剖宫产瘢痕妊娠的磁共振诊断及其风险因素的分析
|
摘要
第一部分剖宫产瘢痕妊娠的MRI影像学特点
目的
1、探讨剖宫产后子宫切口瘢痕的MRI表现。
2、探讨剖宫产后子宫切口瘢痕妊娠(cesarean scar pregnancy CSP)的分型
及其MRI影像表现。
方法
1、研究对象
一般资料：收集南方医院、广州市花都区人民医院、广州市花都区妇幼保健院2010年3月-2012年1月期间,经手术证实的28例CSP病例的MRI及经阴道超声资料,年龄21-42岁,平均年龄29岁。临床表现：28例患者停经时间14-90天,尿HCG均阳性,下腹痛伴阴道流血21例；下腹痛5例；其余2例无不适。所有患者有1-3次剖宫产史。距离前次剖宫产时间为3-96个月。
主要仪器与设备
24例患者采用荷兰PILLIPS公司的ARCHIVA1.5超导磁共振机,4例患者采用GE EXCITE3.0超导磁共振进行检查。体部相控阵线圈。
2、扫描方法
28例患者均行MRI平扫及增强扫描,病人仰卧位,平静呼吸,扫描范围包括整个盆腔,先进行MRI平扫,扫描序列包括：T1WI TSE序列,横断位,矢状位；T2W TSE序列横断位、矢状位；横断SPIR压脂序列,然后进行增强扫描,使用(喷替酸葡甲胺)Gd-DTPA,按0.1mmol/kg体重,流率2.0ml/s由肘静脉注射,3-10分钟后进行T1WI SPIR压脂增强横断位,矢状位扫描。视野(FOV)200-300,层厚5mm,层间隔lmm。采集矩阵300-512,重建矩阵：320-512。
2、图像分析
由至少两位MRI室高级医师用双盲法单独阅读首次MRI片,细致观察1)、孕囊着床位于子宫的位置。2)、观察前次手术瘢痕位置。3)、判断孕囊植子宫肌层的情况及其与瘢痕的关系。4)、判断测量孕囊与膀胱之间肌层厚度。意见不一致时,协商后得出结果。术中观察孕囊位置及其孕囊植入子宫肌层情况。术后将清除之胚囊组织及瘢痕组织送病理检查。
结果
1、子宫下段切口瘢痕的影像表现：
28例CSP中手术瘢痕位于子宫下段-子宫峡部前壁者27例,1例瘢痕位于子宫体部前壁,MRI表现为局部子宫肌层连续性中断,局部向内凹陷或变薄,T1WI、及T2WI瘢痕均表现为低信号。
2、孕囊的分型及影像学表现：
1)、囊状孕囊：28例CSP均清楚显示孕囊,孕囊大小10x6x7mm-30x20x16mm不等。其中23例呈囊状信号特征,孕囊在T1WI上表现为边界不清圆形、椭圆形低信号影,在T2WI上表现为一边界清楚囊状高信号,增强后孕囊壁可见环形薄壁强化,23例囊性孕囊中9例孕囊位于子宫肌层,余14例孕囊向子宫肌层浸润同时向宫腔内生长,局部子宫峡部前壁明显变薄。
2)、包块型孕囊：28例中5例孕囊表现为不规则包块影,T1W呈等信号中夹杂局限性高信号,在T2WI上呈等、高混杂信号,5例包块型者宫腔内均见积血。包块向宫腔内生长并向子宫前壁肌层浸润生长,增强后表现为包块内突起状明显强化。
3、孕囊与膀胱的关系
23例囊性孕囊中9例孕囊位于瘢痕周围肌层内,9例中5例孕囊向前方膀胱方向突出生长,14例位于瘢痕处及宫腔内,即：孕囊大部位于瘢痕上方的下段宫腔内,小部分深入瘢痕处；5例包块型者孕囊均位于瘢痕处,2例孕囊向膀胱方向突出生长,突出于子宫轮廓外。3例见子宫前壁肌层浸润,增强后表现为包块内突起状明显强化。孕囊着床的瘢痕处肌层明显变薄,肌层厚度1.1-4Imm。
结论
剖宫产瘢痕妊娠具有一定的MRI特征,正确掌握其影像特征可以对临床治疗起到正确的指导作用。
第二部分MRI对剖宫产瘢痕妊娠的诊断价值及其与超声的对照研究
目的
1、探讨MRI对剖宫产后子宫切口瘢痕妊娠的诊断优势。
2、探讨经阴道超声对剖宫产瘢痕妊娠的诊断优势。
3、MRI、经阴道超声在剖宫产瘢痕妊娠诊断中的价值比较。
方法
1、研究对象
一般资料；收集南方医院、广州市花都区人民医院、广州市花都区妇幼保健院2010年3月-2012年1月期间,经手术证实的28例CSP病例的MRI及经阴道超声资料,年龄21-42岁,平均年龄29岁。临床表现：28例患者停经时间14-90天,尿HCG均阳性,下腹痛伴阴道流血21例；下腹痛5例；其余2例无不适。所有患者有1-3次剖宫产史。距离前次剖宫产时间为3-96个月。
2、仪器设备
MRI仪器：24例患者使用荷兰PILLIPS公司的ARCHIVA1.5超导磁共振机,体部相控阵线圈进行扫描。4例患者采用GE EXCITE3.0超导磁共振、体部相控阵线圈进行扫描。
经阴道超声仪器：28例患者采用经阴道超声采用东芝Xario型超声诊断仪,经阴道探头,频率为5-7MHz。19例患者同时还进行了经阴道彩色多普勒检查,采用阿洛卡SSD-ALPHAS超声诊断仪,经阴道探头,频率7.5Hz。
