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1、剖宫产术后子宫瘢痕妊娠诊治专家共识2016 中华医学会妇产科学分会计划生育学组选自：中华妇产科杂志2016 年 8 月第 51 卷第 8 期第 568-572 页剖宫产术后子宫瘢痕妊娠cesarean scarpregnancy,CSP 是指受精卵着床于前次剖宫产子宫切口瘢痕处的1 种异位妊娠，是1 个限时定义，仅限于早孕期12周；孕12 周以后的中孕期CSP 则诊断为“宫内中孕，剖宫产术后子宫瘢痕妊娠，胎盘植入”，如并发有胎盘前置，则诊断为“宫内中孕，剖宫产术后子宫瘢痕妊娠，胎盘植入，胎盘前置状态”，到了中晚孕期则为胎盘植入及前置胎盘，即形成所谓的凶险性前置胎盘pernicious plac
2、entaprevia。由于 CSP 可以造成清宫手术中及术后难以控制的大出血、子宫破裂、周围器官损伤，甚至切除子宫等，严重威胁妇女的生殖健康甚至生命，已引起临床上的高度重视。CSP 的发生率为12 2161 1 800，占有剖宫产史妇女的1.15%，占有前次剖宫产史妇女异位妊娠的6.1%1-2。目前，CSP 的发病机制尚不清楚，对CSP 的诊断与治疗在国内外均无统一的标准和指南以及较好的循证医学证据，缺乏大样本量的随机对照研究。鉴于 CSP 发生率逐渐升高及其所引起的严重并发症，以及近几年对CSP 诊治经验的积累及大量的临床研究结果，有必要结合2012 年中华医学会计划生育学分会制定的“CSP
3、 诊治共识”3，改良并形成我国关于CSP 诊治的新的专家共识，以指导临床工作，标准临床诊疗行为。特别说明的是，本共识仅针对的是孕12 周内的早孕期CSP。1 临床表现CSP 早孕期无特异性的临床表现，或仅有类似先兆流产的表现，如阴道少量流血、轻微下腹痛等4。2 诊断 CSP 的诊断方法首选超声检查，特别是经阴道和经腹超声联合使用，不仅可以帮助定位妊娠囊，更有利于明确妊娠囊与子宫前壁下段肌层及膀胱的关系。典型的超声表现5为：1宫腔内、子宫颈管内空虚，未见妊娠囊；2妊娠囊着床于子宫前壁下段肌层相当于前次剖宫产子宫切口部位，部分妊娠囊内可见胎芽或胎心搏动；3子宫前壁肌层连续性中断，妊娠囊与膀胱之间的
4、子宫肌层明显变薄、甚至消失；4彩色多普勒血流显像colorDoppler flow imaging，CDFI 显示妊娠囊周边高速低阻血流信号。当超声检查无法明确妊娠囊与子宫及其周围器官的关系时，可进行MRI 检查。MRI 检查矢状面及横断面的T1、T2 加权连续扫描均能清晰地显示子宫前壁下段内的妊娠囊与子宫及其周围器官的关系。但因为费用较昂贵，所以，MRI 检查不作为首选的诊断方法。血清 -hCG 对于 CSP 的诊断并无特异性，有胎心的CSP 血清 -hCG 水平可以高过100 000 U/L。对于异常升高的-hCG 也要警惕是否合并妊娠滋养细胞肿瘤。-hCG 在治疗后的随诊中评价治疗效果时
5、非常重要。3 分型根据超声检查显示的着床于子宫前壁瘢痕处的妊娠囊的生长方向以及子宫前壁妊娠囊与膀胱间子宫肌层的厚度进行分型6。此分型方法有利于临床的实际操作。型：1妊娠囊部分着床于子宫瘢痕处，部分或大部分位于宫腔内，少数甚或达宫底部宫腔；文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z
6、7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI
7、4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5
8、V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 Z
9、T2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8
10、S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文
11、档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX
12、2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A102妊娠囊明显变形、拉长、下端成锐角；3妊娠囊与膀胱间子宫肌层变薄，厚度3 mm；4CDFI：瘢痕处见滋养层血流信号低阻血流。型：1妊娠囊部分着床于子宫瘢痕处，部分或大部分位于宫腔内，少数甚或达宫底部宫腔；2妊娠囊明显变形、拉长、下端成锐角；3妊娠囊与膀胱间子宫肌层变薄，厚度3 mm；4CDFI：瘢痕处见滋养层血流信号低阻血流。型：1妊娠囊完全着床于子宫瘢痕处肌层并向膀胱方向外凸；2宫腔及子宫颈管内空虚；3妊娠囊与膀胱之间子宫肌层明显变薄、甚或缺失，厚度3 mm；4CDFI：瘢痕处见滋养层血流信号低阻血流。其中，型中还有1 种
13、特殊的超声表现CSP，即包块型，其声像图的特点7：1位于子宫下段瘢痕处的混合回声呈囊实性包块，有时呈类实性；包块向膀胱方向隆起；2包块与膀胱间子宫肌层明显变薄、甚或缺失；3CDFI：包块周边见较丰富的血流信号，可为低阻血流，少数也可仅见少许血流信号、或无血流信号。包块型多见于CSP 流产后如药物流产后或负压吸引术后子宫瘢痕处妊娠物残留并出血所致。这种分型方法有别于2000 年 Vial 等 8的两分法 内生型和外生型。后者根据妊娠囊植入子宫瘢痕处的程度和妊娠囊的生长方向进行分型，缺乏用于指导临床治疗的可以依据的数据文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A
