剖宫产瘢痕妊娠与胎盘植入关系及超声征象诊断胎盘植入价值探讨

发布时间：2018-05-12 22:12

本文选题：剖宫产瘢痕妊娠 + 胎盘植入　；参考：《山东大学》2017年硕士论文

【摘要】：第一部分探讨超声诊断剖宫产瘢痕妊娠与胎盘植植入关系目的:本研究的目的是探讨超声诊断剖宫产瘢痕妊娠与胎盘植入的关系,为瘢痕妊娠的自然发展提供更多循证学依据,并且针对瘢痕妊娠病人进行分型,了解不同类型的剖宫产瘢痕妊娠病人的临床结局。资料和方法回顾性收集2014年1月至2017年2月于山东大学齐鲁医院超声诊断为剖宫产瘢痕妊娠并选择继续妊娠管理的病人19例。获取其诊断剖宫产瘢痕妊娠及随后不同孕周的超声图像、临床资料、病理资料。将获取的瘢痕妊娠超声图像进行分组(即低风险组与高风险组),比较两组妊娠结局,探究剖宫产瘢痕妊娠与胎盘植入的关系。结果:19例病人中,16(16/19)例在随后孕周超声检查提示胎盘植入,18(18/19)例临床/病理诊断为胎盘植入,超声诊断胎盘植入敏感性为88.99%,阳性预测价值100%。4例胎盘穿透病人均在早孕期(12周,12周,9周+6天,10周)超声检查就提示胎盘植入。将瘢痕妊娠病人分为低风险组10例,高风险组9例,比较两组的临床结局:术中出血低风险组1100ml低于高风险组2000ml,P=0.269;活产儿低风险组中有9例(9/10)高于高风险组中4例(4/9),P=0.057;子宫切除低风险组1例(1/10),高风险组1例(1/9),P=1.000;胎盘穿透4(4/9)例均出现在高风险组,p=0.033。结论:剖宫产瘢痕妊娠与胎盘植入关系密切,瘢痕妊娠可能是胎盘植入的前期表现形式。胎盘穿透的病人在早孕期即出现典型的胎盘植入的超声征象。通过超声对瘢痕妊娠进行分型可以预测其临床结局。第二部分产前不同超声征象诊断胎盘植入价值的meta分析目的:应用meta分析探讨不同的超声征象在产前诊断胎盘植入的价值。资料和方法:通过PubMed、Cochrane图书馆、万方、CNKI及维普数据库上检索从2006年1月至2016年10月发表的有关产前超声诊断胎盘植入的中英文文献,按照纳入和排除标准,提取纳入文献中的相关信息,通过QUADAS-2评价系统制定质量评价标准,针对纳入的文献进行质量评价。用Review Manager5.3和Meta-DiSc 1.4统计软件计算纳入文献的不同超声征象在产前诊断胎盘植入的敏感度、特异度绘制森林图,汇总敏感度(SEN)、汇总特异度(SPE)及相应的95%的置信区间(CI),得出阴性似然比和阳性似然比、诊断比值比(D0R),针对≥5篇文献报道过的征象绘制综合受试者工作特征曲线(SR0C)及计算面积(AUC)。结果:共纳入12篇文献,1392例具有植入高风险病例,其中胎盘植入349例。结果显示:胎盘后间隙消失/破坏:SEN0.83(0.78-0.88)、SPE0.86(0.83-0.88)、AUC0.9042;胎盘漩涡:SEN0.71(0.67-0.76)、SPE0.83(0.81-0.85)、AUC0.8580;子宫膀胧交界面破坏:SENO.46(0.38-0.54)、SPE 0.98(0.96-0.99)、AUCO.9083;胎盘/子宫膀胱交界面丰富血流信号:SEN0.67(0.60-0.72)、SPE0.95(0.93-0.96)、AUC0.9470;胎盘内穿支血流:SEN0.59(0.50-0.68)、SPE0.91(0.88-0.94);局部突出于子宫的肿块:SEN0.23(0.17-0.32)、SPE0.98(0.96-0.99);胎盘后子宫肌层厚度≤1mm:SEN0.58(0.50-0.66)、SPE0.92(0.89-0.94)。结论:在高危孕妇中,尤其是前置胎盘伴有剖宫产史或子宫手术史,不同超声征象在评估胎盘植入均具有一定的价值。其中判断胎盘漩涡时应结合彩色多普勒漩涡内血流信号。所有征象中,多普勒示胎盘/子宫膀胱交界面丰富血流信号诊断准确性最高。
[Abstract]:The first part is to explore the relationship between caesarean scar pregnancy and placental implantation. The purpose of this study is to explore the relationship between caesarean scar pregnancy and placental implantation by ultrasonic diagnosis, to provide more evidence-based evidence for the natural development of scar pregnancy, and to classify the patients with scar pregnancy to understand the different types of cesarean section. The clinical outcome of cicatricial pregnancy patients. Data and methods were collected from January 2014 to February 2017 in 19 cases of caesarean scar pregnancy diagnosed by ultrasound in Qilu Hospital of Shandong University and selected to continue pregnancy management. The ultrasonic images, clinical data and pathological data of the diagnosis of cesarean scar pregnancy and subsequent pregnancy were obtained. The ultrasonic images of cicatricial pregnancy were divided into groups (low risk group and high risk group), and the relationship between two groups of pregnancy outcomes was compared and the relationship between caesarean scar pregnancy and placenta implantation was explored. Results: among 19 cases, 16 (16/19) cases were followed by ultrasound examination of placenta implantation, 18 (18/19) clinical / pathological diagnosis of placenta implantation and ultrasonic diagnosis of placenta The sensitivity of the implant was 88.99%, the positive predictive value of 100%.4 placenta penetrating patients were all in the early pregnancy (12 weeks, 12 weeks, 9 weeks +6 days, 10 weeks) with the placental implantation. The