3、检查方法
MRI扫描方法：28例患者均行MRI平扫及增强扫描,病人仰卧位,平静呼吸,扫描范围包括整个盆腔。先进行MRI平扫,扫描序列包括：T1WI TSE序列,横断位,矢状位；T2W TSE序列横断位、矢状位；横断SPIR压脂序列,然后进行增强扫描,使用(喷替酸葡甲胺)Gd-DTPA,按0.1mmol/kg体重,流率2.0ml/s由肘静脉注射,后进行T1WI SPIR压脂增强横断位,矢状位扫描。视野(FOV)200-300,层厚5mm,层间隔1mm。采集矩阵300-512,重建矩阵：320-512。28例均于经阴道超声检查1—2天内进行MRI检查。
超声检查方法：患者检查前排空膀胱,取膀胱截石位,将阴道探头套上安全套,再缓慢将探头放置于阴道内。
4、MRI、经阴道超声图像分析
由至少两位MRI室、经阴道超声高级医师用双盲法单独阅读首次MRI片,及操作经阴道超声检查,细致观察1)、孕囊大小、性质、着床位于子宫的位置。2)、观察前次手术瘢痕位置。3)、瘢痕厚度、孕囊植入子宫肌层的情况及其与瘢痕的关系。4)、判断测量孕囊与膀胱之间肌层厚度。5)、宫腔出血及孕囊内出血情况。6)、阴道超声孕囊卵黄囊是否存在、胚芽搏动情况。意见不一致时,协商后得出结果。
5、手术方式
28例中19例行经阴道剖宫产瘢痕妊娠切除术,4例经腹孕囊清除及瘢痕切除术；阴式剖宫产瘢痕妊娠切除术采取环形切开阴道前穹窿,分离膀胱与阴道前壁间隙,暴露宫颈峡部瘢痕组织,横行切开瘢痕,观察孕囊位置及其孕囊植入子宫肌层情况,负压吸出孕囊,用中号刮匙搔刮宫腔至粗糙,切除瘢痕组织。内见绒毛；3例无完整孕囊,28例中1例于宫颈下段瘢痕处见蓝紫色突出,约8x8x7cm,阴式剖宫产瘢痕妊娠切除术术中宫腔大量出血,随行全子宫切除术。
结果
1、MRI对孕囊的诊断：
28例中23例孕囊表现为囊性信号,在T1WI上表现为边界不清圆形、椭圆形低信号影。在T2WI上表现为一边界清楚囊状影,可见薄层囊壁,增强后囊壁呈环形均匀强化,其中合并孕囊内出血6例,表现为囊内点状、线状短T1W信号,9例孕囊位于瘢痕周围肌层内,其中5例向前方突出生长,14例位于瘢痕处及宫腔内,即：孕囊大部位于瘢痕上方的下段宫腔内,小部分深入瘢痕处。宫腔内积血13例。
28例中5例表现为包块型,T1W、T2W呈等、高混杂信号,包块型孕囊均位于瘢痕处,增强后可见孕囊向子宫前壁肌层植入,合并宫腔内积血5例。
2、经阴道超声对孕囊的诊断：
28例中经阴道超声诊断23例为囊状回声,内为液性暗区,其中2例囊内见絮状不均质出血回声,12例可见卵黄囊,其中10例见脉管搏动,23例中合并宫腔内积血3例,表现为宫腔分离,并见絮状回声。8例位于子宫瘢痕处肌层内,15例位于瘢痕处及宫腔内。14例同时行经阴道彩色多普勒超声检查,表现为孕囊周边环形血流信号,可测及低阻血流频谱；
28例中5例表现为包块型,包膜皱缩,内为不均质杂乱、中、低回声,合并宫腔内积血5例。5例均同时行经阴道彩色多普勒检查,表现为混合包块内部及包块周边肌层丰富血流信号,2例尚可测及动静脉瘘血流频谱及低阻型血流频谱。
3、经阴道超声、MRI对子宫切口瘢痕的诊断
28例中27例子宫瘢痕位于子宫下段峡部前壁,1例位于子宫体部前壁。经阴道超声表现为子宫肌层连续性中断,局部呈楔形凹陷或变薄,MRI信号T1W、T2W均为低信号,子宫前壁明显变薄,孕囊与膀胱之间子宫肌层的厚度超声为1.3-4mm、MRI判断孕囊与膀胱之间子宫肌层的厚度为1.1—4mm。
4、经阴道超声、MRI对子宫切口瘢痕诊断价值的比较：
MRI及经阴道超声显示囊性孕囊23例,其中MRI诊断孕囊内合并出血6例,经阴道超声发现囊内出血2例,经阴道超声发现卵黄囊12例,其中胚胎存活10例；MRI无法显示卵黄囊及判断胚胎是否存活,MRI显示位于瘢痕处肌层内孕囊9例,其中5例同时向前方突出生长；位于瘢痕处向宫腔方向延伸14例,经阴道超声诊断位于肌层8例,瘢痕及宫腔内15例；包块型孕囊5例,经阴道超声诊断包块内出血3例,MRI诊断5例,MRI诊断包块对子宫肌层浸润5例,经阴道超声无法判断孕囊对子宫肌层的浸润。MRI诊断宫腔内积血18例,经阴道超声诊断6例。
结论
1、经阴道超声在判断卵黄囊着床位置及其胚囊是否存活有优势。
2、MRI在判断孕囊与瘢痕关系、宫腔及孕囊内少量出血方面较经阴道超声有优势。
3、在判断孕囊孕囊大小、瘢痕位置、瘢痕厚度方面无明显差别。
第三部分剖宫产瘢痕妊娠的风险因素分析
目的：
探讨指标：年龄、剖宫产次数、人工流产次数、末次剖宫产时间、末次人流时间与剖宫产瘢痕妊娠发生的相关性。
研究对象：
