoS One. 2018 Aug 9;13(8):e0202020. doi: 10.1371/journal.pone.0202020. eCollection 2018.
A cesarean section pregnancy (CSP) indicated the gestational sac (GS) implanted in the previous cesarean scar. The clinical manifestations of CSP present a wide range of variations, and the optimal management is yet to be defined. We retrospectively enrolled 109 patients with the diagnosis of CSP from our department and categorized them into four grades based on the ultrasound presentation. Grade I CSP indicated the GS embedded in less than one-half thickness of the lower anterior corpus; and grade II CSP represented the GS extended to more than one-half thickness of overlying myometrium. Grade III CSP implied the GS bulged out of the cesarean scar; and grade IV CSP denoted that GS became an amorphous tumor with rich vascularity at the cesarean scar. Seventy-eight women received surgery, and the complication rate was 14.1% (11/78). Linear regression analysis demonstrated a significant association between the invasiveness of the surgery and their ultrasound gradings. The mainstream operation for grade I CSP was transcervical resection, while the majority of grade III and IV patients required hysterotomy or hysterectomy. Another 31 women received chemotherapy with methotrexate as their initial treatment. The success rate for chemotherapy was 61.3%; the remaining patients required further surgery due to persistent CSP or heavy bleeding during or after chemotherapy. Fifteen patients (48.3%) receiving chemotherapy suffered from complications (mostly bleeding). Among them, 7 (22.6%) patients experienced bleeding of more than 1,000 mL, and 9 (29.0%) of these 31 patients required blood transfusions. Our novel ultrasound grading system for CSP may help to communicate between physicians, and determine the optimal surgical strategy. Chemotherapy with methotrexate for CSP is not satisfactory and is associated with a higher rate of complications.
剖宫产术后妊娠（CSP）是指孕囊（GS）着床于既往剖宫产瘢痕处。CSP 的临床表现差异较大，其最佳管理方法尚未确定。我们回顾性地纳入了我科 109 例 CSP 患者，并根据超声表现将其分为四级。I 级 CSP 指 GS 埋入前壁下段肌层厚度＜1/2；II 级 CSP 指 GS 延伸至超过前壁下段肌层厚度的 1/2；III 级 CSP 指 GS 自剖宫产瘢痕处向外突出；IV 级 CSP 指 GS 在剖宫产瘢痕处呈不规则团块状，血流丰富。78 例患者接受了手术治疗，并发症发生率为 14.1%（11/78）。线性回归分析表明，手术的侵袭性与超声分级显著相关。I 级 CSP 的主流手术方式为经宫颈切除，而大部分 III 级和 IV 级患者需要行剖宫产切口切开或子宫切除术。另有 31 例患者接受甲氨蝶呤化疗作为初始治疗。化疗的成功率为 61.3%；其余患者因 CSP 持续存在或化疗期间或之后大出血而需要进一步手术。31 例接受化疗的患者中有 15 例（48.3%）发生并发症（多为出血）。其中，7 例（22.6%）患者出血量超过 1000ml，9 例（29.0%）患者需要输血。我们提出的 CSP 超声分级新系统有助于医患之间的沟通，并确定最佳的手术策略。CSP 采用甲氨蝶呤化疗效果并不理想，且与较高的并发症发生率相关。
