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.

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

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