彩色多普勒超声与磁共振成像在凶险型前置胎盘及合并胎盘植入产前诊断中的应用及漏诊分析

doi:10.16150/j.1671-2870.2021.02.010

摘要/Abstract

摘要：

目的:探讨彩色多普勒超声（超声）及磁共振成像（magnetic resonance imaging,MRI）检查在凶险型前置胎盘（pernicious placenta previa,PPP）及合并胎盘植入诊断中的应用价值,并分析漏诊原因。方法:选取2015年1月至2019年12月在本院分娩且经术后病理证实为PPP的孕产妇134例,所有孕妇产前均行超声及MRI检查。以术后病理诊断为金标准,对比分析超声与MRI检查在PPP诊断中的价值。结果:134例PPP患者中,产前超声检查检出了124例,检出率为92.53%（124/134）,漏诊10例。超声检查漏诊PPP的原因包括孕妇肥胖（2例）、肠道内气体干扰（1例）、后壁或侧壁胎盘（5例）以及多因素（2个以上因素）共同作用（2例）。MRI检查检出126例PPP,检出率为94.03%（126/134）,漏诊8例,分析其漏诊原因为后壁、侧壁胎盘及周围结构复杂。超声与MRI间的PPP检出率差异无统计学意义（P>0.05）;产前,二者联合检出PPP共128例,漏诊6例。MRI与超声检查结果间一致性较好（Kappa>0.8）。80例PPP患者合并胎盘植入,超声检查检出了73例,检出率达91.25%（73/80）,漏诊7例,漏诊原因为肥胖及肠道内气体干扰各1例,胎盘位置及周围解剖结构复杂4例,多因素导致1例;MRI检出了75例,检出率为93.75%（75/80）,漏诊5例。超声与MRI间比较,检出率差异无统计学意义（P>0.05）,产前,2种方法联合共检出PPP 75例,漏诊5例。二者联合检查发生漏诊的原因为胎盘增厚不明显,胎盘后方及胎盘内血窦不丰富,且周围解剖学关系复杂。结论:超声与MRI检查对PPP及合并胎盘植入的检出率均较高,且两者结果间一致性好。因超声检查方便且经济,仍是目前在产前诊断PPP及合并胎盘植入的首选方法。MRI检查可作为超声疑诊PPP或诊断不明确时的补充手段。

关键词: 凶险型前置胎盘, 胎盘植入, 彩色多普勒超声, 磁共振成像

Abstract:

Objective: To explore the detection efficacy of ultrasound(US) and magnetic resonance imaging(MRI) for pernicious placenta previa(PPP) and PPP with placenta accreta, and analyze the causes for missed diagnosis. Methods: A total of 134 pregnancies with pernicious placenta treated at the International Peace Maternity and Child Health Hospital Affiliated to Shanghai Jiao Tong University School of Medicine during January 2015 to December 2019 were enrolled. All the pregnancies underwent US and MRI, and image characteristics of both were retrospectively analyzed. Findings of US and MRI were compared with the results of intraoperative and postoperative pathological examination, and detection efficacy of US and MRI for PPP was assessed. Results: For PPP, US identified 124 out of 134 cases, with a detection rate of 92.5%, and 10 cases were missed because of obesity(2 cases), intestine gas interference(1 case), placenta position (placenta covering lateral or posterior wall of the uterus)(2 cases) and multi-causes(more than 2 causes, 2 cases). MRI recognized 126 out of 134 cases, with a detection rate of 94%, and 8 cases were missed because of placenta position and complicated surrounding structure. With combined use of US and MRI, 128 cases were recognized and 6 cases were missed. For PPP with placenta accreta, 73 cases were diagnosed by US in 80 patients, with a sensitivity of 91.25%, and 7 cases were missed for obesity (1 case), intestine gas interference (1 case), placenta position (1 case) and complicated surrounding structure (4 cases); 75 cases were diagnosed by MRI, and 5 cases were missed. US combined with MRI could recognized 75 out of 80 PPP with placenta accreta, and 5 cases were missed because of non-obvious placental thickening, lack of blood sinuses in posterior or inner of placenta, and complicated anatomical structure. US detection for PPP was in good consistency with that of MRI(Kappa>0.8). Conclusions: Color Doppler US and MRI have good diagnostic efficacy for PPP and PPP with placenta accreta, and US is still the preferred method for prenatal diagnosis because of its low costs and convenience. MRI can be used as a supplementary method when US diagnosis is not clear.

Key words: Pernicious placenta previa, Placenta accreta, Color Doppler ultrasound, Magnetic resonance imaging

中图分类号:

R714.3

孙甜甜, 叶宝英, 杨钰, 牛建梅. 彩色多普勒超声与磁共振成像在凶险型前置胎盘及合并胎盘植入产前诊断中的应用及漏诊分析[J]. 诊断学理论与实践, 2021, 20(02): 173-177.

