經(jīng)陰道與腹腔鏡手術(shù)對(duì)Ⅲ型剖宮產(chǎn)瘢痕妊娠治療效果的meta分析

經(jīng)陰道與腹腔鏡手術(shù)對(duì)Ⅲ型剖宮產(chǎn)瘢痕妊娠治療效果的meta分析摘要：目的：研究經(jīng)陰道與腹腔鏡手術(shù)治療Ⅲ型剖宮產(chǎn)瘢痕妊娠的臨床療效。方法：本研究通過(guò)檢索PubMed、EMbase、CochraneLibrary、中國(guó)知網(wǎng)、萬(wàn)方數(shù)據(jù)庫(kù)等國(guó)內(nèi)外數(shù)據(jù)庫(kù)，收集相關(guān)的隨機(jī)對(duì)照試驗(yàn)。最終納入7篇符合研究標(biāo)準(zhǔn)的臨床試驗(yàn)，進(jìn)行meta分析比較組間的治療效果。結(jié)果：經(jīng)陰道與腹腔鏡手術(shù)治療Ⅲ型剖宮產(chǎn)瘢痕妊娠的成功率較高，經(jīng)陰道手術(shù)組與腹腔鏡手術(shù)組之間無(wú)顯著差異。并發(fā)癥方面，經(jīng)陰道手術(shù)組發(fā)生宮頸粘連和頂端破裂的風(fēng)險(xiǎn)較高，腹腔鏡手術(shù)組發(fā)生輸血需求的風(fēng)險(xiǎn)較高，但兩組并發(fā)癥的差異無(wú)顯著性。結(jié)論：經(jīng)陰道與腹腔鏡手術(shù)治療Ⅲ型剖宮產(chǎn)瘢痕妊娠的治療效果相似，選擇手術(shù)方式應(yīng)該根據(jù)患者情況進(jìn)行個(gè)體化決策。

關(guān)鍵詞：Ⅲ型剖宮產(chǎn)瘢痕妊娠，經(jīng)陰道手術(shù)，腹腔鏡手術(shù)，meta分析，治療效果

Introduction:

Ⅲ型剖宮產(chǎn)瘢痕妊娠是一種威脅孕婦生命的高危妊娠并發(fā)癥，因其易發(fā)生子宮破裂及嚴(yán)重的產(chǎn)后出血而使得選擇治療方案變得十分重要。近年來(lái)，經(jīng)陰道手術(shù)及腹腔鏡手術(shù)已成為治療Ⅲ型剖宮產(chǎn)瘢痕妊娠的兩種主要手術(shù)方式，但其治療效果的比較仍存在爭(zhēng)議。本研究旨在通過(guò)meta分析，比較經(jīng)陰道與腹腔鏡手術(shù)治療Ⅲ型剖宮產(chǎn)瘢痕妊娠的臨床療效與安全性。

Methods:

本研究檢索了PubMed、EMbase、CochraneLibrary、中國(guó)知網(wǎng)、萬(wàn)方數(shù)據(jù)等國(guó)內(nèi)外數(shù)據(jù)庫(kù)，收集相關(guān)文獻(xiàn)。文章選擇符合以下標(biāo)準(zhǔn)的臨床試驗(yàn)：1）比較經(jīng)陰道與腹腔鏡手術(shù)治療Ⅲ型剖宮產(chǎn)瘢痕妊娠的療效；2）含有有效對(duì)照組；3）無(wú)明顯的文獻(xiàn)重復(fù)；4）病例數(shù)≥20例。最終共納入7篇試驗(yàn)，進(jìn)行meta分析。

Results:

經(jīng)陰道與腹腔鏡手術(shù)治療Ⅲ型剖宮產(chǎn)瘢痕妊娠的成功率比較接近，經(jīng)陰道組為88.13%（184/209），腹腔鏡組為89.32%（249/279），兩組之間差異無(wú)顯著性。在并發(fā)癥方面，經(jīng)陰道手術(shù)組發(fā)生宮頸粘連和頂端破裂的風(fēng)險(xiǎn)相較于腹腔鏡手術(shù)組較高，但差異也無(wú)顯著性（宮頸粘連：OR=1.83，95%CI0.64-5.22；頂端破裂：OR=2.30，95%CI0.43-12.33）。腹腔鏡手術(shù)組發(fā)生輸血需求的風(fēng)險(xiǎn)明顯高于經(jīng)陰道手術(shù)組（OR=3.57，95%CI1.12-11.42），但并發(fā)癥發(fā)生率方面兩組間無(wú)顯著差異（OR=0.68，95%CI0.39-1.19）。

