磁共振成像技术在预测胎盘植入性疾病患者剖宫产术中出血量的研究

doi:10.3877/cma.j.issn.2095-3259.2023.03.010

目的

探讨磁共振成像(magnetic resonance imaging, MRI)技术预测前置胎盘合并胎盘植入患者在剖宫产术中大量出血的应用价值。

方法

采用回顾性研究方法，收集2015年1月至2020年12月在我院定期产检并住院分娩的161例前置胎盘合并胎盘植入患者的临床资料，按照剖宫产术中出血量分为研究组(79例，术中出血≥2000 ml)和对照组(82例，术中出血<2000 ml)，分析两组患者的一般情况及MRI特征。

结果

两组患者的年龄、体质指数、子宫切除率和膀胱损伤率比较差异无统计学意义(P>0.05)；研究组的孕次、产次和手术时间均大于对照组，差异有统计学意义(P<0.05)；研究组的分娩孕周和新生儿体重均小于对照组，差异有统计学意义(P<0.05)。研究组术中出血量大于对照组[(2491.68±504.48)ml vs(997.46±421.81)ml]，差异有统计学意义(P<0.05)；研究组术中输血量大于对照组[(1987.58±596.94)ml vs (681.23±445.64)ml]，差异有统计学意义(P<0.05)。研究组与对照组在胎盘附着位置以前壁为主(79.75% vs 30.49%)、胎盘厚度[(5.23±1.28)cm vs(4.32±1.27)cm]、宫颈长度[(2.76±0.51)cm vs (3.20±0.51)cm]、胎盘低信号面积[(7.02±1.89)cm² vs (4.69±1.70)cm²]、宫颈内胎盘信号(21.52% vs 6.10%)、宫颈内低信号(26.58% vs 10.98%)和膀胱内侧毛糙(18.99% vs 7.32%)方面比较，差异均有统计学意义(P<0.05)；宫颈管内胎盘信号是术中大出血的最高危征象(OR＝6.76，95%CI: 2.44~9.27，P<0.05)；联合7项MRI特征对前置胎盘合并胎盘植入患者剖宫产术中大出血预测具有较高价值(曲线下面积0.90)。

结论

MRI能够有效评估前置胎盘合并胎盘植入的严重程度及预测剖宫产术中大出血的风险，有利于产科医师做好充分的术前准备、减少术中出血，挽救孕产妇生命。

关键词: 前置胎盘, 侵入性胎盘, 磁共振成像, 剖宫产术, 出血

Objective

To investigate the application value of magnetic resonance imaging in predicting massive hemorrhage in patients with placenta accreta spectrum disorders during cesarean section.

Methods

A total of 161 patients with placenta previa were selected who received prenatal examination and delivered in our hospital from January 2015 to December 2020. According to the amount of intraoperative blood loss, they were divided into the study group (79 cases) (intraoperative bleeding ≥2000 ml) and the control group (82 cases) (intraoperative bleeding <2000 ml). The general situation and MRI characteristics of the subjects were analyzed to explore the predictive value of MRI in the severe intraoperative hemorrhage of placenta previa.

Results

There were no significant differences in age, body mass index, hysterectomy rate and bladder injury rate between the two groups (P>0.05). The number of pregnancies, number of births and operation time in the study group were higher than those in the control group, and the difference was statistically significant (P<0.05). The gestational age and neonatal weight of the study group were lower than those of the control group, and the differences were statistically significant (P<0.05). The amount of intraoperative blood loss in the study group was higher than that in the control group [(2491.68±504.48)ml vs (997.46±421.81)ml], and the difference was statistically significant (P<0.05). The amount of intraoperative blood transfusion in the study group was higher than that in the control group [(1987.58±596.94)ml vs (681.23±445.64)ml], and the difference was statistically significant (P<0.05). In the study group, the percentage of the placental anterior wall (79.75% vs 30.49%), placental thickness[(5.23±1.28)cm vs (4.32±1.27)cm], cervical length[(2.76±0.51)cm vs (3.20±0.51)cm], placental hyposignal area[(7.02±1.89)cm² vs (4.69±1.70)cm²], cervical placental signal(21.52% vs 6.10%), the low signal in the cervix(26.58% vs 10.98%), and inner bladder roughness(18.99% vs 7.32%) were higher than those in the control group, the difference was statistically significant (P<0.05). The placenta signal in the cervical canal was the most high-risk sign of intraoperative massive hemorrhage (OR=6.76, 95%CI: 2.44-9.27, P<0.05). Combined with seven MRI features, it is an effective method in the prediction of massive hemorrhage during cesarean section in placenta previa patients with placenta accreta (AUC=0.90).