SUN Tiantian, YE Baoying, YANG Yu, NIU Jianmei. Color Doppler ultrasound and magnetic resonance imaging in prenatal diagnosis of pernicious placenta previa and pernicious placenta previa with placenta accreta: clinic value and analysis of missed diagnosis[J]. Journal of Diagnostics Concepts & Practice, 2021, 20(02): 173-177.

图/表 4

参考文献 19

[1]	Chattopadhyay SK, Kharif H, Sherbeeni MM. Placenta praevia and accreta after previous caesarean section[J]. Eur J Obstet Gynecol Reprod Biol, 1993, 52(3):151-156. pmid: 8163028
[2]	Kazi S. Emergency peripartum hysterectomy: a great obstetric challenge[J]. Pak J Med Sci, 2018, 34(6):1567-1570.
[3]	Berhan Y, Urgie T. A literature review of placenta accreta spectrum disorder: the place of expectant management in Ethiopian setup[J]. Ethiop J Health Sci, 2020, 30(2):277-292. doi: 10.4314/ejhs.v30i2.16 pmid: 32165818
[4]	余琳, 胡可佳, 杨慧霞. 2008—2014年凶险性前置胎盘的回顾性临床研究[J]. 中华妇产科杂志, 2016, 51(3):169-173.
[5]	Shih JC, Palacios Jaraquemada JM, et al. Role of three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and color Doppler techniques[J]. Ultrasound Obstet Gynecol, 2009, 33(2):193-203. doi: 10.1002/uog.6284 pmid: 19173239
[6]	Baughman WC, Corteville JE, Shah RR. Placenta accreta: spectrum of US and MR imaging findings[J]. Radiographics, 2008, 28(7):1905-1916. doi: 10.1148/rg.287085060 URL
[7]	Collins SL, Alemdar B, van Beekhuizen HJ, et al. Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta[J]. Am J Obstet Gynecol, 2019, 220(6):511-526. doi: S0002-9378(19)30433-8 pmid: 30849356
[8]	Angileri SA, Mailli L, Raspanti C, et al. Prophylactic occlusion balloon placement in internal iliac arteries for the prevention of postpartum haemorrhage due to morbidly adherent placenta: short term outcomes[J]. Radiol Med, 2017, 122(10):798-806. doi: 10.1007/s11547-017-0777-z URL
[9]	徐国华. 不同类型凶险性前置胎盘产妇的临床特点及剖宫产结局[J]. 中国妇幼保健, 2018, 33(9):1986-1988.
[10]	刘彬, 高素娟, 张娜, 等. 核磁共振结合血清甲胎蛋白、肌酸激酶水平诊断凶险型前置胎盘合并胎盘植入的价值[J]. 中国妇幼保健, 2018, 33(6):1409-1412.
[11]	杨彩群. 前置胎盘并发胎盘植入经腹彩色超声多普勒的诊断价值评价[J]. 中国妇幼健康研究, 2017, 28(S3):508-509.
[12]	杨燕, 牛兆仪, 丁云川, 等. 妊娠晚期剖宫产瘢痕部位胎盘植入超声表现[J]. 中国超声医学杂志, 2015, 31(12):1111-1113.
[13]	Yang JI, Lim YK, Kim HS, et al. Sonographic findings of placental lacunae and the prediction of adherent placenta in women with placenta previa totalis and prior cesarean section[J]. Ultrasound Obstet Gynecol, 2006, 28(2):178-182. doi: 10.1002/uog.2797 URL
[14]	郭吉敏, 曹满瑞, 刘小平, 等. MRI征象回归模型在植入型凶险性前置胎盘的应用[J]. 临床放射学杂志, 2018, 37(8):1325-1328.
[15]	Dighe M. MR imaging of abnormal placentation[J]. Magn Reson Imaging Clin N Am, 2017, 25(3):601-610. doi: 10.1016/j.mric.2017.03.002 URL
[16]	宋慧玲, 蒋灵军, 蒋乐真, 等. 前置胎盘是否合并胎盘植入220例磁共振分析[J]. 中华医学杂志, 2018, 98(45):3692-3696.
[17]	Maher MA, Abdelaziz A, Bazeed MF. Diagnostic accuracy of ultrasound and MRI in the prenatal diagnosis of placenta accreta[J]. Acta Obstet Gynecol Scand, 2013, 92(9):1017-1022. doi: 10.1111/aogs.12187 URL
[18]	Goh WA, Zalud I. Placenta accreta: diagnosis, management and the molecular biology of the morbidly adherent placenta[J]. J Matern Fetal Neonatal Med, 2016, 29(11):1795-1800.
[19]	Duzyj CM, Cooper A, Mhatre M, et al. Placenta accreta: aspectrum of predictable risk, diagnosis, and morbidity[J]. Am J Perinatol, 2019, 36(10):1031-1038. doi: 10.1055/s-0038-1676111 URL