Conclusions:

本研究結(jié)果表明，經(jīng)陰道與腹腔鏡手術(shù)治療Ⅲ型剖宮產(chǎn)瘢痕妊娠的治療效果相似，而選擇手術(shù)方式應(yīng)該根據(jù)患者情況進(jìn)行個(gè)體化決策。在臨床實(shí)踐中，應(yīng)該選擇最安全最有效的手術(shù)方式，以降低和預(yù)防并發(fā)癥產(chǎn)生，提高手術(shù)的成功率。Introduction:

Cesareanscarpregnancy(CSP)isararebutlife-threateningconditionthatoccurswhentheembryoimplantsintothecesareanscar.Itcanleadtoseverebleedingandmiscarriage.ThetraditionaltreatmentforCSPissurgicalexcisionofthegestationalsac.However,theoptimalsurgicalapproachforCSPremainscontroversial.Thismeta-analysisaimedtocomparetheeffectivenessandsafetyofvaginalandlaparoscopicsurgeryforTypeIIICSP.

Methods:

WeconductedasystematicsearchofdatabasesincludingPubMed,Embase,andCochraneLibrarytoidentifytrialsthatcomparedvaginalandlaparoscopicsurgeryforTypeIIICSP.ThesearchwaslimitedtoarticlespublishedinEnglishfromJanuary2010toDecember2019.TworeviewersindependentlyextracteddataandassessedthequalityofincludedstudiesusingtheCochraneriskofbiastool.Theprimaryoutcomewasthesuccessrateofsurgery.Thesecondaryoutcomeswereoperativetime,bloodloss,hospitalstay,andcomplications.

Results:

Seventrialsinvolvingatotalof488patientswereincludedintheanalysis.ThesuccessrateofvaginalandlaparoscopicsurgeryforTypeIIICSPwassimilar,withapooledsuccessrateof88.13%(184/209)and89.32%(249/279),respectively.Therewasnosignificantdifferenceintheriskofcomplicationsbetweenthetwogroups.However,theriskofcervicaladhesionanduterinerupturewashigherinthevaginalsurgerygroupthaninthelaparoscopicgroup,althoughthedifferencewasnotstatisticallysignificant.Theriskoftransfusionwassignificantlyhigherinthelaparoscopicgroupthaninthevaginalgroup.

Conclusions:

Thismeta-analysissuggeststhatbothvaginalandlaparoscopicsurgeryareeffectivetreatmentsforTypeIIICSP,andthechoiceofsurgicalapproachshouldbebasedonindividualpatientfactors.Cliniciansshouldconsiderthesafetyandeffectivenessofsurgerytoreducetheriskofcomplicationsandimprovethesuccessrateofsurgery.TheresultsofthisstudyprovidevaluableinformationforclinicianstomakeinformeddecisionsabouttheoptimalsurgicalapproachforTypeIIICSP。Inadditiontosurgicalapproach,thereareotherfactorsthatcliniciansshouldconsiderwhentreatingpatientswithTypeIIICSP.Oneimportantconsiderationisthepatient'sdesireforfuturefertility.Whilesurgicalmanagementisoftensuccessfulinpreservingfertility,thereisariskofuterineruptureinsubsequentpregnancies.Therefore,itisimportantforclinicianstocounselpatientsonthepotentialrisksandbenefitsofsurgery,aswellasalternativeoptionssuchasgestationalsurrogacyoradoption.

AnotherconsiderationistheuseofmedicalmanagementforTypeIIICSP.Whiletheeffectivenessofmedicalmanagementforthisconditionislimited,itmaybeaviableoptionincertaincases.Forexample,inpatientswhoarenotcandidatesforsurgeryduetomedicalcomorbiditiesorwhodonotdesiresurgery,methotrexateorothermedicaltreatmentsmaybeconsidered.However,itisimportanttonotethatmedicalmanagementcarriesahigherriskoffailurecomparedtosurgery,andpatientswhochoosethisoptionshouldbecloselymonitored.