14、10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码
15、:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7
16、V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3
17、 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V1
18、0Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V
19、2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X
20、5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10及定量指标，不利于实际操作。4 鉴别诊断1.子宫颈妊娠：为妊娠囊着床于子宫颈管内，但子宫前壁下段的肌层连续性无中断。盆腔检查时，可发现子宫颈膨大，甚至可呈上小下大的葫芦形，子宫颈可成紫蓝色，但子宫颈外口闭合。鉴别时主要依据是否有剖宫产史，超声检查妊
21、娠囊着床的位置能进一步明确诊断。当妊娠周数较大或包块较大时，区分起来可能比较困难，如患者有剖宫产史，应高度疑心CSP。2.宫内妊娠难免流产：当宫内妊娠难免流产时，宫内妊娠囊向体外排出时暂时停留于前次剖宫产子宫瘢痕处，此时超声检查可以在子宫瘢痕部位见妊娠囊或混合回声包块。鉴别时要注意病史，如有腹痛、阴道流血、子宫颈口张开，多是宫内早孕、难免流产。此外，超声检查需注意妊娠囊或包块在子宫瘢痕处有无高速低阻血流、前次剖宫产子宫瘢痕处的肌层是否有连续性中断。3.妊娠滋养细胞肿瘤：CSP 清宫不全或不全流产后残留的妊娠物继续生长在子宫前壁下段形成包块，其超声影像类似于妊娠滋养细胞肿瘤的表现，如与肌层无明显
22、界线、局部肌层缺如或变薄、局部血流信号极其丰富、可探及高速低阻血流、甚至出现动静脉瘘的花色血流信号等，易误诊为妊娠滋养细胞肿瘤。但CSP 有明确的剖宫产史，常常有人工流产或药物流产史，包块位于子宫前壁下段、与子宫瘢痕关系密切，且血-hCG 水平通常不会很高，很少超过 100 000 U/L。结合病史和辅助检查，应首先考虑CSP 的可能，不要盲目按照妊娠滋养细胞肿瘤进行化疗9。5 治疗早孕期 CSP 作为 1 种特殊类型的异位妊娠，诊治原则是：早诊断，早终止，早清除。早诊断是指对有剖宫产史的妇女再次妊娠时应尽早行超声检查排除CSP。一旦诊断为CSP 应给文档编码:CX2V7V8Z7D3 HI4V
23、10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2
24、V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2
25、X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1
26、A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编
27、码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V
28、7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D
29、3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10出终止妊娠的医学建议，并尽早清除妊娠物。如患者因自身原因坚决要求继续妊娠，应交待继续妊娠可能发生的风险和并发症，如前置胎盘、胎盘植入、子宫破裂等所致的产时或产后难以控制的大出血甚至子宫切除、危及生命等险恶结局，
30、并签署知情同意书。终止妊娠时应尽可能遵循和选择终止早孕的基本原则和方法，以减小损伤，尽可能保留患者的生育能力为目的。治疗方法有药物治疗、手术治疗或两者的联合。子宫动脉栓塞术uterine artery embolization，UAE)是用于辅助治疗CSP 的重要手段，与药物治疗或手术治疗联合可更有效地处理 CSP。一药物治疗目前，较为公认的治疗药物是甲氨蝶呤methotrexate，MTX，MTX 治疗早孕期CSP 的适应证：1.生命体征平稳，血常规、肝肾功能基本正常。2.不愿意或不适合手术治疗的早孕期CSP 患者。孕周越小，-hCG 水平越低，成功率越高。3.型和型CSP 患者在行清宫手术
31、或CSP 妊娠物清除手术前的预处理，可及时阻止妊娠的进一步发展，降低术中出血的风险。4.手术治疗后血-hCG 水平下降缓慢或再次升高，不适合再次手术的患者，可采用MTX 保守治疗。美国食品药品管理局 FDA 关于单剂量MTX 治疗异位妊娠的标准是否适合CSP，目前尚无很好的循证医学证据。临床中，有 MTX 联合 UAEMTX25 mg，分别双侧子宫动脉注射后栓塞，总量50 mg、也有超声引导下妊娠囊内局部注射2550 mg、或全身单剂量注射 MTX50 mg/m2 等方案治疗CSP，研究结果显示，无论单独应用MTX 或联合 UAE，治疗 CSP 具有一定的效果，但治疗总时间长，并且有治疗失败的
