超声多模态评估复发性流产患者的子宫内膜容受性与妊娠结局相关性研究

Study on the correlation between endometrial receptivity and pregnancy outcome in patients with recurrent spontaneous abortion evaluated by multimodal ultrasound imaging

目的:探讨多模态超声评估复发性流产(RSA)患者子宫内膜容受性(ER)与妊娠结局相关性分析。方法:采用前瞻性双盲队列研究,选取在潍坊市人民医院于黄体中期(排卵后7~9天)行经阴道超声ER评估的2 458例,筛选后随机选取98例RSA患者作为研究组,随机选取96例正常人(无自然流产史且具有正常生育史)为正常对照组,分别记录两组子宫内膜形态学参数(内膜厚度、内膜容积、内膜类型、内膜蠕动频率)以及子宫血流动力学参数(内膜及内膜下血流类型、血管血流指数(VFI)、血管化指数(VI)、血流指数(FI)、子宫动脉收缩峰值血流速度与舒张末期血流速度比值(S/D)、子宫动脉搏动指数(PI)、阻力指数(RI))。追踪RSA组和对照组的妊娠结局,分为RSA妊娠成功组(46例)、RSA未妊娠组(52例)、正常妊娠成功组(80例)和正常未妊娠组(16例),使用统计学方法对不同妊娠结局患者的ER超声参数进行差异分析,以受试者工作特征曲线(ROC曲线)分析各参数以及各参数并联诊断对妊娠结局的预测价值。结果:RSA组子宫内膜厚度、内膜容积、VI、FI、VFI均小于对照组,子宫动脉RI、PI、S/D高于对照组。追踪妊娠结局:RSA妊娠成功患者的VI、FI、VFI显著高于RSA未妊娠组,差异有统计学意义(P<0.05)。Ⅰ、Ⅱ、Ⅲ型内膜血流的妊娠成功率分别为63.8%、77.6%、92.5%,A、B、C型内膜的妊娠成功率分别为89.8%、66.6%、65.5%,差异有统计学差异(P<0.05)。通过ROC曲线分析,各超声参数的最佳截断值、AUC、特异性、灵敏性分别为:子宫内膜厚度(6.2 mm、0.664、0.365、0.894)、子宫内膜容积(2.13 cm3、0.776、0.500、0.831)、子宫动脉RI(0.84、0.639、0.472、0.788)、PI(2.27、0.591、0.493、0.692)、S/D (6.295、0.622、0.788、0.507)、VI (6.09、0.846、0.923、0.655)、FI (12.61、0.736、0.769、0.704),VFI(0.775、0.841、0.904、0.676)。各参数并联诊断预测妊娠结局的AUC为0.867,敏感性为82.4%,特异性为84.6%。结论:RSA患者于黄体中期行超声检查发现子宫内膜形态学及血流动力学较正常人有明显差异,ER可以通过超声技术来预测RSA患者的妊娠结局,将各超声参数并联诊断ER的价值较单一参数更大。

Objective:To explore the correlation between endometrial receptivity(ER) and pregnancy outcome by multimodal ultrasound in patients with recurrent spontaneous abortion(RSA).Methods:A prospective,double-blind cohort study was conducted,in which 2 458 cases who were evaluated by transvaginal ultrasound in the middle luteal phase(7~9 days after ovulation) in Weifang People's Hospital were selected.After screening,98 cases with RSA were randomly selected as the study group,and 96 normal people(no history of spontaneous abortion) were randomly selected as the normal control group.The endometrial morphological parameters(endometrial thickness,endometrial volume,endometrial type and endometrial peristalsis frequency) and uterine hemodynamic parameters(endometrial and subendothelial blood flow types,vascular blood flow index(VFI),vascularization index(VI),flow index(FI),the ratio of uterine artery systolic peak blood flow velocity to end diastolic blood flow velocity(S/D),uterine artery pulse index(PI),resistance index(RI)) were recorded in the two groups respectively.The pregnancy outcomes of RSA group and control group were tracked and divided into RSA pregnancy success group(46 cases),RSA nonpregnancy group(52 cases),normal pregnancy success group(80 cases) and normal non-pregnancy group(16 cases).The ultrasonic parameters of endometrial receptivity of patients with different pregnancy outcomes were analyzed by statistical method,and the predictive value of each parameter and its parallel diagnosis were analyzed by receiver operating characteristic(ROC)curve.Results:The endometrial thickness,endometrial volume,VI,FI and VFI in RSA group were all lower than those in the control group,while the RI,PI and S/D of uterine artery were higher than those in the control group.Tracking the pregnancy outcome:the VI,FI and VFI in RSA pregnant patients were significantly higher than those in RSA non-pregnant group,with statistical significance(P<0.05).The pregnancy success rate of type Ⅰ,Ⅱ and Ⅲ intima blood flow was 63.8%,77.6% and 92.5% respectively,and the pregnancy success rate of type A,B and C intima was 89.8%,66.6% and 65.5% respectively,with statistical differences.Through ROC curve analysis,the best cutoff value,AUC,specificity and sensitivity of each ultrasound parameter were:endometrial thickness(6.2 mm,0.664,0.365,0.894),endometrial volume(2.13 cm3,0.776,0.500,0.831) and uterine artery RI(0.84,0.639,0.472,0.788),PI(2.27,0.591,0.493,0.692),S/D(6.295,0.622,0.788,0.507),VI(6.09,0.846,0.923,0.655),FI(12.61,0.736,0.769,0.704),VFI(0.775,0.841,0.904,0.676).The AUC,sensitivity and specificity of parallel diagnosis of each parameter in predicting pregnancy outcome were 0.867,82.4% and 84.6%.Conclusion:Ultrasound examination of RSA patients in the middle luteal phase reveals significant differences in endometrial morphology and hemodynamics compared to normal individuals,ER can predict pregnancy outcomes in RSA patients through ultrasound technology,and the value of diagnosing endometrial receptivity in parallel with each ultrasound parameter is greater than that of a single parameter.