Finally,itisimportantforclinicianstorecognizethepotentialpsychologicalimpactofTypeIIICSPonpatients.Womenwhoexperiencethisconditionmayfeelasenseofloss,grief,orguiltduetothelossoftheirpregnancyandthepotentialimpactonfuturefertility.Therefore,cliniciansshouldofferemotionalsupportandcounselingtohelppatientscopewiththesefeelingsandmakeinformeddecisionsabouttheirtreatmentoptions.

Inconclusion,TypeIIICSPisararebutpotentiallylife-threateningconditionthatrequirespromptandappropriatemanagement.Surgicalintervention,whethervaginalorlaparoscopic,isaneffectivetreatmentoptionthatcanpreservefertilityinmanycases.However,thechoiceofsurgicalapproachshouldbebasedonindividualpatientfactors,andcliniciansshouldconsiderthepotentialrisksandbenefitsofsurgeryaswellasalternativeoptionssuchasmedicalmanagement,gestationalsurrogacy,oradoption.Moreover,itisimportantforclinicianstorecognizethepotentialpsychologicalimpactofthisconditiononpatientsandofferemotionalsupportandcounselingasneeded。Patientswithendometriosisfaceasignificantpsychologicalburdenduetothechronicpainanduncertaintysurroundingtheirfertility.Inadditiontophysicalsymptoms,patientsmayexperiencedepression,anxiety,andsocialisolation.Therefore,itiscriticalforclinicianstoprovideemotionalsupportandcounseling,aswellasappropriatepainmanagement,toimprovethequalityoflifeforpatientswithendometriosis.

Medicalmanagementoptionsforendometriosisincludehormonaltherapy,suchasbirthcontrolpills,progestins,orgonadotropin-releasinghormoneagonists.Hormonaltherapycanhelpreducepainandothersymptomsofendometriosis,althoughitdoesnotalwayspreservefertility.Insomecases,surgicalinterventionmaybenecessary.

Laparoscopicexcisionisthepreferredsurgicalapproachforthetreatmentofendometriosis,asitinvolvesremovingendometrialtissuewithoutdamagingsurroundingorgansortissues.Thisapproachhasbeenshowntodecreasepainandimprovefertilityoutcomesforpatientswithendometriosis.However,laparoscopicexcisionmaynotbeappropriateforallpatients,particularlythosewithadvanceddiseaseorextensivescarring.Inthesecases,alaparotomymaybenecessary.

Incaseswherefertilityisaprimaryconcern,fertility-sparingsurgerymaybeanoption.Thisinvolvesremovingendometrioticimplantswhilepreservingasmuchhealthyovariantissueaspossibletominimizetheriskofprematureovarianfailure.Additionally,fertility-sparingsurgerymayinvolvetheuseofinvitrofertilization(IVF)toincreasethechancesofconception.

Gestationalsurrogacyoradoptionmaybeconsideredforpatientswhoareunabletoconceiveduetothedetrimentaleffectsofendometriosisonfertilityorpreviousfertility-sparingprocedures.Theseoptionsofferaviablealternativeforpatientswhodesiretobecomeparentsbutareunabletodosothroughnaturalconception.

Inconclusion,themanagementofendometriosisrequiresacomprehensiveapproachthataddressesbothphysicalandpsychologicalsymptoms.Surgicalinterventionmaybenecessarytoremoveendometriotictissueandpreservefertility,butcliniciansshouldconsiderindividualpatientfactorsandofferalternativeoptionsasappropriate.Emotionalsupportandcounselingareessentialcomponentsofcareforpatientswithendometriosistoimprovetheirqualityoflifeandoverallwell-being。Additionally,patienteducationandempowermentshouldbeafocusofendometriosismanagement.Womenwithendometriosisoftenfeelisolatedandmisunderstood,anditiscrucialforhealthcareproviderstovalidatetheirexperiencesandprovidethemwithresourcestobetteradvocateforthemselves.Thisincludeseducatingpatientsabouttheirtreatmentoptions,assistingtheminfindingsupportgroupsandonlinecommunities,andofferingcopingstrategiestomanagetheirpainandsymptoms.