一、搜集收集南方医院、广州市花都区人民医院、广州市花都区妇幼保健院2010年3月-2012年1月期间,经手术证实的CSP病例28例,收集其临床资料：包括1、年龄2、剖宫产次数、3、人工流产次数。4、最后一次剖宫产或流产距诊断为CSP的时间(末次剖宫/人流时间)。
二、随机抽取广州市花都区人民医院2010年3月-2012年有剖宫产病史,此次顺利生产的住院病人34例,作为对照组,收集其临床资料：包括1、年龄2、剖宫产次数、3、人工流产次数。5、最后一次剖宫/流产距此次妊娠的时间(末次剖宫/人流时间)。
统计学方法：
1、采用病例-病例对照研究,将手术证实的CSP病例28例与随机抽取的有剖宫产病史,此次再次顺利生产的病例34例做对照,
2、分析的风险因素包括1、年龄2、剖宫产次数、3、人工流产次数。4、末次剖宫产时间。
3、纳入标准：
CSP的纳入标准：①、手术证实为瘢痕妊娠。②、有完整临床病史：年龄、剖宫产次数、人工流产次数、末次剖宫/人流时间)
对照组的纳入标准：①、曾有至少一次剖宫产病史。②、再次妊娠为宫内妊娠并顺利生产。③、有本次妊娠产前超声检查资料：④临床资料：剖宫产次数、具体时间、人流次数,具体时间。
对照组排除标准：①、临床资料欠完整。②、本次妊娠发生前置胎盘、胎盘早剥等,未能顺利生产。
4、使用spss13.0进行统计学分析,CSP组与对照组之间风险因素的分析采用两组资料独立样本t检验,以观察两组风险因素之间是否有显著性差异。以年龄,人流次数,剖宫次数,末次剖宫/人流时间四个因素为自变量,以是否发生CSP为应变量,作Logistic回归分析,分析CSP发生的相关风险因素。
5、结果：
1、应用t检验对两组的年龄,人流次数,剖宫次数,末次剖宫/人流时间作了统计分析结果显示两组的年龄没有差别(t=-1.067,P=0.291,P>0.05),人流次数(t=4.643,P=0.000,P<0.05),剖宫次数(t=4.036,P=0.000,P<0.05),末次剖宫/人流时间有差别(t=-4.181,P=0.000,P<0.05)。
2、以年龄,人流次数,剖宫次数,末次剖宫/人流时间四个因素为自变量,以是否发生CSP为应变量,作Logistic回归分析,结果显示：人流次数(p=0.003,OR=0.295),末次剖宫产/人流时间(p=0.040,OR=1.042)对瘢痕有影响。
3、结论：
多次人流、末次剖宫产/人流时间是剖宫产瘢痕妊娠的发生风险因素,应该尽量避免。
Object
1、To explore the MRI signs of cesarean scar.
2、To explore classification types and MRI signs of cesarean scar pregnancy.
Material and Method:
subject:
MRI materials of28patients respectively from Nan Fang hospital affiliated to Southern Medical University, Huadu district hospital affiliated to Southern Medical University and women and children health care centre of Huadu district were studied, Time from March2010to January2012.All cases were confirmed by operation and clinical. The patients age from21-42.The middle age is29.Clinical manifestation as: menopause for14-90days, urine test of HCG is positive in all28cases, lower abdominal pain companied vaginal bleeding in21cases; Only lower abdominal pain in5cases; had no uncomfortable in2cases. All patients had1to3times cesarean delivery experience. Time from the latest cesarean delivery to this time to see doctor is3to96month.
Main instrument and equipment
