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Correlation between the Ultrasound Parameters of Uterine Scar after Cesarean Section and the Amount of Intraoperative Blood Loss in Patients with Cesarean Scar Pregnancy
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摘要:
目的 探讨剖宫产切口瘢痕妊娠二维、三维超声参数与手术中出血量的相关性, 分析影响手术出血量的独立危险因素。 方法 收集2011年11月至2013年1月北京协和医院临床确诊为剖宫产切口瘢痕妊娠、并接受手术治疗的35例患者, 术前进行二维及三维超声检查, 获得病灶最大径、病灶平均径、病灶植入瘢痕面积、植入体积及植入深度; 按有无胎心搏动、病灶类型、彩色多普勒血流分级及术前有/无甲氨蝶呤联合治疗进行分组。记录患者手术中出血量, 分析超声参数与出血量的相关性, 比较组间出血量差异; 将病灶按出血量进行分组, ≥ 200 ml组和 < 200 ml组, 应用Logistic回归分析影响出血量的独立危险因素。 结果 病灶最大径和病灶植入瘢痕面积与出血量存在线性关系(P=0.009和0.008)。病灶平均径、病灶植入体积、病灶植入深度与出血量无线性关系(P=0.017, 0.044和0.423)。有/无胎心搏动组间出血量(分别为23.38和13.47 ml)差异有统计学意义(P=0.004);病灶类型、彩色多普勒血流分级及术前有/无甲氨蝶呤联合治疗组间出血量差异无统计学意义(P=0.131, 0.044和0.047)。Logistic回归分析显示病灶植入瘢痕面积为影响手术中出血量的独立危险因素(P=0.007), 受试者工作特征曲线下面积为0.839(0.606~1.071)。 结论 剖宫产切口瘢痕妊娠病灶最大径、病灶植入瘢痕面积及有/无胎心搏动与手术中出血量密切相关, 其中病灶植入瘢痕面积是影响剖宫产切口瘢痕妊娠手术中出血量的独立危险因素, 本研究结果可为临床决策(包括是否手术及术式选择)提供重要参考依据。 Abstract:Objective To analyze the correlation between ultrasound parameters of uterine scar after cesarean section and the amount of intraoperative blood loss in patients with cesarean scar pregnancy(CSP). Methods A total of 35 CSP patients who received operational treatment from November 2011 to January 2013 were enrolled in this study. The 2-and 3-dimensional ultrasound examinations were performed before the surgery, and the following parameters were recorded:maximum diameter of lesion(Dmax), average diameter of lesion(Dmean), implantation area of lesion(S), implantation volume of lesion(V), and implantation depth of lesion(Dimp). All these cases were divided into different groups according to the following characteristics separately:with/without fetal heart beat, lesion shown as gestational sac/mass, vasculature grade poor/median/rich, whetheror not combined with methotrexate(MTX) treatment prior to operations. The amount of bleeding during the operation was recorded. The correlation between the above parameters and the amount of intraoperative bleeding was analyzed. The bleeding amount of different groups was compared. Also, the patients were divided into two groups according to bleeding amount ≥ 200 ml and < 200 ml, and the potential independent risk factors of bleeding were analyzed using Logistic regression. Results Dmax and S had a linear correlation with bleeding amount (P=0.009 and 0.008). Dmean, V, and Dimp had no linear correlation with bleeding amount(P=0.017, 