经阴道超声及超声造影对剖宫产瘢痕妊娠病人术中大出血的风险评估

Transvaginal ultrasound and contrast-enhanced ultrasound in the risk assessment of intraoperative bleeding in patients with scar pregnancy

目的探讨经阴道超声(TVS)及超声造影(CEUS)对瘢痕妊娠(CSP)病人术中大出血风险评估的价值。方法以2018年2月至2020年2月在甘肃省妇幼保健院就诊的104例CSP病人为研究对象,将术中出血≥400 mL的26例病人作为观察组,出血<400 mL的78例病人作为对照组。比较两组造影后病灶的绒毛距浆膜层最近的距离、丛密绒毛膜厚度、病灶长径、病灶突入切口的平均径。采用logistic回归模型评估病人发生术中大出血风险的概率。结果与对照组病人比较,观察组病人剖宫次数≥2次者比例(69.2%比32.1%)、丛密绒毛膜厚度[1.25(0.95,1.69)cm比0.40(0.33,0.58)cm]、病灶长径[4.47(3.11,5.91)cm比1.66(1.44,2.12)cm]、病灶突入切口的平均径[3.35(2.75,4.33)cm比1.18(0.82,1.75)cm]显著升高(P<0.05),病灶绒毛膜距浆膜层最近距离[0.08(0.02,0.13)cm比0.21(0.20,0.25)cm]显著降低(P<0.05)。预测模型的ROC曲线下面积是0.834[P<0.001,95%CI为(0.769,0.886)]。当概率值取最佳截断值0.650时,模型预测的准确度、灵敏度、特异度分别为84.62%、85.92%、81.82%。结论术前进行TVS及CEUS检查能较准确地评估CSP手术治疗中发生大出血的风险,对病人个体化手术治疗方案的制定具有重要的借鉴价值。

Objective To explore the value of transvaginal ultrasound(TVS)and contrast-enhanced ultrasound(CEUS)in the risk assessment of intraoperative bleeding in patients with scar pregnancy(CSP).Methods A total of 104 CSP patients who were treated in Gansu Maternal and Child Health Hospital from February 2018 to February 2020 were selected as the research objects.Twenty-six patients with intraoperative bleeding≥400 mL were selected as the observation group,and 78 patients with bleeding<400 mL were selected as the control group.The closest distance between the villi of the lesion and the serosal layer,the thickness of the dense chorion,the largest diameter of the lesion,and the average diameter of the lesion protruding into the incision were compared between the two groups after CEUS.The logistic regression was used to assess the probability of patients with major intraoperative hemorrhage.Results Compared with patients in the control group,the proportion of patients with cesarean sections more than or equal to 2 times(69.2%vs.32.1%),the thickness of dense chorion[1.25(0.95,1.69)cm vs.0.40(0.33,0.58)cm],the largest diameter of the lesion[4.47(3.11,5.91)cm vs.1.66(1.44,2.12)cm],and the average diameter of the lesion protruding into the incision[3.35(2.75,4.33)cm vs.1.18(0.82,1.75)cm]in the observation group were significantly increased(P<0.05),and the closest distance between the chorion of the lesion and the serosa[0.08(0.02,0.13)cm vs.0.21(0.20,0.25)cm]in the observation group was significantly reduced(P<0.05).Area under curve for the prediction model was 0.834[P<0.001,95%CI:(0.769,0.886)].When the probability value took the best cut-off value of 0.650,the accuracy,sensitivity and specificity of model prediction were 84.62%,85.92%and 81.82%,respectively.Conclusion Preoperative transvaginal ultrasonography and contrast-enhanced ultrasonography can accurately assess the risk of major bleeding during CSP surgical treatment,which has important reference value for the formulation of individualized surgical treatment plans for patients.