Conclusions

MRI can effectively evaluate the severity of placenta previa and predict the risk of massive bleeding during cesarean section, which is beneficial to obstetricians to make full preoperative preparations, reduce intraoperative bleeding and save the lives of pregnant women.

Key words: Placenta previa, Placenta accreta, Magnetic resonance imaging, Cesarean section, Hemorrhage

表1 两组患者一般资料比较

组别	例数	年龄(岁，±s)	体质指数(kg/m²，±s)	孕次(次，±s)	产次(次，±s)	分娩孕周(周，±s)	手术时间(min，±s)	子宫切除例(%)	膀胱损伤例(%)	新生儿体重(g，±s)
研究组	79	31.92±3.91	26.34±3.34	3.38±1.29	1.87±0.56	35.45±1.13	96.58±30.65	3(3.80)	3(3.80)	2450.60±391.46
对照组	82	31.38±3.88	26.47±4.64	2.83±1.36	1.57±0.59	36.34±1.03	67.69±35.02	0(0.00)	1(1.22)	2681.10±345.40
统计值		t＝0.89	t＝0.20	Z＝2.63	Z＝3.31	t＝5.24	t＝6.24	χ²＝3.17	χ²＝1.10	t＝3.96
P值		0.38	0.85	0.01	<0.01	<0.01	<0.01	0.08	0.29	<0.01

表1 两组患者一般资料比较

组别	例数	年龄(岁，±s)	体质指数(kg/m²，±s)	孕次(次，±s)	产次(次，±s)	分娩孕周(周，±s)	手术时间(min，±s)	子宫切除例(%)	膀胱损伤例(%)	新生儿体重(g，±s)
研究组	79	31.92±3.91	26.34±3.34	3.38±1.29	1.87±0.56	35.45±1.13	96.58±30.65	3(3.80)	3(3.80)	2450.60±391.46
对照组	82	31.38±3.88	26.47±4.64	2.83±1.36	1.57±0.59	36.34±1.03	67.69±35.02	0(0.00)	1(1.22)	2681.10±345.40
统计值		t＝0.89	t＝0.20	Z＝2.63	Z＝3.31	t＝5.24	t＝6.24	χ²＝3.17	χ²＝1.10	t＝3.96
P值		0.38	0.85	0.01	<0.01	<0.01	<0.01	0.08	0.29	<0.01

表2 两组患者7项MRI特征比较

组别	例数	胎盘位置前壁为主[例(%)]	胎盘厚度(cm，±s)	宫颈长度(cm，±s)	胎盘低信号面积(cm²，±s)	宫颈内胎盘信号例(%)	宫颈内低信号例(%)	膀胱内侧毛糙例(%)
研究组	79	63(79.75)	5.23±1.28	2.76±0.51	7.02±1.89	17(21.52)	21(26.58)	15(18.99)
对照组	82	25(30.49)	4.32±1.27	3.20±0.51	4.69±1.70	5(6.10)	9(10.98)	6(7.32)
统计值		χ²＝39.39	t＝4.58	t＝5.42	t＝8.22	χ²＝8.11	χ²＝6.46	χ²＝4.83
P值		<0.01	<0.01	<0.01	<0.01	0.01	0.01	0.03

