剖宫产术后子宫瘢痕憩室再次妊娠的不良妊娠结局分析及预测

Prediction and analysis of adverse pregnancy outcomes in pregnant women with cesarean scar diverticulum

目的探讨剖宫产术后子宫瘢痕憩室(CSD)孕妇再次妊娠的妊娠结局及预测不良妊娠结局的相关指标。方法前瞻性收集2015年1月至2019年3月于妊娠早期开始在北京大学第一医院行规律产前检查并最终分娩的既往有剖宫产史的单胎妊娠孕妇501例,根据妊娠早期超声检查有无CSD分为CSD组127例(25.3%,127/501)及无CSD组374例(74.7%,374/501),根据分娩方式及剖宫产术中所见子宫下段分级,进一步将CSD组分为未破裂组(包括自然分娩和子宫下段分级Ⅰ级者)108例(85.0%,108/127)和破裂组(包括子宫下段分级Ⅱ~Ⅳ级者)19例(15.0%,19/127),比较各组的一般临床资料、妊娠结局、憩室相关指标[包括长径、宽径、深度、平均径、体积及残余肌层厚度(RMT)]。评价CSD孕妇子宫破裂高风险指标憩室深度/邻近肌层厚度≥50%、RMT≤2.2 mm及憩室深度/RMT>1.3对子宫破裂发生的预测价值。结果(1)CSD组与无CSD组的比较:CSD组孕妇妊娠晚期子宫下段厚度小于无CSD组[分别为(1.2±0.5)、(1.4±0.6)mm],其子宫破裂的发生率高于无CSD组[分别为15.0%(19/127)、8.0%(30/374)],分别比较,差异均有统计学意义(P均<0.05);两组其他临床资料和妊娠结局分别比较,差异均无统计学意义(P均>0.05)。(2)破裂组与未破裂组的比较:破裂组妊娠晚期子宫下段厚度[(0.6±0.5)mm]小于未破裂组[(1.2±0.6)mm],两组比较,差异有统计学意义(t=3.486,P=0.001);两组憩室相关指标分别比较,差异均无统计学意义(P均>0.05)。(3)CSD孕妇子宫破裂预测指标与实际发生子宫破裂的相关性:憩室深度/邻近肌层厚度≥50%、RMT≤2.2 mm及憩室深度/RMT>1.3预测子宫破裂发生的敏感度分别为94.7%、57.9%、73.6%,特异度分别为12.0%、40.7%、24.1%,阳性预测值分别为15.9%、14.7%、14.6%,阴性预测值分别为92.8%、84.6%、83.9%。结论CSD孕妇较无CSD孕妇子宫破裂的发生风险高。妊娠早期憩室相关指标与子宫破裂的发生无明显相关性,妊娠晚期监测子宫下段厚度有助于预测不良妊娠结局。

Objective To investigate the pregnancy outcomes of pregnant women with cesarean scar diverticulum(CSD)and to find the relevant factors that predict the occurrence of adverse pregnancy outcomes.Methods From January 2015 to March 2019,501 singleton pregnant women with a history of cesarean section who underwent regular prenatal examination in early pregnancy and eventually delivered in Peking University First Hospital were prospectively collected.According to the presence or absence of CSD in the first trimester of pregnancy,the pregnant women were divided into the CSD group(n=127,25.3%)and the non-CSD group(n=374,74.7%).According to the mode of delivery and the classification of the lower uterine segment seen during cesarean section,the CSD group was further divided into the non-rupture group(including spontaneous delivery and lower uterine segment gradeⅠ;n=108,85.0%)and rupture group(including lower uterine segment gradeⅡ-Ⅳ;n=19,15.0%).The general clinical data,pregnancy outcomes,diverticulum-related indexes[including length,width,depth(D),average diameter,volume,and residual myometrial thickness(RMT)]were compared.The predictive values of D/adjacent myometrial thickness≥50%,RMT≤2.2 mm and D/RMT>1.3 for uterine rupture in CSD pregnant women were verified.Results(1)Comparison between CSD group and non-CSD group:the lower uterine segment thickness in the third trimester of pregnancy in the CSD group was lower than that in the non-CSD group[(1.2±0.5)vs(1.4±0.6)mm,respectively],and the incidence of uterine rupture was higher than that in the non-CSD group[15.0%(19/127)vs 8.0%(30/374),respectively],and the differences were statistically significant(both P<0.05).There were no significant differences in other clinical data and pregnancy outcomes between the two groups(all P>0.05).(2)Comparison of rupture group and non-rupture group:the lower uterine segment thickness in the third trimester of pregnancy in rupture group[(0.6±0.5)mm]was lower than that in non-rupture group[(1.2±0.6)mm],and the difference was statistically significant(t=3.486,P=0.001).There were no significant differences in diverticulum-related indexes between the two groups(all P>0.05).(3)Relationship between high risk predictors of uterine rupture and actual uterine rupture:the sensitivity of D/adjacent muscle thickness≥50%,RMT≤2.2 mm and D/RMT>1.3 in predicting the high risk of uterine rupture were 94.7%,57.9%and 73.6%,the specificity were 12.0%,40.7%and 24.1%,the positive predictive value were 15.9%,14.7%,14.6%,and the negative predictive value were 92.8%,84.6%,83.9%,respectively.Conclusions The risk of uterine rupture in pregnant women with CSD is higher than that in those without CSD.There is no significant correlation between CSD related indexes and uterine rupture in the first trimester.Monitoring the lower uterine segment thickness in the third trimester might be helpful to predict the occurrence of adverse pregnancy outcomes.