24patients were examined with ARCHIVA1.5T superconducting magnetic resonance scanner, from PILLIPS Company in Holland.4patients were examined with GE EXCITE3.0T superconducting magnetic resonance scanner, phased array body coil.
Scanning method
28cases patients were all proceeded MRI plane scan and enhanced scan. Patients lie supine, calm breathing, scanning range including whole pelvic, first for MRI plane scan, scan sequence including:axial position and sagittal position of T1WI TSE sequence and T1W TSE sequence, axial position SPIR fat press sequence, then for enhanced scan, using Gd-DTPA, by O.lmmol/kg weight, flow rate2.0ml/s by elbow intravenous,3-10minutes later after injection, Perform T1WI SPIR sequence scanning,in axial and sagittal position. FOV:200-300, slice:5mm, interval gap:1mm. Aqusition matrix:300-512, Reconstruction matrix:320-512.
Image analysis
At least two senior MRI doctors read the first MRI imaging independently, use double blind method, careful observe the followings:1), the implantation position of gestational sac to the uterus.2), observation of the location of previous caesarean scar.3),estimate the degree of gestational sac planting into the muscular layer of the uterus and judge the relationship between gestational sac and the scar.4), measure muscle layer thickness between the pregnancy sac and the bladder. When disagree occur, results can be made after consultations. During operation, observe the position of gestational sac and it implantation into the uterus muscle layer, after operation, the embryo sac tissue and scar tissue were send to pathological examination.
Results:
1、Imaging features of lower uterine segment cesarean scars:
Among28cases of CSP, cesarean scars is in the anterior wall of the lower uterine segment(isthmus of uterus wall) in27cases, in the anterior wall of the uterine body in1case, The MRI signal of local muscular layer of the uterus does not continue, become thinning and collapse inwards, In T1WI,and T2WI sequence showed lower signal.