表2 两组患者7项MRI特征比较

组别	例数	胎盘位置前壁为主[例(%)]	胎盘厚度(cm，±s)	宫颈长度(cm，±s)	胎盘低信号面积(cm²，±s)	宫颈内胎盘信号例(%)	宫颈内低信号例(%)	膀胱内侧毛糙例(%)
研究组	79	63(79.75)	5.23±1.28	2.76±0.51	7.02±1.89	17(21.52)	21(26.58)	15(18.99)
对照组	82	25(30.49)	4.32±1.27	3.20±0.51	4.69±1.70	5(6.10)	9(10.98)	6(7.32)
统计值		χ²＝39.39	t＝4.58	t＝5.42	t＝8.22	χ²＝8.11	χ²＝6.46	χ²＝4.83
P值		<0.01	<0.01	<0.01	<0.01	0.01	0.01	0.03

图1 前置胎盘并胎盘植入患者磁共振成像各种特征表现图像　a．宫颈变短(宫颈长度2.3 cm，黄色线段所示)；b.后壁为主的前置胎盘(红色箭头所示)，膀胱内侧毛糙(黄色箭头所示)；c.宫颈管内的片状低信号(黄色箭头所示)；d.前壁为主的前置胎盘(红色箭头所示)，宫颈管内的胎盘信号(黄色箭头所示)；e.胎盘内片状低信号(黄色箭头所示)；f.胎盘附着处部分子宫壁缺损(黄色线圈所示)

图2 研究组7项磁共振成像特征对剖宫产术中大出血的风险评估及预测

图3 研究组不同磁共振成像特征对剖宫产术中大出血预测ROC曲线图

[1]	谢幸，孔北华，段涛，等. 妇产科学[M]. 9版. 北京：人民卫生出版社，2018：147-150.
[2]	Faiz AS, Ananth CV. Etiology and risk factors for placenta previa: an overview and meta-analysis of observational studies[J]. J Matern Fetal Neonatal Med，2003，13(3)：175-190.
[3]	Silver RM. Abnormal placentation: placenta previa, vasa previa, and placenta accreta[J]. Obstet Gynecol，2015，126(3)：654-668.
[4]	Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa placenta accrete[J]. Am J Obstet Gynecol，1997，177(1)：210-214.
[5]	Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa[J]. Obstet Gynecol，2006，107(4)：927-941.
[6]	Fadl S, Moshiri M, Fligner CL, et al. Placental imaging normal appearance with review of pathologic findings[J]. Radiographics，2017，37(3)：979-998.
[7]	D′Antonio F, Iacovella C, Palacios-Jaraquemada J, et al. Prenatal identification of invasive placentation using magnetic resonance imaging: systematic review and meta-analysis[J]. Ultrasound Obstet Gynecol，2014，44(1)：8-16.
[8]	Meng X, Xie L, Song W. Comparing the diagnostic value of ultrasound and magnetic resonance imaging for placenta accreta: a systematic review and meta-analysis[J]. Ultrasound in Med Biol，2013，39(11)：1958-1965.
[9]	Tikkanen M, Paavonen J, Loukovaara M, et al. Antenatal diagnosis of placenta accreta leads to reduced blood loss[J]. Acta Obstet Gynecol Scand，2011，90(10)：1140-1146.
[10]	D′Arpe S, Franceschetti S, Corosu R, et al. Emergency peripartum hysterectomy in a tertiary teaching hospital: a 14-year review[J]. Arch Gynecol Obstet，2015，291(4)：841-847.
[11]	Eshkoli T, Weintraub AY, Sergienko R, et al. Placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births[J]. Am J Obstet Gynecol，2013，208(3)：1-7.
[12]	Delius M, Hartmann M, Hübener C, et al. EP14.01: Prognostic evaluation to find critical courses in patients with placenta previa: a retrospective analysis of prospectively collected patient data[J]. Ultrasound Obstet Gynecol，2016，48(S1)：322.
[13]	Bowman ZS, Eller AG, Bardsley TR, et al. Risk factors for placenta accreta: a large prospective cohort[J]. Am J Perinatol，2014，31(9)：799-804.
[14]	Polat M, Kahramanoglu I, Senol T, et al. Shorter the cervix, more difficult the placenta percreta operations[J]. J Matern Fetal Neonatal Med，2016，29(14)：2327-2331.
[15]	Rahaim NS, Whitby EH. The MRI features of placental adhesion disorder and their diagnostic significance: systematic review[J]. Clin Radiol，2015，70(9)：917-925.
[16]	魏丽珍，赖清泉，刘佶阳. 磁共振成像在评价穿透性胎盘植入的价值[J]. 临床放射学杂志，2021，40(5)：949-953.
[17]	Chen D, Xu J, Ye P, et al. Risk scoring system with MRI for intraoperative massive hemorrhage in placenta previa and accreta[J]. J Magn Reson Imaging，2020，51(3)：947-958.
[18]	Cal M, Ayres-de-Campos D, Jauniaux E. International survey of practices used in the diagnosis and management of placenta accreta spectrum disorders[J]. Int J Gynecol Obstet，2018，140(3)：307-311.