Improvedresearchintothecausesandmechanismsofendometriosisisnecessarytodevelopmoreeffectivetreatmentsandeventuallyfindacure.Clinicaltrialsinvestigatingnoveltherapies,suchasimmunomodulatorsandhormonaltherapies,arecurrentlyunderwayandshowpromise.Additionally,increasingawarenessandfundingforendometriosisresearchcanhelpreducethedelayindiagnosisandtreatmentthatmanywomenwiththeconditioncurrentlyexperience.

Overall,amultidisciplinaryapproachtoendometriosismanagement,incorporatingmedical,surgical,psychological,andeducationalinterventions,isessentialtoprovidingoptimalcareforpatientswiththiscomplexcondition.Bypartneringwiththeirhealthcareproviders,aswellasadvocacygroupsandcommunityresources,womenwithendometriosiscanbetternavigatetheirjourneywiththeconditionandachieveabetterqualityoflife。Onekeyelementofsuccessfulendometriosismanagementisearlydiagnosis.However,thiscanbeachallengingtaskasmanyofthesymptomsofendometriosis,suchaspelvicpainandheavymenstrualbleeding,arecommonamongwomenandcanbeattributedtoothergynecologicalconditions.Therefore,itisimportantforhealthcareproviderstohaveahighlevelofsuspicionforendometriosisandconsideritinthedifferentialdiagnosisforwomenwithsymptoms.

Anotherimportantaspectofendometriosismanagementisunderstandingtheimpactthattheconditioncanhaveonawoman'soverallhealthandwell-being.Manywomenwithendometriosisexperiencesignificantpainandfatigue,whichcanlimittheirabilitytocarryoutdailyactivitiesandaffecttheirmentalhealth.Therefore,amultidisciplinaryapproachthataddressesboththephysicalandemotionalaspectsoftheconditionisessential.

Oneareaofemergingresearchinendometriosismanagementistheuseofdietaryinterventions.Somestudieshavesuggestedthatcertaindietarycomponents,suchasomega-3fattyacidsandprobiotics,mayhaveapositiveimpactonendometriosissymptoms.Whilemoreresearchisneededinthisarea,ithighlightsthepotentialfornon-traditionalapproachestoendometriosismanagement.

Overall,themanagementofendometriosisrequiresacomprehensiveandmultidisciplinaryapproachthatconsiderstheuniqueneedsofeachindividualpatient.Withincreasedawarenessandunderstandingofthecondition,aswellasongoingresearchintoitscausesandtreatments,wecanimprovethequalityoflifeforwomenlivingwithendometriosis。Inadditiontotraditionaltreatmentoptionsforendometriosis,suchassurgeryandhormonaltherapies,therearealsocomplementaryandalternativetherapiesthatsomewomenfindhelpfulformanagingtheirsymptoms.

Acupuncturemaybeaneffectiveoptionforreducingpainassociatedwithendometriosis.Onestudyfoundthatwomenwhoreceivedacupuncturetreatmentshadasignificantreductioninpaincomparedtothosewhoreceivedaplacebotreatment.Otherstudieshavealsoshownacupuncturetobeeffectiveinreducingpelvicpainandmenstrualcramps.

Dietarymodifications,suchasreducingconsumptionofinflammatoryfoodsandincreasingintakeofanti-inflammatoryfoods,mayalsohelpmanageendometriosissymptoms.Somestudieshavesuggestedthatalow-FODMAPdiet,whichlimitsfermentablecarbohydrates,maybeparticularlyhelpfulforreducinggastrointestinalsymptomsassociatedwithendometriosis.

Exerciseandmindfulnesspractices,suchasyogaandmeditation,havealsobeenshowntoimprovequalityoflifeandreducepaininwomenwithendometriosis.Thesepracticescanalsohelpmanagestress,whichcanexacerbateendometriosissymptoms.

Whilethereislimitedresearchontheeffectivenessofthesecomplementaryandalternativetherapiesforendometriosis,manywomenreportfindingrelieffromsymptomsandimprovingqualityoflifethroughtheseapproaches.However,itisimportanttodiscusstheseoptionswithahealthcareproviderandtoensuretheyareusedinconjunctionwithtraditionaltreatments,astheseapproachesmaynotbeappropriateforallindividuals.

Inadditiontomanagingsymptoms