Risk factors and early diagnosis of persistent ectopic pregnancy in fallopian tubal pregnancy patients: propensity score matching analysis

doi:10.3877/cma.j.issn.1673-5250.2020.02.009

Objective

To explore risk factors and early diagnosis method of persistent ectopic pregnancy (PEP) in fallopian tubal pregnancy (FTP) patients based on propensity score matching (PSM) analysis.

Methods

From January 2011 to December 2018, a total of 17 patients with FTP who underwent laparoscopic conservative operations therapy (COT) in the West China Second University Hospital of Sichuan University and developed to PEP after operation were selected as research subjects and included into PEP group. At the same time, 148 patients who received laparoscopic COT in our hospital during the same period and recovered well after operation were randomly selected as control group. Clinical data of patients in two groups were collected by retrospective analysis. Mann-Whitney U test was used to compare the duration of serum β-human chorionic gonadotropin (hCG) decreased to <20 mIU/mL and <10 mIU/mL after operation, and the decrease ratio of serum β-hCG within 24-48 h after operation compared with that before operation in two matched groups. The incidence rates of pelvic adhesion, tubal interstitial and ampulla pregnancy were compared by chi-square test. The receiver operator characteristic (ROC) curve of decrease ratio of serum β-hCG within 24-48 h after operation compared with that before operation for diagnosis of PEP in FTP patients after COT was drawn and the area under ROC curve (ROC-AUC) was calculated. According to the maximum principle of Youden index, the optimal cut-off value of decrease ratio of serum β-hCG within 24-48 h after operation compared with that before operation for diagnosis of PEP in FTP patients after COT was determined. This study met the requirements of World Medical Association Declaration of Helsinki revised in 2013.

Results

①After PSM, 65 patients in control group were matched successfully. There were no significant differences between two groups matched by PSM in terms of age, gravidity, body mass index (BMI) and menopause duration (P>0.05). ②After PSM, the incidence rates of pelvic adhesion and tubal interstitial pregnancy in PEP group were 88.2% (15/17) and 29.4% (5/17), respectively, which were significantly higher than those 61.5% (40/65) and 3.1% (2/65) in control group, and both the differences were statistically significant (χ²=4.349, P=0.037; χ²=8.834, P=0.003). ③After PSM, the duration of serum β-hCG decreased to <20 mIU/mL and <10 mIU/mL after operation in PEP group was 45.0 d (32.7-61.2 d) and 59.5 d (41.0-68.7 d), respectively, which were significantly longer than those 15.0 d (10.0-19.0 d) and 17.5 d (10.7-27.2 d) in control group, and both the differences were statistically significant (Z=4.703, 4.418; P<0.001). ④After PSM, the decrease ratio of serum β-hCG within 24-48 h after operation compared with that before operation in PEP group was 47.0% (-8.0%-70.1%), which was significantly lower than that 69.0% (61.2%-79.2%) in control group, and the difference was statistically significant (Z=3.506, P<0.001). The ROC-AUC of decrease ratio of serum β-hCG within 24-48 h after operation compared with that before operation for diagnosis of PEP in FTP patients after COT was 0.777 (95%CI: 0.626-0.929, P<0.001). According to the maximum principle of Youden index, the optimal cut-off value of decrease ratio of serum β-hCG within 24-48 h after operation compared with that before operation for diagnosis of PEP in FTP patients after COT was 52.9%, and the sensitivity, specificity, positive predictive value, negative predictive value, accuracy, missed diagnosis rate and misdiagnosis rate were 64.7%, 95.4%, 78.6%, 91.2%, 89.0%, 35.3% and 4.6%, respectively.

Conclusions

Tubal interstitial pregnancy and pelvic adhesion may be high risk factors of PEP in FTP patients after COT. The decrease ratio of serum β-hCG within 24-48 h after operation compared with that before operation may be one of the indicators for early diagnosis of PEP in FTP patients after COT.

