Objective: To analyze the clinical features, diagnosis and treatment of gestational trophoblastic diseases in cesarean scar.
Methods: Clinical data of three cases of gestational trophoblastic diseases in cesarean scar diagnosed in Women's Hospital, Zhejiang University School of Medicine during December 2011 and December 2016 were collected. And literature search was performed in Wanfang data, VIP, CNKI, PubMed, ISI Web of Knowledge and EMbase database.
Results: A total of 20 cases of gestational trophoblastic diseases were included in the analysis. Clinical features were mainly abnormal vaginal bleeding after menopause, artificial abortion or medical abortion, which might be accompanied by abdominal pain. Serum β-human chorionic gonadotropin (β-hCG) levels were increased in 19 patients. The sonographic features were increase of uterine volume, honeycomb-like abnormal intrauterine echo (or described as multiple cystic dark area, multiple anechoic area and multiple liquid dark area) or heterogeneity echo conglomeration, and no clear bound with muscular layer in some cases. There were abundant blood flow signals inside or around the lesions. The ultrasonography indicated that the lesions were located in the anterior side of the uterine isthmus with the involvement of cesarean section scar. In 12 cases with lesions in cesarean scar shown by preliminary diagnosis, 9 underwent uterine artery embolization (UAE) for pretreatment; the blood loss greater than 1500 mL was observed in only one case without UAE; no patient received hysterectomy. In 8 patients whose lesions were not shown in cesarean scar, only one case received UAE pretreatment, and hysterectomy was performed in 3 cases due to blood loss greater than 1500 mL. Two cases were lost in follow-up and no death was reported in remaining 18 cases. The serum β-hCG levels returned to normal or satisfactory level during the follow-up in 17 cases with increased β-hCG levels before treatment and no recurrence was observed.
Conclusions: The misdiagnosis rate and missed diagnosis rate of gestational trophoblastic diseases in cesarean section scar are high. The identification of cesarean section scar involvement and UAE may reduce the bleeding and avoid hysterectomy.
目的: 探讨剖宫产术后瘢痕部位妊娠滋养细胞疾病的临床特点、诊断以及治疗方法。
方法: 收集浙江大学医学院附属妇产科医院2011年12月至2016年12月收治的3例剖宫产术后瘢痕部位妊娠滋养细胞疾病患者的临床资料。同时，检索万方数据、维普资讯中文期刊服务平台、中国知网、PubMed、ISI Web of Knowledge和荷兰《医学文摘》，筛选出剖宫产术后瘢痕部位妊娠滋养细胞疾病病例，并进行回顾性分析。
结果: 共有20例患者纳入分析。临床主要表现为停经或人工流产后异常阴道出血，可伴有腹痛；19例患者伴有血β人绒毛膜促性腺激素（β-hCG）异常增高。典型超声表现主要有子宫体积异常增大，宫腔内见蜂窝样异常回声（或描述为多个囊性暗区、多个无回声区及多个液性暗区）或不均质回声团块，可与肌层分界不清，病灶内或周边血流信号丰富；部分超声检查同时提示病灶位于前峡部或累及剖宫产术后瘢痕部位。初步诊断提示为剖宫产术后瘢痕部位病灶的12例患者中，9例接受了子宫动脉栓塞术（UAE）预处理，仅1例未行UAE的患者出血量大于1500 mL，均未发生因大出血而切除子宫的情况；而初步诊断未提示剖宫产术后瘢痕部位病灶的8例患者中，其中1例接受了UAE预处理，3例因出血量大于1500 mL而切除子宫。除2例患者未提供随访信息或失访，18例患者随访至今均无死亡病例。其中15例患者血β-hCG降至正常，2例血β-hCG下降理想，1例血β-hCG阴性，随访期间所有患者均未复发。
结论: 剖宫产术后瘢痕部位妊娠滋养细胞疾病出血风险高，误诊、漏诊率高，初步诊断是否发现病灶累及剖宫产术后瘢痕部位可间接影响总出血量和子宫切除的风险，而UAE是减少出血量和降低子宫切除率的有效手段。