探讨既往剖宫产瘢痕处双胎异位妊娠(TEPC)患者的临床特征、诊治经过，并进行相关文献复习。

选择2019年9月24日，杭州市妇产科医院收治的要求终止妊娠的1例TEPC患者为研究对象。采用回顾性分析方法，收集其临床病例资料，进行临床表现和诊治经过分析。同时，以"剖宫产瘢痕妊娠""双胎妊娠""cesarean scar pregnancy""twin pregnancy"为关键词，对中国知网数据库、万方数据知识服务平台、PubMed数据库中，TEPC相关文献进行检索。文献检索时间设定为各数据库建库至2019年12月31日。总结TEPC患者的临床特点及诊治方案。本研究遵循的程序符合2013年新修订的《世界医学协会赫尔辛基宣言》要求。

①本例要求终止妊娠患者年龄为35岁，2019年9月24日因"外院超声提示异位妊娠"，于本院妇科门诊就诊收治入院，G₆P₂，为剖宫产术分娩后月经尚未来潮，哺乳期意外妊娠患者，入院时为剖宫产术后8个月。入院检查：血清β-人绒毛膜促性腺激素(hCG)为18 587 mIU/mL；阴道超声检查可见子宫呈葫芦状，子宫下段2.9 cm×1.7 cm×1.5 cm、1.7 cm×1.6 cm×1.3 cm混合回声暗区，局部向膀胱凸起，孕囊种植瘢痕处肌层厚度仅为0.10 cm，确定孕龄为6⁺孕周。2019年9月26日，对患者进行双侧子宫动脉栓塞术(UEA)，24 h后再进行经腹部超声引导下清宫术，术中出血量为300 mL，术后采取宫腔放置16F气囊压迫止血。术后每周检测1次血清β-hCG水平，第63天时降至<5 mIU/mL。②根据本研究设定的文献检索策略进行检索的结果显示，共计4篇TEPC相关病例报道，纳入TEPC患者为5例。其中3例患者被确诊为TEPC时孕龄较小，采取甲氨蝶呤治疗，2例治疗成功，1例治疗失败后，采取宫腔镜下清宫术；1例因孕囊种植瘢痕处肌层较薄，周围血供丰富，采取经腹部超声引导下清宫术；1例采取宫腔镜下清宫术联合腹腔镜下子宫瘢痕修复术。这5例患者均预后良好。

临床早期诊断TEPC患者，应结合病史、临床症状及超声检查结果等综合判断。根据TEPC患者孕龄、孕囊种植瘢痕处肌层厚度、接诊医师临床经验等，对其制定个体化治疗方案，最终达到安全、有效治疗该病患者的目的。

To explore clinical features and treatment of patients with twin ectopic pregnancy in a previous cesarean scar section (TEPC), and review relevant literature.

One TEPC patient admitted to Hangzhou Women′s Hospital on September 24, 2019, who required pregnancy termination was selected as research subject. Clinical data of the patient was collected by retrospective analysis method, and her clinical features, diagnosis and treatment methods were analyzed. With the following key words of " cesarean scar pregnancy" " twin pregnancy" both in Chinese and English, literature related to TEPC were searched from China National Knowledge Infrastructure, Wanfang data knowledge service platform and PubMed database. Literature retrieval time was set from construction of each database to December 31, 2019. Clinical features, diagnosis and treatment methods of TEPC patients in searched literature were summarized. This study was consistent with the World Medical Association Declaration of Helsinki revised in 2013.

①This patient with requirement of pregnancy termination was a 35 years old female who was admitted to the gynecological clinic of our hospital on September 24, 2019 because of " ectopic pregnancy indicated by ultrasound in other hospital" . She was G₆P₂. She still did not have menstruation after the second cesarean section and was unexpectedly pregnant during lactation. It was 8 months after cesarean section on admission. Serum β-human chorionic gonadotropin (hCG) after admission was 18 587 mIU/mL. Results of transvaginal ultrasound showed that her uterus was gourd shaped, and 2.9 cm × 1.7 cm × 1.5 cm and 1.7 cm × 1.6 cm × 1.3 cm mixed echo dark area which were locally protruded to bladder could be found in lower part of uterus, thickness of scar muscle layer where gestational sac planted was 0.10 cm. Her gestational age was 6⁺ weeks. On September 26, 2019, she underwent bilateral uterine artery embolization (UEA). And then 24 hours later, she underwent transabdominal ultrasound-guided uterine curettage. The amount of transoperative bleeding was 300 mL. After operation, a 16F air bag urinary catheter was placed in her uterine cavity to stop bleeding. She received detection of serum β-hCG once a week after operation, and her serum β-hCG decreased to <5 mIU/mL on the 63th day after operation. ②According to the literature search strategy set in this study, literature search results showed that a total of 4 TEPC related case reports were retrieved, involving 5 TEPC patients. Among them, 3 cases with small gestational weeks when they were diagnosed as TEPC were treated conservatively with methotrexate, and 2 cases were treated sucessfully, 1 case was treated by hysteroscopic curettage after failure of methotrexate treatment. 1 case was treated by transabdominal curettage due to thin muscle layer at the scar and abundant peripheral blood supply. And 1 case underwent hysteroscopic curettage combined with laparoscopic uterine scar repair. All those 5 patients had a good prognosis.

Early clinical diagnosis of TEPC patients should be based on a comprehensive judgment based on the patient′s medical history, clinical symptoms, and ultrasound examination results. For TEPC patients, individualized treatment options should be formulated according to the patient′s gestational age, thickness of myometrium at the scar of gestational sac implantation, and clinical experience of attending physician, so as to achieve the goal of safe and effective treatment of patients with TEPC.