0.044, and 0.423, respectively). The difference of bleeding amount between groups with and without fetal heart beat was significant(23.38 ml vs 13.47 ml, P=0.004). There were no significant differences between groups of lesion types, color grades, and with/without MTX treatment(P=0.131, 0.044, and 0.047, respectively). The Logistic regression showed that S was an independent risk factor of operation bleeding amount(P=0.007), with an area under the receiver operating characteristic(ROC) curve of 0.839(0.606-1.071). Conclusions The Dmax and S of CSP as well as with/without fetal heart beat obtained from the 2-and 3-dimensional ultrasound have close correlations with the intraoperative bleeding amount in CSP patients. In particular, the S of the CSP is an independent risk factor for bleeding. -
Key words:
- ultrasonography /
- cesarean section /
- pregnancy /
- cicatrix
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图 1 应用QLab软件测量剖宫产切口瘢痕妊娠病灶植入面积
激活Area模块，于A平面(矢状切面)上确定病灶植入剖宫产瘢痕部分起止点，将X轴(蓝色线轴)置于此水平，在C平面(冠状面)勾画病灶范围(包括代表绒毛组织的高回声区)，软件自动给出植入面积ROI=20.5 cm2(右上角)
图 2 应用QLab软件测量剖宫产切口瘢痕妊娠病灶植入体积
激活体积模块，在A平面画取样线(起止点为“×”虚线)，即病灶植入瘢痕部位的起止点，软件自动生成7条垂直线，在B平面依次手动勾画每一垂直线对应平面中病灶植入瘢痕部分范围(不包括取样线下方部分，因此部分病灶未植入子宫前壁下段肌层，仍在扩张的宫腔内)，勾勒完毕软件自动给出植入体积=57.3 ml(右上角)
图 3 患者女，33岁, 二维超声示剖宫产切口子宫前壁下段瘢痕妊娠病灶
A.纵切面；B.横切面；*：子宫宫腔；a：上下径；b：左右径；c：前后径; 测量点取病灶外缘(包括代表绒毛组织的高回声区)，其中最大径线为病灶最大径(Dmax)，三者平均值为病灶平均径(Dmean)
图 4 剖宫产切口瘢痕妊娠病灶超声类型
A.患者女，31岁，孕囊型剖宫产切口瘢痕妊娠，子宫前壁下段可见妊娠囊，内可见胎芽，前壁下段肌层菲薄；B.患者女，28岁，包块型剖宫产切口瘢痕妊娠，病灶内部呈现杂乱的混合回声，无明确妊娠囊结构、胎芽或胎心搏动；F：宫腔积液；*：同图 3
图 5 剖宫产切口瘢痕妊娠病灶彩色多普勒血流分级
A.Ⅰ级-乏血供，患者女，35岁，病灶周边及内部仅可探及点状或短条状、分布稀疏的血流信号；B.Ⅱ级-中等血供，患者女，27岁，病灶周边及内部可见多支条状血流；C, D.Ⅲ级-动静脉瘘形成，患者女，31岁，可见病灶周边和/或内部出现明亮花色血流信号伴血管明显增粗、走行迂曲，低阻型动静脉瘘频谱
表 1 剖宫产切口瘢痕妊娠患者超声参数与出血量的相关性
超声参数与出血量 最小值/25%数 最大值/75%数 x±s/中位数 正态分布检验P值 相关性检验P值† Dmax(cm) 0.70 10.0 4.40±2.09 0.2 0.009 Dmean(cm) 0.70 8.3 3.51±1.72 0.012 0.017 S(cm2)* 1.30 39.1 5.70 0.002 0.008 V(ml)* 0.68 254.67 4.21 0 0.044 Dimp(cm)* 1.04 19.54 2.61 0 0.423 出血量(ml)* 5.00 700.00 50.00 0 - Dmax：病灶最大径；Dmean：病灶平均径；S：病灶植入瘢痕面积；V：病灶植入瘢痕体积；Dimp：病灶植入瘢痕深度；*非正态分布；†与出血量相关性检验P值 
下载: 导出CSV
表 2 剖宫产切口瘢痕妊娠患者胎心搏动、病灶类型、彩色多普勒血流分级及甲氨蝶呤联合治疗组间出血量比较
特征 例数(%) 出血量(ml) P值 平均秩 秩和 胎心搏动 0.004 有 16(45.7) 23.38 374 无 19(54.3) 13.47 256 病灶类型 0.131 孕囊型 25(71.4) 19.68 492 包块型 10(28.6) 13.80 138 彩色多普勒血流分级* 0.044 1级 10(28.6) 13.75 - 2级 20(57.1) 16.77 - 3级 3(8.6) 29.33 - MTX联合治疗 0.047 有 11(31.4) 12.95 143 无 24(68.6) 20.31 488 *2例资料缺失；MTX：甲氨蝶呤
下载: 导出CSV
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