【作者】 刘新宇；

【导师】 谷丽萍；

【作者基本信息】 吉林大学 ， 临床医学硕士（专业学位）， 2017， 硕士

【摘要】 研究背景:剖宫产瘢痕妊娠是一种较少见的异位妊娠类型,发生率在1/2216~1/1800之间,但近年来临床发病率呈上升趋势,CSP患者如果不能及时诊断及妥善治疗,将会出现大出血、子宫破裂、子宫切除甚至危及患者的生命。但由于国内外对剖宫产瘢痕妊娠的治疗缺乏足够有力的循证医学依据,目前CSP尚无规范统一的治疗指南。因此,通过循证医学探寻一种创伤小、恢复快、安全有效的治疗方式对于最大限度的保护患者的健康、提高患者的生活质量有重要意义。目的:研究子宫瘢痕妊娠的治疗方法,对临床应用较多、创伤较小、患者接受度高的子宫动脉化疗栓塞术联合清宫术、甲氨蝶呤联合清宫术、阴式病灶切除术及腹腔镜下病灶切除术等四种治疗方式从治愈率、术中出血量、血β-h CG降至正常的时间、住院时间、住院费用、月经复潮的时间等多个观察指标进行系统评价、荟萃分析。方法:依据《Systematic Review in Heath Care:Meta-analysis in Context》制作步骤,针对要评价的问题,确定纳入和排除标准。制定检索策略,利用计算机在线检索Pubmed,Embase,Cochrane Library,Medline,OVID,Web of science;中国期刊全文数据库(CNKI)、万方数据库、中国生物医学文献服务系统(Sino Med)、重庆维普中文期刊全文数据库(VIP)等,人工检索吉林大学医学图书馆相关杂志,全面搜集2012年1月至2016年12月中英文发表及未发表的剖宫产瘢痕妊娠治疗方法的有关文献。由两位评价员独立选择研究、评估研究的质量及提取数据,使用Review Manager5.3软件完成纳入文献的Meta分析。结果:两位评价员依据纳入及排除标准共纳入文献19篇,有关子宫动脉化疗栓塞术联合清宫术及甲氨蝶呤联合清宫术治疗CSP的文献15篇,有关阴式病灶切除术及腹腔镜下病灶切除术治疗CSP的文献4篇。其中,533例患者行子宫动脉化疗栓塞术联合清宫术治疗,383例患者行甲氨蝶呤联合清宫术治疗,114例患者行阴式病灶切除术,125例患者行腹腔镜下病灶切除术。使用Review Manager5.3软件进行Meta分析,结果显示:⑴子宫动脉化疗栓塞术联合清宫术与甲氨蝶呤联合清宫术治愈率对比,纳入15篇文献,合并分析结果示:OR=2.5,95%CI为(1.43,4.38),Z=3.20,P=0.001,P<0.05,两组数据差异有统计学意义;子宫动脉化疗栓塞术联合清宫术与甲氨蝶呤联合清宫术术中出血量、血β-HCG降至正常的时间及住院费用对比,因纳入研究异质性大,无法合并分析。⑵阴式病灶切除术与腹腔镜下病灶切除术治愈率对比,纳入4篇文献,合并分析结果示:RR=1.00,95%CI为(0.97,1.03),且Z=0.20,P=0.84,P>0.05,两组数据差异无统计学意义;术中出血量对比,纳入3篇文献,合并分析结果示:SMD=1.17,95%CI为(0.82,1.51),且Z=6.68,P<0.00001,P<0.05,两组数据差异有统计学意义;手术时间对比,纳入文献3篇,合并分析结果示:MD=25.23,95%CI为(20.08,30.38),且Z=9.61,P<0.00001,P<0.05,两组数据差异有统计学意义;月经复潮时间对比,纳入文献4篇,合并分析结果示:MD=0.76,95%CI为(-0.96,2.48),且Z=0.87,P=0.39,P>0.05,两组数据差异无统计学意义;血β-HCG降至正常的时间、住院费用对比,因纳入研究异质性大,无法合并分析。结论:1.UAEC联合清宫术治疗CSP比MTX联合清宫术治疗CSP治愈率高,术中大出血及进一步治疗的概率低,为更安全有效的治疗方式。2.阴式病灶切除术与腹腔镜下病灶切除术,治愈率无明显差异,且治愈率均较高。3.阴式病灶切除术治疗CSP比腹腔镜下病灶切除术治疗CSP术中出血量少,手术时间短,两种方式治疗CSP后,月经复潮时间无明显差异。更多还原

【Abstract】 Background: Caesarean scar pregnancy is the rarest form of ectopic pregnancy and has been increasingly diagnosed all over the world.The early and accurate diagnosis with timely management can prevent pregnancy complications such as haemorrhage,uterine rupture and can preserve fertility.At present,no standardized management has been available,although some medical and surgical treatment modalities have been suggested.By evidence-based medicine,therefore,exploring a management which is small trauma,quick recovery,safe and effective for cesarean scar pregnancy has important significance.Objective: Research the treatments of caesarean scar pregnancy,such as uterine artery chemoembolization in combination with curettage and aspiration,methotrexate in conjunction with curettage and aspiration,transvaginal debridement and laparoscopic management,to evaluate the clinical effectiveness of these management options of cesarean scar pregnancy.Methods: According to Systematic Review in Heath Care:Meta-analysis in Context,formulated into and exclusion criteria of this research.We conducted literature in the following databases: Pubmed,Embase,Cochrane Library,Medline,OVID,Web of science,CNKI,Wanfang database,Sino Med and VIP database from January 2012 to December 2016.Meanwhile manual searching was involved in journals of Jilin University Medical Library.After all these procedures,two reviewers accomplished study selection,data extraction and quality assessment.Finally,use Review Manager 5.3 software to complete the Meta-analysis.Results: 19 studies were selected for analysis in terms of into and exclusion criteria.Among the 19 studies,15 reported on uterine artery chemoembolization in combination with curettage and aspiration comparing with methotrexate in conjunction with curettage and aspiration,and 4 reported on transvaginal debridement contrast with laparoscopic management.Among total cases,there were 533 patients treated by uterine artery chemoembolization in combination withcurettage and aspiration,383 patients treated by methotrexate in conjunction with curettage and aspiration,114 patients treated by transvaginal debridement and 125 patients treated by laparoscopic management.The Meta-analysis showed: ⑴uterine artery chemoembolization in combination with curettage and aspiration comparing with methotrexate in conjunction with curettage and aspiration,the result of cure rate showed:OR=2.5,95%CI(1.43,4.38),Z=3.20,P=0.001,P<0.05.⑵transvaginal debridement contrast with laparoscopic management,among the included four groups,the result of cure rate showed:RR=1.00,95%CI(0.97,1.03),Z=0.20,P=0.84,P>0.05;blood loss of the operation:SMD=1.17,95%CI(0.82,1.51),Z=6.68,P<0.00001,P<0.05;the result of time of operation:MD=25.23,95%CI(20.08,30.38),Z=9.61,P<0.00001,P<0.05;the return of menses:MD=0.76,95%CI(-0.96,2.48),Z=0.87,P=0.39,P>0.05.Conclusion: ⑴ Uterine artery chemoembolization in combination with curettage and aspiration high cure rate than methotrexate in conjunction with curettage and aspiration.⑵ The curing rate of transvaginal debridement and laparoscopic management had no obvious difference.⑶ The amount of hemorrhage and time of surgery of transvaginal debridement were significantly lower and shorter than those of laparoscopic management.更多还原