2、The classification of gestational sac and imaging findings in MRI
1) Cystic gestational sac:28cases of CSP are clearly showed the gestational sac, The sizes of gestational sac ranging from10x6x7mm-30x20x16mm. Among28cases,23cases showed cystic signal features, in T1WI sequence showed round or oval shape lower signal, its boundary does not clear, In T2WI sequence, appear as cystic high signal, Clear in boundary, ring thin-wall enhancement can be seen in pregnancy wall. Among23of Cystic gestational sac cases, Cystic gestational sac is located in uterine muscle layer in9cases, more than14cases gestational sac implant into uterine muscle layer,meanwhile grow towards uterine cavity, The anterior wall of uterus isthmus became significantly thinner.
2) Mass-gestational sac:Among28cases of CSP,5cases present as irregular mass type, they showed medium signal, high signal in T1W and T2W sequence, haemorrhage can be seen in the uterine cavity in5cases. Mass-pregnancy SAC grew towards intrauterine cavity, meanwhile implanted into anterior uterine myometrial tissue. Tree fork structure enhancement can be seen within masses.
4、The relationship between gestational sac and the bladder
Among23cystic gestational sac cases, gestational sac is located within muscle layer of scar in9cases,5cases in9cases grows towards the bladder direction,14cases in the sar and the uterine cavity, that is:gestational sac located at the lower segment uterine cavity, a small part extended deeply into the scars.5cases of mass-gestational sac is within the scar.2cases grow to the direction of bladder, protrudes from the outside contour of the uterus.3cases can be seen implanted into uterine wall myometrial, Tree fork structure enhancement can be seen within masses. Scar muscular layer becomes apparently thinner, muscle thickness1.1-4mm.
Conclusions:
Cesarean section scar pregnancy has certain MRI features, Correctly grasp its image features can give the correct guiding effect on clinical treatment
PART TWO
A comparative study of the Value of MRI in the diagnosis of Cesarean sac pregnancy and transvaginal ultrasound
Object:
1、Explore the value of MRI in the diagnosis of Cesarean scar pregnancy.
2、Explore the value of Transvaginal ultrasound in the diagnosis of Cesarean scar pregnancy.
3、Comparison of MRI and Transvaginal ultrasound in the diagnosis of Cesarean scar pregnancy.
subject:
MRI materials of28patients respectively from Nan Fang hospital affiliated to Southern Medical University, Huadu district hospital affiliated to Southern Medical University and women and children health care centre of Huadu district were studied, Time from March2010to January2012.All cases were confirmed by operation and clinical. The patients age from21-42.The middle age is29.Clinical manifestation as: menopause for14-90days, urine test of HCG is positive in all28cases, lower abdominal pain companied vaginal bleeding in21cases; Only lower abdominal pain in5cases; had no uncomfortable in2cases. All patients had1to3times cesarean delivery experience. Time from the latest cesarean delivery to this time to see doctor is3to96months.
Main instrument and equipment
24patients were examined with ARCHIVA1.5T superconducting magnetic resonance scanner, from PILLIPS Company in Holland.4patients were examined with GE EXCITE3.0T superconducting magnetic resonance scanner, phased array body coil.
Transvaginal ultrasound apparatus:28cases were examined by using Oshiba Xario ultrasound transvaginal instrument. transvaginal ultrasound probe, frequency is5-7MHz.19cases were also examined by using transvaginal color Doppler ultrasound instrument, The instrument sty is Aluoka SSD-ALPHAS, transvaginal probe, frequency is7.5Hz. Scanning method
28cases patients were all proceeded MRI plane scan and enhanced scan. Patients lie supine, calm breathing, scanning range including whole pelvic, first for MRI plane scan, scan sequence including:axial position and sagittal position of T1WI TSE sequence and T1W TSE sequence, axial position SPIR fat press sequence, then for enhanced scan, using Gd-DTPA, by0.1mmol/kg weight, flow rate2.0ml/s by elbow intravenous,3-10minutes later after injection, Perform T1WI SPIR sequence scanning,in axial and sagittal position. FOV:200-300, slice:5mm, interval gap:1mm. Aqusition matrix:300-512, Reconstruction matrix:320-512. All28Patients were examined within1-2days of ultrasound examination.
Ultrasound examination:Before examine tell patients empty their bladder.lie in the dorsal lithotomy position, put condom on the surface of probe, then slowly put the probe into vagina.