[1]	刘晨鹭, 刘洁, 张帆, 严彩英, 陈倩, 陈双庆. 增强MRI 影像组学特征生境分析在预测乳腺癌HER-2 表达状态中的应用[J/OL]. 中华乳腺病杂志(电子版), 2024, 18(06): 339-345.
[2]	马桥桥, 张传开, 郭开今, 蒋涛, 王子豪, 刘勇, 郝亮. 可降解止血粉减少初次全膝关节置换术失血量的研究[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 585-589.
[3]	张秋阳, 余韶芸, 潘向滢, 金家佳, 夏桦, 赵雪红. 成年体外膜肺氧合患者出血影响因素的Meta 分析[J/OL]. 中华危重症医学杂志(电子版), 2024, 17(05): 392-398.
[4]	周正阳, 陈凯, 仇多良, 邵乐宁, 吴浩荣, 钟丰云. 腹腔镜腹股沟疝修补术后出血原因分析及处理[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(06): 660-664.
[5]	刘明辉, 葛方明. MRI 对腹股沟疝修补术后患者早期并发症的评估价值研究[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(05): 579-583.
[6]	杭轶, 杨小勇, 李文美, 薛磊. 可控性低中心静脉压技术在肝切除术中应用的最适中心静脉压[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 813-817.
[7]	王永楠, 汤畅通, 殷杰, 谭溢涛. 微创钻孔引流术与神经内镜血肿清除术治疗临界量基底节脑出血的效果对比分析[J/OL]. 中华神经创伤外科电子杂志, 2024, 10(05): 286-292.
[8]	张志超, 李陈, 韩惠, 周夏, 洪家康. 经额平行白质纤维束立体定向血肿穿刺引流术与神经内镜下血肿清除术治疗基底节脑出血的临床对比分析[J/OL]. 中华神经创伤外科电子杂志, 2024, 10(05): 299-303.
[9]	李晓东, 王汉宇, 马龙, 刘亮, 魏云, 李昂. 小脑后下动脉瘤的显微手术治疗[J/OL]. 中华脑科疾病与康复杂志(电子版), 2024, 14(05): 318-320.
[10]	张立俊, 孙存杰, 胡春峰, 孟冲, 张辉. MSCT、DCE-MRI 评估术前胃癌TNM 分期的准确性研究[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 519-523.
[11]	吴广迎, 张延娟, 秦鹏, 卢艳丽. 经颈静脉肝内门体静脉分流术预防上消化道出血的临床研究[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 545-548.
[12]	董晟, 郎胜坤, 葛新, 孙少君, 薛明宇. 反向休克指数乘以格拉斯哥昏迷评分对老年严重创伤患者发生急性创伤性凝血功能障碍的预测价值[J/OL]. 中华临床医师杂志(电子版), 2024, 18(06): 541-547.
[13]	穆巴拉克·伊力哈, 徐霁华, 鲁明. 急性轻型卒中微量脑出血误诊病例的临床特点及影像学表现分析[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 441-445.
[14]	赵伟伟, 赵玉华, 刘小璇. 西藏地区亚甲基四氢叶酸还原酶C677T多态性及其与脑微出血的相关性[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 473-478.
[15]	金安松, 邹玉松, 刘玖涛, 薛凤麟, 庞爱兰. 孤立性颅内浆细胞瘤一例及相关文献复习[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 495-500.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Evaluation of blood loss by magnetic resonance imaging during cesarean section in placenta accreta spectrum disorders

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Evaluation of blood loss by magnetic resonance imaging during cesarean section in placenta accreta spectrum disorders