凶险性前置胎盘合并胎盘植入演变过程的超声诊断价值

Diagnostic value of ultrasound in perilous placenta previa with placental implantation evolution process

目的探讨凶险性前置胎盘合并胎盘植入各孕期的超声表现特征,提高对凶险性前置胎盘合并胎盘植入的认识,为早期诊断提供有效帮助。方法选择18例凶险性前置胎盘合并胎盘植入的孕妇,年龄26~36岁,平均年龄29岁。回顾性分析孕妇各孕期的超声声像图,记录孕囊或胎盘位置、胎盘厚度、胎盘内回声、胎盘后间隙、子宫肌壁内及与膀胱壁之间的关系,同时应用彩色多普勒显示植入区域血流情况。采取择期剖宫产手术治疗,包括子宫下段剖宫产术、腹主动脉球囊植入术,对穿透型胎盘植入孕妇另行经输尿管镜支架植入术,术后病理诊断方法为活体组织检查和免疫组织化学检查。结果早孕期8例孕囊着床位置低,3例为瘢痕妊娠,3例雏形胎盘伸入瘢痕内且子宫肌层变薄。中孕期12例"胎盘漩涡"形成,12例胎盘后间隙消失,6例子宫肌层变薄,4例子宫肌层连续性中断但未穿透浆膜层。晚孕期18例均见"胎盘漩涡"且胎盘后间隙消失,子宫肌层更薄或中断,6例穿透浆膜层达膀胱后壁。剖宫产术后无子宫切除情况,术中出血1 000~3 000 mL,术后恢复良好。术后病理粘连型1例,植入型11例,穿透型6例。结论对于有剖宫产史的孕妇早孕期应重点观察孕囊或胎盘与子宫前壁下段瘢痕之间的关系,中晚孕观察胎盘、胎盘后间隙、子宫下段肌层及膀胱后壁回声。产前超声正确诊断凶险性前置胎盘合并胎盘植入能有效帮助临床及时发现并制定有效的诊疗方案,降低母婴死亡风险,避免严重并发症的发生。

Objective To investigate the ultrasonographic characteristics of dangerous placenta previa and placenta implanta-tion in pregnancy, and improve the awareness of dangerous placenta previa and implantation, which be helpful in early diagno-sis. Methods A total of 18 perilous placenta previa pregnant women combined with placenta implantation were enrolled,which aged 26-36 years old with mean age of 29 years old. The ultrasonographic features of pregnant women in pregnancy were retrospectively analyzed. The location of gestational sac or placenta, placental thickness, placental echo, placental poste-rior space, intramural wall and wall of bladder were recorded. Meanwhile, the color Doppler flow imaging was used to show blood flow of implanted area. All of them performed elective cesarean section of lower uterine segment cesarean section and abdominal aorta balloon implantation. The pregnant women with penetrating placenta implantation were performed ureteroscop-ic stent implantation, The postoperative pathological diagnosis methods were biopsy and immunohistochemical examination.Results In the early pregnancy, 8 cases showed low implantation position, 3 of cicatricial pregnancy, 3 of embryonic placenta in scar with myometrium thinning. There were 12 cases of placental whirlpool in mid pregnancy, 12 of posterior placental space disappeared, 6 of myometrium thinning, 4 of continuous interruption myometrium but no serous layer. In the late preg-nancy, 18 cases showed placental whirlpool with posterior placental space disappeared, the myometrium thinner or interrupted,and 6 of penetrated serous layer to bladder posterior wall. There was no hysterectomy after cesarean section, intraoperative bleeding was 1 000-3 000 m L, which postoperative recovered were well. The postoperative pathological showed that adhesion in 1 case, implantation in 11 cases and penetrating in 6 cases. Conclusion It is demonstrated that in pregnant women with cesarean section history, the relationship between gestational sac or placenta and the lower scar of anterior uterine wall should be emphasized in the first trimester. The placenta, posterior placental space, the lower uterine muscle layer and bladder poste-rior wall should be observed in the second trimester. The correct prenatal ultrasound diagnosis of placenta previa with placenta accreta could develop effective diagnosis and treatment plan in time, reduce the risk of maternal and infant mortality, and avoid serious complications.