经阴道超声监测孕囊参数评估剖宫产术后瘢痕妊娠术中出血风险的价值

Value of monitoring gestational sac parameters by transvaginal ultrasound in risk assessment of intraoperative hemorrhage at evacuation of cesarean scar pregnancy

目的探究经阴道超声监测孕囊参数对剖宫产术后瘢痕妊娠(CSP)术中出血风险的评估价值。方法回顾性分析郑州人民医院2016年2月至2019年12月收治的63例行手术治疗的CSP患者的临床资料,将患者分为研究组(术中出血量>200 ml,27例)及对照组(术中出血量≤200 ml,36例)。比较两组患者的基线资料及经阴道超声检查参数(孕囊长径、孕囊类型、血流分级和残余肌层厚度),选取存在差异的指标,进行非条件Logistic多元逐步回归分析,探究CSP患者术中出血的危险因素。并采用受试者工作特征曲线(ROC)评价孕囊长径对CSP患者术中出血的预测价值。结果两组患者年龄、孕次、基础疾病史(糖尿病、高血压、冠心病)、手术方法(病灶切除术、清宫术)比较差异未见统计学意义(P>0.05);患者经阴道超声检查参数(孕囊长径、孕囊类型、血流分级、残余肌层厚度)为CSP患者术中出血的危险因素(P<0.05)。经非条件Logistic多元逐步回归分析可知,孕囊偏大、外生型孕囊、血流分级Ⅲ级、残余肌层偏厚为CSP患者术中出血的独立影响因素(P<0.05)。孕囊长径、孕囊类型、血流分级及残余肌层厚度预测CSP患者术中出血的ROC曲线下面积(AUC)均高于参考线(P<0.05)。孕囊长径截断值为37.52 cm,灵敏度为88.46%,特异度为86.11%;孕囊类型灵敏度为46.15%,特异度为83.33%;血流分级灵敏度为46.15%,特异度为80.56%;残余肌层厚度截断值为2.24 cm,灵敏度为92.31%,特异度为86.11%。联合预测的AUC值高于参考线(P<0.05)。结论经阴道超声检查孕囊偏大、外生型孕囊、血流分级Ⅲ级、残余肌层偏厚均为CSP患者术中出血的独立影响因素,均可为预测其出血风险提供参考,临床针对高危手术患者需引起足够重视。

Objective To investigate the value of monitoring gestational sac parameters by transvaginal ultrasound in the risk assessment of intraoperative hemorrhage at evacuation of cesarean scar pregnancy(CSP).Methods The clinical data of 63 patients with CSP undergoing surgery admitted to Zhengzhou People’s Hospital from February 2016 to December 2019 were retrospectively analyzed.The patients were divided into study group(intraoperative blood loss>200 ml,27 cases)and control group(intraoperative blood loss≤200 ml,36 cases).The baseline data and transvaginal ultrasound parameters(gestational sac size,types of gestational sac,blood flow grades,residual muscular thickness)were compared between the two group.The indicators with significant differences between the two groups were selected for unconditional Logistic multiple stepwise regression analysis to detect the risk factors of intraoperative hemorrhage in patients with CSP.Receiver operating characteristic(ROC)curve was used to evaluate the predictive value of gestational sac major diameter on intraoperative hemorrhage in patients with CSP.Results There was no significant difference between the two groups in age,gravidity,history of underlying diseases(diabetes mellitus,hypertension,coronary heart disease),and surgical methods(lesionectomy,uterine curettage),P>0.05.And the transvaginal ultrasound parameters(gestational sac major diameter,gestational sac types,blood flow grades,residual muscular thickness)were all risk factors of intraoperative hemorrhage in patients with CSP(P<0.05).Unconditional Logistic multiple stepwise regression analysis showed that large gestational sac,exogenous gestational sac,blood flow gradeⅢ,and thick residual muscular layer were independent influencing factors of intraoperative hemorrhage in patients with CSP(P<0.05).The values of area under curve(AUC)of gestational sac major diameter,gestational sac types,blood flow grades,and residual muscular thickness in predicting intraoperative hemorrhage in patients with CSP were significantly higher than the reference line(P<0.05).The cut-off value,sensitivity and specificity of gestational sac major diameter were 37.52 cm,88.46%and 86.11%;the sensitivity and specificity of gestational sac types were 46.15%and 83.33%,respectively;the sensitivity and specificity of blood flow grades were 46.15%and 80.56%,respectively;and the cut-off value,sensitivity and specificity of residual muscular thickness were 2.24 cm,92.31%and 86.11%,respectively.The AUC of combinarion of gestational sac parameters in prediction was significantly higher than the reference line(P<0.05).Conclusions Transvaginal ultrasound examination of large gestational sac,exogenous gestational sac,blood flow gradeⅢ,and thick residual muscular layer are all independent influencing factors of intraoperative hemorrhage in patients with CSP,and they can provide references for predicting the risk of hemorrhage.