经阴道彩色多普勒超声在剖宫产术后子宫瘢痕妊娠诊治中的价值

Value of transvaginal color Doppler ultrasound in the diagnosis and treatment of cesarean scar pregnancy

目的：探讨经阴道彩色多普勒超声在剖宫产术后子宫瘢痕妊娠（CSP）诊断和治疗中的临床价值。方法回顾性分析2009年1月～2014年10月广东省东莞市第三人民医院收治的21例CSP患者的超声声像图特征，21例患者均采用经阴道彩色多普勒超声检查，并在阴道超声下进行穿刺注药治疗。总结21例患者的经阴道超声表现，比较穿刺注药治疗前后病灶长径、宽径、子宫前壁下段肌层厚度和病灶周围动脉血流阻力指数（RI）。结果21例CSP患者中单纯孕囊型18例，超声表现子宫前壁下段切口处肌壁间完整的孕囊，11例孕囊内见卵黄囊、胎芽和原始的胎心搏动，3例孕囊内见卵黄囊和胎芽，未见胎心搏动，2例孕囊内仅见卵黄囊，无胎芽和胎心搏动，2例孕囊皱缩、变形。团块型3例，超声表现为子宫前壁下段切口处混合回声团块，与子宫肌层分界不清，切口区域肌层菲薄，彩色多普勒超声显示孕囊或团块周围可见丰富的血流信号，滋养血管来自切口处子宫肌层，3例团块型病灶内部可见血流信号，频谱多普勒呈低速低阻型，RI值为0.32～0.56。穿刺注药治疗后，21例CSP病灶长径和宽径与治疗前比较差异无统计学意义（P〉0.05），但子宫前壁下段肌层厚度较治疗前明显增加（P〈0.01），病灶及周围肌层回声减低，病灶周围血流信号减少，RI值较前明显增加（P〈0.01）。16例单纯孕囊型CSP患者穿刺注药后临床治愈。2例单纯孕囊型CSP患者治疗后症状不缓解，行手术治疗后痊愈。3例团块型病灶治疗后血HCG下降不明显，行超声引导下清宫术治愈。结论经阴道彩色多普勒超声在剖宫产术后瘢痕妊娠的诊断和治疗中具有重要价值。

Objective To investigate the clinical value of transvaginal color Doppler ultrasound in the diagnosis and treatment of cesarean scar pregnancy （CSP）. Methods Sonographic characteristics of 21 patients with CSP in the Third People＇s Hospital of Dongguan City from January 2009 to October 2014 were analyzed retrospectively, 21 cases were examined by transvaginal color Doppler ultrasound, and treated with puncture and injection of medicine under vaginal ultrasonography detection, transvaginal ultrasound manifestations of 21 cases were summarized, the lesion length to diameter, wide diameter, anterior uterine wall peripheral arterial resistance thickness and lesions with muscular segment index （resistive index, RI） before and after drug injection for the treatment of puncture were compared. Results 21 cases with CSP were divided into the following types pure gestational sac type （18 cases）, and complete gestational sac were showed in anterior wall of the lower part of the incision of uterus intramural under ultrasond, yolk sac, embryo bud and original fetal heart beat were seen in gestational sac of 11 cases, yolk sac, embryo bud were seen in gestational sac of 3 cases, but no fetal heart beat, yolk sac were only seen in gestational sac of 2 cases but no embryo bud or fetal heart beat, gestational sac shrinkage, deformation were in 2 cases, and 3 cases were the mass type, and mixed echogenic mass were showed in the incision of the anterior wall of hypomere of the uterus, and uterine muscular layer boundary was not clear, the incision area muscle layer was humble, ditissimus blood flow signals were showed around the gestational sac or clumps under color Doppler ultrasond, nourishing vessels were from the incision of uterine muscular layer, blood flow signals were seen in the mass lesions of 3 cases, spectral Doppler showed a low speed and low resistance, the RI value was 0.32-0.56. Compared with before treatment, the length and width of CSP lesions in 21 patients after the treatment of puncture and injection of medicine, there were no statistical significant differences （P〉 0.05）, but the muscle layer thickness of anterior wall in the lower part of uterus significantly increased than before treatment （P〈 0.01）, hypoechoic of the lesions and the surrounding muscle layer reduced and blood flow signals reduced, RI value significantly increased （P 〈 0.01）. 16 patients with simple gestational sac type were healed after clinical cure of puncture and injection. 2 patients with simple gestational sac type did not alleviate the symptoms, and the two cases were cured after operation, blood HCG of mass lesions in 3 cases decreased not obviously after treatment, and the 3 cases were cured after the uterus curettage. Conclusion It has important value of transvaginal color Doppler ultrasound in the diagnosis and treatment of CSP.