patients were divided into 10 cases of low risk group, 9 cases of high risk group, and two groups of clinical outcomes: the 1100ml in the low risk group of bleeding in the operation was lower than the high risk group 2000ml, P=0.26 9, 9 cases of low risk group (9/10) were higher than high risk group (4/9), P=0.057, 1 cases with low risk of hysterectomy (1/10), 1 cases of high risk group (1/9) and P=1.000; placental penetration 4 (4/9) all appeared in high risk group. P=0.033. conclusion: Caesarean scar pregnancy is closely related to placental implantation, scar pregnancy may be the preplacental table of placental implantation Present form. The ultrasonic signs of typical placental implantation occur in the early pregnancy period of the patients with penetrating placenta. The clinical outcome can be predicted by typing the scar pregnancy by ultrasound. Second parts of the meta analysis of the value of placental implantation for the diagnosis of the prenatal different ultrasound signs: the application of meta analysis to explore the prenatal diagnosis of fetal diagnosis. Value and methods of disc implantation. Data and methods were retrieved from the PubMed, Cochrane library, Wanfang, CNKI, and VP databases on prenatal ultrasound diagnosis of placenta implantation from January 2006 to October 2016. According to the inclusion and exclusion criteria, the relevant information included in the literature was extracted, and the quality of the system was formulated by the QUADAS-2 evaluation system. Quantitative evaluation criteria were used to evaluate the quality of the included literature. Review Manager5.3 and Meta-DiSc 1.4 statistical software were used to calculate the sensitivity, the specificity of the forest map, the SEN, the SPE and the corresponding 95% confidence interval (CI) for the prenatal diagnosis of placenta implantation. The ratio and positive likelihood ratio, the ratio of diagnostic ratio (D0R), the work feature curve (SR0C) and calculation area (AUC) were drawn for more than 5 literature. Results: 12 articles were included, 1392 cases had high risk of implantation, among which 349 placental implants were implanted. The results showed that the post placental space disappearance / destruction: SEN0.83 (0.78-0.88), S PE0.86 (0.83-0.88), AUC0.9042; placental whirlpool: SEN0.71 (0.67-0.76), SPE0.83 (0.81-0.85), AUC0.8580, uterine bladder interface disruption: SENO.46 (0.38-0.54), SPE 0.98 (0.96-0.99); 8), SPE0.91 (0.88-0.94); locally prominent masses of the uterus: SEN0.23 (0.17-0.32), SPE0.98 (0.96-0.99); the thickness of the postplacental uterine myometrium is less than 1mm:SEN0.58 (0.50-0.66) and SPE0.92 (0.89-0.94). Conclusion: in high risk pregnant women, especially placenta previa with the history of cesarean section or uterine surgery, different ultrasound signs are all in the assessment of placenta implantation. The diagnostic value of the placental whirlpool should be combined with the color Doppler vortex in the whirlpool. In all the signs, Doppler shows the highest diagnostic accuracy in the placental / uterine bladder interface with rich blood flow signals.

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R445.1;R714.22

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