32、可能10-11，成功率文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8
33、S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文
34、档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX
35、2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z
36、7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI
37、4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5
38、V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10在 71%83%12。MTX 治疗期间随时会发生严重的子宫出血，需在有条件进一步处理的医院进行。在药物治疗中须采用经阴道彩超监测妊娠囊或包块周围血
39、流信号的变化，定期检测血-hCG 水平，以了解治疗效果。如治疗效果满意每周检测1 次，每次-hCG 下降幅度 15%，可视为有效 13，则血流明显减少甚至消失，包块明显缩小。如血-hCG 下降不满意，或高速低阻血流信号持续存在，提示患者对MTX 治疗反应差，可1 周后增加药物治疗次数，或改变治疗方法。应用MTX 保守治疗的CSP 患者，在血-hCG 下降至 50 U/L 或正常后可在B 超监护下行清宫手术以缩短治疗时间，减少大出血的风险14。单纯药物治疗不作为治疗CSP 的首选方案 15。二 UAE 1.适应证:1用于 CSP 终止妊娠的手术时或自然流产时发生大出血需要紧急止血；2型和型CSP
40、，包块型血液供给丰富者，手术前预处理行UAE，以减少清宫手术或 CSP 妊娠物清除手术中的出血风险。2.注意事项：1剖宫产术后子宫下段可出现异生血管，故 UAE 较其他情况更困难。栓塞剂使用量大，术后发生栓塞剂脱落的风险增高。栓塞不完全的概率增加，术中止血的保障成效下降。2建议使用新鲜明胶海绵颗粒直径1 3 mm，栓塞双侧子宫动脉，如有其他髂内动脉分支供血，可栓塞髂内动脉前干。3建议在UAE 后 72 h 内完成清除CSP 妊娠物的手术清除操作，以免侧支循环建立，降低止血效果 16。文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7
41、D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4
42、V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V
43、2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT
44、2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S
45、1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档
46、编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2
47、V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10三手术治疗手术方法分为清宫手术、妊娠物清除术及子宫瘢痕修补术、子宫切除术。清宫手术包括：超声监视下清宫手术、宫腔镜下妊娠物清除术等。妊娠物清除术及子宫瘢痕修补术可通过开腹、腹腔镜 或联合宫腔镜，也有报道可经阴道途径手术。子宫切除术是在紧急情况下为挽救患者生命或患者无生育要求时的选
48、择，可选择开腹或腹腔镜途径。选择各种手术治疗方法需依据分型、发生出血的危险因素以及患者的生育要求。有出血高风险时可在手术前进行预处理，如MTX 治疗或 UAE。现就各种手术方法的适应证及注意事项具体阐述如下。1.超声监视下清宫手术：1适应证：生命体征平稳，孕周8 周的型 CSP。型、型CSP 以及孕周 8 周的型 CSP 如行清宫手术前需进行术前预处理，如 UAE 或 MTX 治疗，以减少术中出血17。2注意事项：清宫时应先吸除子宫中上段及下段后壁的蜕膜组织，再尽量吸去妊娠囊，之后以较小的压力200 300 mmHg；1 mmHg 0.133 kPa 清理前次剖宫产子宫瘢痕处的蜕膜和残余的绒毛
49、组织；尽量防止搔刮，尤其是过度搔刮。对于孕周6 cm 者则不宜选择经阴道手术。文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V
50、7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D3 HI4V10Z5V2V2 ZT2X5H8S1A10文档编码:CX2V7V8Z7D