4、MRI and Transvaginal ultrasound image analysis At least two senior MRI doctors read first MRI results, two transvaginal ultrasound doctors examine patients with double-blind method. Observe the followings:1)、 gestational sac size, nature, implantation position of gestational sac;2X Observation of the previous caesarean scar location;3)、Implantation of gestational sac into muscle layer of the uterus and its relationship with the scar.4)、caesarean scar thickness.5)、haemorrhage in uterus cavity and in gestational sac.6)s if gestational sac、yolk sac exist, observe the beating of the embryo. When disagree occur, results can be made after consultations.
5、Surgical procedure
21of28cases experience gestation sac excision、cesarean scar excision through vaginal.1cases experience hysterectomy,6cases operation procedure was not known. Slice open the front of Vaginal fornix separate the bladder and vaginal anterior wall, expose cervical isthmus scar tissue, incision scars in transverse direction, observe the position of gestation sac implanting to the muscular layer of the uterus, vacuum out the gestation sac, scratched the uterine wall with medium curettes to rough in the local tissue, Cut off scar tissue. Among27cases, gestation sacs were integrity in24cases, pathology results:down can be seen in gestation sacs. Without integrity gestation sacs in3cases, blue and purple highlights can be seen in1of28cases in the scar under, about8x8x7cm size, uterine bleeding was found in procedure of operation then the uterus was removed.
Results
1、MRI findings of gestation sac
Among28cases, gestation sacs showed cystic signal in23cases, in T1WI sequence showed round or oval shape lower signal, its boundary does not clear, In T2WI sequence, appear as cystic high signal, Clear in boundary, ring thin-wall enhancement can be seen in pregnancy wall, hemorrhage can be seen within gestation sacs, present as line ship,short T1W signal. Among23of Cystic gestational sac cases, Cystic gestational sac is located in uterine muscle layer in9cases, more than14cases gestational sac implant into uterine muscle layer,meanwhile grow towards uterine cavity, The anterior wall of uterus isthmus became significantly thinner. Hemorrhage in uterine cavity in13cases.
2、Transvaginal ultrasonography in diagnosing pregnancy sac
Among28cases, cystic echo of liquid was found by transvaginal Sonography in23cases, in which2cases were found cotton like echo, that is hemorrhage echo, yolk sac can be seen in12cases,10case of them vascular pulsation can be seen,3in23cases with intrauterine hemorrhage, that is:depart of the uterus cavity and flocculent echo were detect. In8cases、gestational sac were at muscle layer of uterine scarring, in15cases, is at the scar and the uterine cavity.14cases at the same time had transvaginal color Doppler ultrasonic examination, performance for the pregnancy sac surrounding by annular flow signal, low resistance flow pattern.
Among28cases,5cases present for the package block type, envelope wrinkling, heterogeneity clutter, medium and low echoes, combined with intrauterine hemorrhage in5cases. Transvaginal colour Doppler were conducted in the5cases. Characterized by mixed masses and rich blood flow signal surrounding the local muscular layer, arteriovenous fistula blood flow and a low resistance of blood flow spectrum can be measured in2cases.
3、Transvaginal ultrasound and MRI findings of cesarean scars
In27of28cases, the uterine scar is located in lower uterine segment anterior wall of isthmus,1case is located in the anterior wall of uterine body. Muscular layer of the uterus were not continue in Transvaginal ultrasound, wedge-shaped depressions or thinning, MRI signal in T1W, T2W is low signal, anterior uterine wall significantly thinned, gestational sac between the bladder and womb muscle layer were thickness,1.3-4mm by ultrasonic,1.1-4mm by MRI.
4、Comparetion of Transvaginal ultrasound and MRI in the diagnosis of cesarean scar pregnancy.
MRI and transvaginal ultrasound shows23cases of cystic pregnancy sac, in which MRI found cyst pregnancy sac complicated with hemorrhage in6cases; transvaginal ultrasound found2cases of cyst hemorrhage; found yolk sac in12cases, embryo survival in10cases. MRI cannot display the yolk sac and determine whether the embryo survival, MRI shows pregnancy sac at muscular layer scar in9cases, extending to the uterine cavity in14cases, transvaginal ultrasonic found in muscle in8cases, and within intrauterine scar grow towards uterine cavity in15cases.
