MRI预测子宫剖宫产瘢痕妊娠清宫术中风险的价值

The Value of MRI for Predicting Risk during Uterine Curettage in Patients with Cesarean Scar Pregnancy

目的探讨术前MRI预测剖宫产切口瘢痕妊娠(CSP)清宫手术风险的价值。方法回顾性分析135例经手术及病理证实的CSP患者的临床及术前MRI资料,分析各临床及MRI特征与术中大出血(≥200 ml)、术中转变手术方式及宫腔球囊填塞压迫止血的关系。单因素分析采用Mann-Whitney U检验或χ;检验,将单因素分析中有统计学差异的指标进行多因素Logistic回归分析,筛选出预测手术风险的独立危险因素。绘制受试者工作特征曲线(ROC)评价各独立危险因素的预测效能。结果手术风险相关因素包括停经时间、既往CSP次数、术前β-HCG、瘢痕处子宫轮廓外凸、瘢痕厚度、憩室深度、憩室入口长度、胚芽显示、妊娠物体积、孕囊主体位于憩室内、孕囊与肌层分界不清及动脉期瘢痕处胎盘组织显著强化(P均<0.05)。术中大出血的独立危险因素为瘢痕厚度(P=0.002,OR=0.038,95%CI:0.005~0.306)、β-HCG(P=0.002,OR=1.021,95%CI:1.008~1.035)及孕囊主体位于憩室内(P=0.009,OR=12.549,95%CI:1.864~84.460),ROC曲线下面积(AUC)分别为0.932、0.815及0.697,瘢痕厚度及术前β-HCG的最佳截断值分别为2.15 mm及82.443×10^(3)mIU/ml;宫腔球囊填塞压迫止血的独立危险因素为瘢痕厚度(P=0.015,OR=0.046,95%CI:0.004~0.544)与术前β-HCG(P=0.08,OR=1.019,95%CI:1.005~1.033),AUC及最佳截断值分别为0.923 mm、0.856 mm及1.95 mm、104.831×10^(3)mIU/ml;术中转变手术方式的独立危险因素为瘢痕厚度(P<0.001,OR=0.093,95%CI:0.026~0.325),AUC及最佳截断值分别为0.853及2.05 mm。结论术前MRI对于评估CSP患者清宫手术风险有重要价值。

Objective To explore the value of the preoperative MRI in predicting risk(massive hemorrhage, change the operation approaches, and hemostasis by intrauterine balloon packing) during uterine curettage in patients with cesarean scar pregnancy(CSP). Methods The clinical and MRI data of 135 patients with CSP confirmed by operation and pathology were analyzed retrospectively. The relationship between the clinical and MRI characteristics and intraoperative massive bleeding(≥200 ml),change in operation approaches and hemostasis by balloon packing of uterus was analyzed with Mann-Whitney U test, chi-square and Fisher’s exact tests for univariate analysis, and multivariate Logistic regression analysis was performed on the indicators with statistical differences in univariate analysis to identification independent risk factors for predicting surgical risk.The receiver operating characteristic curve(ROC) was used to evaluate the diagnostic efficacy. Results The risk factors related to uterine curettage included age ofmenopause, number of previous CSP,preoperative β-HCG level, uterine scar bulging out of the contour of the uterus, uterine scar thickness, depth of cesarean scar diverticulum, length of diverticulum inlet, embryo seen in gestational sac, volume of gestation sac, mainbody of the gestational sac located in diverticulum, indistinct demarcation between gestational sac and myometrium and obvious enhancement of placental tissue in arterial phase(P< 0.05).The independent risk factors of intraoperative massive hemorrhage were the uterine scar thickness(P=0.002,OR=0.038,95%CI:0.005-0.306),β-HCG(P=0.002,OR=1.021,95%CI:1.008-1.035)and main body of the gestational sac located in diverticulum(P=0.009,OR=12.549,95%CI:1.864-84.460),and ROC analysis showed the area under the curve(AUC) was 0.932,0.815 and 0.697,respectively, with the optimal cutoff values of the uterine scar thickness and β-HCG were 2.15 mm and 82.443 × 10^(3)mIU/ml respectively.The independent risk factors of hemostasis by intrauterine balloon packing were the uterine scar thickness(P=0.015,OR=0.046,95%CI:0.004-0.544)and β-HCG(P=0.08,OR=1.019,95%CI:1.005-1.033),and the AUC and their optimal cutoff values were 0.923 mm, 0.856 mm and 1.95 mm, 104.831×10^(3)mIU/ml respectively.The independent risk factors of intraoperative change the operation approaches were the uterine scar thickness, with the AUC as 0.853 and the optimal cutoff values as 2.05 mm. Conclusion Preoperative MRI is of great value in assessing the risk of uterine curettage in patients with CSP.