Key words: Pregnancy, tubal, Persistent ectopic pregnancy, Propensity score matching, Chorionic gonadotropin, beta subunit, human, Early diagnose, Female

表1 PSM前、后，2组患者一般临床资料比较

组别	PSM前					PSM后
组别	例数	年龄(岁，±s)	孕次[次，M(P₂₅～P₇₅)]	BMI(kg/m²，±s)	停经时间(d，±s)	例数	年龄(岁，±s)	孕次[次，M(P₂₅～P₇₅)]	BMI(kg/m²，±s)	停经时间(d，±s)
PEP组	17	29.2±5.6	3.0(2.0～4.0)	20.4±2.3	46.5±7.3	17	29.2±5.6	3.0(2.0～4.0)	20.4±2.3	46.5±7.3
对照组	148	30.2±5.3	2.0(1.0～3.0)	21.1±2.6	50.2±10.6	65	29.2±4.7	3.0(2.0～4.0)	20.7±2.7	46.3±7.9
检验值	?	t＝0.688	Z＝1.571	t＝0.928	t＝1.392	?	t＝0.003	Z＝0.404	t＝－0.374	t＝0.099
P值	?	0.493	0.116	0.355	0.166	?	0.997	0.687	0.709	0.921

表1 PSM前、后，2组患者一般临床资料比较

组别	PSM前					PSM后
组别	例数	年龄(岁，±s)	孕次[次，M(P₂₅～P₇₅)]	BMI(kg/m²，±s)	停经时间(d，±s)	例数	年龄(岁，±s)	孕次[次，M(P₂₅～P₇₅)]	BMI(kg/m²，±s)	停经时间(d，±s)
PEP组	17	29.2±5.6	3.0(2.0～4.0)	20.4±2.3	46.5±7.3	17	29.2±5.6	3.0(2.0～4.0)	20.4±2.3	46.5±7.3
对照组	148	30.2±5.3	2.0(1.0～3.0)	21.1±2.6	50.2±10.6	65	29.2±4.7	3.0(2.0～4.0)	20.7±2.7	46.3±7.9
检验值	?	t＝0.688	Z＝1.571	t＝0.928	t＝1.392	?	t＝0.003	Z＝0.404	t＝－0.374	t＝0.099
P值	?	0.493	0.116	0.355	0.166	?	0.997	0.687	0.709	0.921

表2 PSM后，2组患者术前相关临床资料比较

组别	例数	超声检查EP包块直径[cm，M(P₂₅～P₇₅)]	术前血清β-hCG水平[mIU/mL，M(P₂₅～P₇₅)]	既往EP史[例数(%)]	输卵管手术史[例数(%)]	其他盆腔手术史[例数(%)]	孕囊[例数(%)]	卵黄囊[例数(%)]	胎心搏动[例数(%)]
PEP组	17	3.0(2.1～3.9)	3 426.7(1 971.3～19 941.6)	3(17.6)	3(17.6)	6(35.3)	3(17.6)	3(17.6)	2(11.8)
对照组	65	3.1(2.2～3.8)	3 032.0(1 362.0～6 396.3)	25(38.5)	19(29.2)	17(26.2)	9(13.8)	8(12.3)	1(1.5)
检验值	?	Z＝0.452	Z＝1.355	χ²＝2.596	χ²＝0.426	χ²＝0.197	χ²<0.001	χ²＝0.031	—
P值	?	0.651	0.175	0.107	0.514	0.657	0.993	0.861	0.107

表2 PSM后，2组患者术前相关临床资料比较

组别	例数	超声检查EP包块直径[cm，M(P₂₅～P₇₅)]	术前血清β-hCG水平[mIU/mL，M(P₂₅～P₇₅)]	既往EP史[例数(%)]	输卵管手术史[例数(%)]	其他盆腔手术史[例数(%)]	孕囊[例数(%)]	卵黄囊[例数(%)]	胎心搏动[例数(%)]
PEP组	17	3.0(2.1～3.9)	3 426.7(1 971.3～19 941.6)	3(17.6)	3(17.6)	6(35.3)	3(17.6)	3(17.6)	2(11.8)
对照组	65	3.1(2.2～3.8)	3 032.0(1 362.0～6 396.3)	25(38.5)	19(29.2)	17(26.2)	9(13.8)	8(12.3)	1(1.5)
检验值	?	Z＝0.452	Z＝1.355	χ²＝2.596	χ²＝0.426	χ²＝0.197	χ²<0.001	χ²＝0.031	—
P值	?	0.651	0.175	0.107	0.514	0.657	0.993	0.861	0.107

