单剂量甲氨蝶呤治疗低水平血清人绒毛膜促性腺激素输卵管妊娠的临床疗效及影响因素分析

Clinical effect of single dose methotrexate (MTX) on tubal pregnancy with low level serum β-hCG and its influencing factors

摘要:

目的： 分析单剂量甲氨蝶呤（methotrexate，MTX）对低水平血清人绒毛膜促性腺激素（human chorionic gonadotropin，β-hCG）输卵管妊娠患者的治疗效果及影响因素，为临床选择合理的治疗方案提供一定依据。方法： 回顾性分析2020年1月至12月重庆医科大学附属妇女儿童医院妇产科收治的214例血清β-hCG低于1 500 IU/L，且采用单剂量MTX杀胚治疗的输卵管妊娠患者临床资料，并选取同期80例血清β-hCG为1 000~1 500 IU/L而直接选择手术治疗的患者为对照。将单剂量MTX杀胚治疗的患者按照初始治疗前血清β-hCG高低分为3个亚组：A组（β-hCG<500 IU/L）、B组（500 IU/L≤β-hCG<1 000 IU/L）、C组（1 000 IU/L≤β-hCG<1 500 IU/L），比较3组患者的临床疗效，并探讨影响其治疗效果的危险因素。结果： ① 3组单剂量MTX治疗患者治疗前包块大小、盆腔积液深度及住院时间组间差异无统计学意义（P >0.05）。C组患者的住院费用及中转手术率最高，初次治疗成功率最低，组间差异有统计学意义（P<0.05）；A组与B组的住院费用、中转手术率及初次治疗成功率差异无统计学意义（P >0.05）。3组患者的二次杀胚率、不良反应发生率及持续性异位妊娠发生率差异无统计学意义（P >0.05）。3组患者血清β-hCG首次降至正常时间的差异有统计学意义（P<0.05），其中A组最短，C组最长。②血清β-hCG在1 000~1 500 IU/L者，手术治疗组盆腔积液深度较单剂量MTX治疗组深、包块较大，组间差异有统计学意义（P<0.05）；而住院时间及血清β-hCG降至正常时间较单剂量MTX治疗组短，组间差异有统计学意义（P<0.05）。③单剂量MTX治疗成功组与失败组间的年龄、盆腔积液深度差异无统计学意义（P >0.05），而β-hCG水平及包块大小组间差异有统计学意义（P<0.05）。④多因素logistic回归分析显示，治疗前1 000 IU/L≤血清β-hCG<1 500 IU/L（OR=3.714，95%CI=1.439~9.583）、包块>3.5 cm（OR=3.022，95%CI=1.298~7.037）是单剂量MTX杀胚治疗失败的危险因素。结论： β-hCG≥1 000 IU/L的患者单剂量MTX杀胚治疗的失败率高，血清β-hCG≥1 000 IU/L及治疗前包块>3.5 cm是影响单剂量MTX初始治疗成功率的独立危险因素。对于β-hCG≥1 000 IU/L的患者选择手术治疗可能更经济有效。

Abstract:

Objective: To analyze the therapeutic effect and influencing factors of single dose methorexate (MTX) on tubal pregnancy patients with low and medium level β-hCG, and to provide some basis for clinical selection of reasonable treatment plans. Methods: A retrospective study was carried out in 214 cases of tubal pregnancy with serum β-hCG lower than 1 500 IU/L using single dose MTX treatment and 80 cases of serum β-hCG 1 000-1 500 IU/L undergoing operation during the same period in our department from January to December 2020. According to the level of serum β-hCG before single dose MTX initial treatment, they were divided into three subgroups: group A (β -hCG<500 IU/L) ; group B (500 IU/L≤β-hCG<1 000 IU/L) ; group C (1 000 IU/L≤β-hCG<1 500 IU/L) , comparing the clinical efficacy and analyzing the factors of influencing the therapeutic effect. Results: ①There were no significant differences in mass size, pelvic effusion depth and hospital day among the three groups (P >0.05). Patients in group C had the highest hospitalization cost and transfer rate of surgery, and the lowest success rate of initial treatment (P<0.05) , but no statistically significant differences in hospitalization cost, transfer rate of surgery and success rate between group A and group B (P >0.05). There were no significant differences in the incidence of adverse reactions and persistent ectopic pregnancy among the three groups after single dose MTX treatment (P >0.05). The time from the first time to normal blood β-hCG in the three groups was statistically significant different (P<0.05) , with the shortest in group A and the longest in group C. ②In patients with serum β-hCG in the range of 1 000-1 500 IU/L, the mass size and pelvic ef-fusion depth were significant different between surgical treatment group and single dose MTX treatment group (P<0.05) , the length of hospital stay and the time for serum β-hCG to return to normal were shorter in the surgical treatment group than in the single dose MTX treatment group (P<0.05). ③For single dose MTX treatment patients, there were no significant differences in age and depth of pelvic effusion between successful group and failed group (P >0.05) , but there were significant differences in β-hCG level and mass size between two groups (P<0.05). ④In multivariate logistic regression analysis, 1 000 IU/L≤serum β-hCG<1 500 IU/L (OR=3.714, 95%CI=1.439-9.583) , and mass>3.5 cm (OR=3.022, 95%CI=1.298-7.037) was a risk factor for failure of single dose MTX therapy. Conclusion: Patients with β-hCG≥1 000 IU/L have a higher failure rate of single-dose MTX treatment, and serum β-hCG≥1 000 IU/L and mass>3.5 cm are independent risk factors for the success rate of single dose MTX treatment. Surgical treatment seems to be more cost-effective for patients with β-hCG≥1 000 IU/L.