The aim is to kill the embryo, exclude the gestational sac, preserve the reproductive function and stop bleeding.
The most commonly used first-line drug is MTX.
It inhibits the growth and reproduction of trophoblast cells, destroys the villi, and causes necrosis, shedding and absorption of the villi. There are many methotrexate treatment options for CSP and no consensus has been reached. The main regimens are as follows.
(1) MTX systemic treatment a. When β-hCG <5 000IU/L, intramuscular MTX is used and the treatment effect is satisfactory.
b. When β-hCG≥6 000 IU/L, in addition to intramuscular injection of MTX, adjuvant treatment is required, including intra-cystal injection of MTX, curettage, uterine artery embolization and catheter balloon compression to stop bleeding. If treatment fails, surgical treatment is still required.
(2) MTX local treatment is more effective with ultrasound-guided local injection of MTX into the fetal sac.
(3) Combination of systemic and local MTX therapy is considered more effective and safe for those with β-hCG >5,000 IU/L.
(4) Mifepristone Mifepristone is a progestin antagonist, which binds to progesterone receptors, blocks the physiological activity of progesterone and causes degeneration and necrosis of the underlying metaplasia due to loss of progesterone support; inhibits villi proliferation, induces and promotes apoptosis, inhibits villi growth, increases fibrinolytic activity of villi and metaplasia, and promotes hydrolysis of the extracellular matrix.
Usage: 50 mg once every 12 h for 3 times, then 25 mg once every 12 h or once daily for 7 days.
(5) The combination of the two drugs MTX inhibits the division and proliferation of trophoblast cells, destroys the living embryonic tissue and leads to embryonic death. And mifepristone competes with progesterone receptor, antagonizes progesterone activity and causes degeneration of chorionic tissue and atrophic necrosis of meconium tissue, leading to embryonic death, and the combination of the two has a synergistic effect. Some scholars have shown that the success rate of combined treatment of the two drugs is 81, 2(6) Fluorouracil trophoblast cells are particularly sensitive to it, and the placental villi can be necrosed and shed after using fluorouracil.
Fluorouracil was injected locally under ultrasound guidance in a single dose of 250-300 mg twice a week, 500-600 mg for one course of treatment.
During the above drug treatment, the patient was observed for vaginal bleeding, abdominal pain, and monitored for blood changes and adverse reactions to drug chemotherapy. 7 days blood β-HCG value was rechecked to decide whether to repeat the drug treatment, and after the blood β-HCG value dropped to a certain level (about 1000 u/L or less), the uterus was cleared under hysteroscopy with ultrasound monitoring. The uterus is cleared under direct vision to completely remove the residual pregnancy tissue, and also to stop the bleeding of the trauma by electrocoagulation to ensure the quality and safety of the operation.
2.Methotrexate conservative treatment with ultrasound-monitored curettage is a safe and effective treatment method suitable for primary hospitals. It is suitable for patients with low vaginal bleeding and good general condition. Follow-up blood β-HCG is the golden indicator to monitor the efficacy. Scraping after the blood β-HCG has returned to nearly normal levels can substantially reduce intraoperative haemorrhage. Ultrasound-monitored curettage can be used for termination of pregnancy to avoid the risk of multiple curettage and uterine perforation.
When conservative treatment for uterine clearance, the amount of bleeding during the operation should be observed, and the cleared tissues should be sent for pathological examination after the operation. After the operation, we can add the auxiliary treatment with traditional Chinese medicine biochemical soup, monitor the blood β-HCG value to the normal time, trace the pathological examination results, the time of vaginal bleeding, and the time of menstrual return to normal.
(1) Timing and principles of curettage under ultrasound monitoring:
To be performed after embryonic death, blood hCG drops to normal or near normal, ultrasound images show no local blood flow, otherwise there is a risk of uterine perforation or uncontrollable hemorrhage, the need for transabdominal uterine plasma layer resection of the pregnancy foci, repair of the uterus or hysterectomy after suspected cesarean section pregnancy at the uterine scar should not be performed immediately after scraping drugs or uterine artery embolization whether scraping, according to the level of the anterior uterine wall scar, muscle layer (2) absolute contraindication to curettage:
The myometrium between the pregnancy and the bladder is so thin that it has even reached the space between the bladder and the uterus or is convex to the bladder.
3, uterine artery embolization (UAE) is considered by some scholars to be the preferred and effective treatment for CSP and the only method that can replace hysterectomy to control pelvic bleeding (1) interventional method: after anesthesia, the patient is punctured from the right femoral artery, the left and right uterine arteries are cannulated successively, and methotrexate 50-100 mg is first instilled bilaterally after confirmation by imaging After the embolization, gelatin sponge pellets were used under fluoroscopy, and the arterial flow was interrupted after reconstructive confirmation, and the occlusion treatment was completed.
Postoperative monitoring of blood β-HCG value, if the decline is not obvious and then with MTX intramuscular injection, each 50 mg every other day, the total amount of not more than 200 mg (2) the need and advantages of interventional treatment timely hemostasis intraoperative simultaneous MTX infusion can kill embryonic tissue, conducive to surgical clearance after 48 hours, 1 week clearing the uterus when the embolization vessels have not been reopened (12-24 days), intraoperative bleeding will be significantly reduced It can avoid the removal of the uterus and preserve the reproductive function (3) Interventional complications generally will not have serious complications, some postoperative will cause hypothermia, abdominal pain, generally do not need special treatment. Uterine artery embolization plus ultrasound-supervised scraping of the uterus can have a better hemostatic effect for patients with a lot of bleeding. It is currently the preferred method to preserve the uterus for effective hemostasis. This method is less invasive, safe and fast, and can clearly show the bleeding vessels and accurately embolize them.
4.Surgical treatment final treatment methods: (1) local lesion excision plus repair : open and lumpectomy two kinds are suitable for: more vaginal bleeding after drug conservative treatment, blood HCG continues not to drop, or drops slowly and rebound after dropping; or when ultrasound suggests that the mass at the caesarean incision in the anterior wall of the uterus isthmus is gradually increasing, and there is even a risk of penetrating the plasma membrane layer.
HCG decreases rapidly: about 1 week; most scholars believe that the lower uterine incisional pregnancy with parallel repair is a safer and more effective method, on the grounds that the operation can not only effectively terminate the pregnancy, but also repair the scar defect and preserve the reproductive function (2) direct vision clearance + uterine repair: this method is suitable for rapid vaginal bleeding during conservative drug treatment or clearance, high blood β-HCG value, and the mass within the mass The method has obvious advantages in emergency situations. This procedure can preserve the uterus and avoid hysterectomy, with a small surgical scope, less damage and correspondingly less risk.
(3) Radiofrequency self-coagulation knife treatment delivers ablative self-coagulation knife to the uterine incision of pregnancy under ultrasound guidance, and electrocoagulates with a power of 50 W for about 3 min, causing a hyperthermal reaction of the tissue until it coagulates, degenerates and necroses, dissolves and discharges, thus achieving the purpose of hemostasis. It is suitable for low vaginal bleeding, no obvious gestational sac at the uterine scar site, low blood β-HCG value or after conservative treatment with CSP drugs.
(4) Hysterectomy:
It can be effective in controlling bleeding and saving lives. Hysterectomy is not always safe and the patient is permanently incapacitated. Preservation of the uterus facilitates endocrine regulation and has a positive effect on ensuring organ integrity and protecting the female physiology and psychology. This procedure is mainly used in women without fertility requirements, in older women and when bleeding is life-threatening.