表3 PSM后，2组患者术中情况比较

组别	例数	盆腔黏连[例数(%)]	左、右侧FTP[例数(%)]		FTP部位[例数(%)]			手术持续时间[min， M(P₂₅～P₇₅)]	术中失血量[mL，M(P₂₅～P₇₅)]
组别	例数	盆腔黏连[例数(%)]	左侧	右侧	间质部	壶腹部	伞部	手术持续时间[min， M(P₂₅～P₇₅)]	术中失血量[mL，M(P₂₅～P₇₅)]
PEP组	17	15(88.2)	3(17.6)	14(82.4)	5(29.4)	11(64.7)	1(5.9)	60.0(37.5～65.0)	150.0(32.5～400.0)
对照组	65	40(61.5)	27(41.5)	38(58.5)	2(3.1)	61(93.8)	2(3.1)	50.0(40.0～72.5)	150.0(60.0～245.0)
检验值	?	χ²＝4.349	χ²＝3.315		χ²＝8.834	χ²＝8.138	—	Z＝0.304	Z＝0.366
P值	?	0.037	0.069		0.003	0.004	0.507	0.761	0.714

表3 PSM后，2组患者术中情况比较

组别	例数	盆腔黏连[例数(%)]	左、右侧FTP[例数(%)]		FTP部位[例数(%)]			手术持续时间[min， M(P₂₅～P₇₅)]	术中失血量[mL，M(P₂₅～P₇₅)]
组别	例数	盆腔黏连[例数(%)]	左侧	右侧	间质部	壶腹部	伞部	手术持续时间[min， M(P₂₅～P₇₅)]	术中失血量[mL，M(P₂₅～P₇₅)]
PEP组	17	15(88.2)	3(17.6)	14(82.4)	5(29.4)	11(64.7)	1(5.9)	60.0(37.5～65.0)	150.0(32.5～400.0)
对照组	65	40(61.5)	27(41.5)	38(58.5)	2(3.1)	61(93.8)	2(3.1)	50.0(40.0～72.5)	150.0(60.0～245.0)
检验值	?	χ²＝4.349	χ²＝3.315		χ²＝8.834	χ²＝8.138	—	Z＝0.304	Z＝0.366
P值	?	0.037	0.069		0.003	0.004	0.507	0.761	0.714

表4 PSM后，2组患者术后血清β-hCG水平下降至<20 mIU/mL与<10 mIU/mL的时间，以及术后24～48 h血清β-hCG水平较术前下降率比较[M(P₂₅～P₇₅)]

组别	术后血清β-hCG水平下降至<20 mIU/mL的时间(d)		术后血清β-hCG水平下降至<10 mIU/mL的时间(d)		术后24～48 h血清β-hCG水平较术前下降率(%)
组别	例数^a	时间	例数^a	时间	例数	下降率
PEP组	14	45.0(32.7～61.2)	12	59.5(41.0～68.7)	17	47.0(－8.0～70.1)
对照组	34	15.0(10.0～19.0)	32	17.5(10.7～27.2)	65	69.0(61.2～79.2)
Z值	?	4.703	?	4.418	?	3.506
P值	?	<0.001	?	<0.001	?	<0.001

表4 PSM后，2组患者术后血清β-hCG水平下降至<20 mIU/mL与<10 mIU/mL的时间，以及术后24～48 h血清β-hCG水平较术前下降率比较[M(P₂₅～P₇₅)]

组别	术后血清β-hCG水平下降至<20 mIU/mL的时间(d)		术后血清β-hCG水平下降至<10 mIU/mL的时间(d)		术后24～48 h血清β-hCG水平较术前下降率(%)
组别	例数^a	时间	例数^a	时间	例数	下降率
PEP组	14	45.0(32.7～61.2)	12	59.5(41.0～68.7)	17	47.0(－8.0～70.1)
对照组	34	15.0(10.0～19.0)	32	17.5(10.7～27.2)	65	69.0(61.2～79.2)
Z值	?	4.703	?	4.418	?	3.506
P值	?	<0.001	?	<0.001	?	<0.001

图1 术后24～48 h血清β-hCG水平较术前下降率诊断FTP患者接受COT后发生PEP的ROC曲线

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