Masses pregnancy sac in5cases, transvaginal ultrasonography found hemorrhage in the mass in3cases; and MRI found in5cases, MRI found implanting to the myometrium in5cases, transvaginal ultrasound cannot judge the pregnancy sac implanting. MRI found intrauterine hemorrhage in18cases, transvaginal ultrasound found intrauterine hemorrhage in6cases.
Conclusions:
1、Transvaginal ultrasonography has advantage in judging of implantation of yolk sac and embryo sac survival.
2、MRI has more advantages than vaginal ultrasound in judging the relationship of pregnancy sac with scars, bleeding in in the uterine cavity
3、There is no significant difference in judging the pregnancy sac size, location of the scar and the scar thickness
Part Three Analysis of risk factors of Cesarean scar pregnancy
Object:
Discussion on indicators:the correlation between the occurrence of Cesarean scar pregnancy and age, position of the uterus (the forward and the backward), the number of Cesarean, the number of abortion, the latest time of cesarean section, the latest time of abortion.
Study object:
Collecting the clinical data of28CPS cases confirmed by Southern Medical University, Huadu district hospital affiliated to Southern Medical University and women and children health care centre of Huadu district, March2010-January2012,which includes1-. Age2, uterus position (forward or backward)3,the number of cesarean section,4the number of abortions5, Cesarean delivery or abortion for the last time from diagnosis to the CSP time (last time of Cesarean)
Randomly select34patients from Haudu hospital affiliated to Southern Medical University who have cesarean delivery history, deliver baby smoothly this time, during March2010-January2012period as contrast. Collecting the clinical data,includes:1、Age.2、uterus position (forward or backward)3、the number of cesarean section,4the number of abortions5,The time from the latest Cesarean delivery to the time of this delivery.
Statistical methods
1、Case-case contrast method was used, comparative study between CSP in28cases confirmed by the operation and random selected cases that have a history of Cesarean section in34cases with successful deliveries.
2、Risk factors analyzed:1、Age2, uterus position (forward or backward)3,the number of cesarean section,4the number of abortions5,the last time of Cesarean
3、 Accepting Standard of CSP:1、Operation confirmed as scar pregnancy;2、A complete clinical history:age、uterus position、the number of cesarean section、 the number of abortions、the last time of Cesarean Accepting Standard of contrast group:1、there have been at least a history of Cesarean section;2、Pregnancy is intrauterine pregnancy again and smoothly delivery;3、ultrasound examination information in the early of pregnancy:provide uterus position (forward or backward);4、Clinical dates:the number of Cesarean section, specific time, the number of abortion Exclusion criteria of contrast group:1、 clinical information incomplete.2、the gestation failed to due to placenta previa, placental abruption
4、used two sets of information for independent samples t test and observed if there is significant difference in terms of risk between the two groups
5、analyzed the CSP-related risk factors by using Logist regression
1、T tested and analyzed on two groups of age, the number of abortion, the number of Cesarean, cesarean section at the end time, the result shows that there is no difference on ages (t=-1.067, P=0.29, p>0.05), the number of abortion (t=4.643, P.=0.000, p<0.05), the number of Cesarean (t=4.036, P.=0.000, p<0.05), the last time of Cesarean differentiated (t=-4.181, P=0.000, p<0.05)
2、Logistic regression analysis on ages, the number of abortion, the number of Cesarean and the last time of cesarean section shows that effects are caused on SCAR based on the number of abortion, the last time of Cesarean.
Conclusion:Multiple abortions and the last time of Cesarean are the risk factors that lead to cesarean scar pregnancy; multiple abortions and repeated cesarean sections should be avoided.
目的
1、探讨剖宫产后子宫切口瘢痕的MRI表现。
2、探讨剖宫产后子宫切口瘢痕妊娠(cesarean scar pregnancy CSP)的分型
及其MRI影像表现。
方法
1、研究对象
一般资料：收集南方医院、广州市花都区人民医院、广州市花都区妇幼保健院2010年3月-2012年1月期间,经手术证实的28例CSP病例的MRI及经阴道超声资料,年龄21-42岁,平均年龄29岁。临床表现：28例患者停经时间14-90天,尿HCG均阳性,下腹痛伴阴道流血21例；下腹痛5例；其余2例无不适。所有患者有1-3次剖宫产史。距离前次剖宫产时间为3-96个月。
主要仪器与设备
24例患者采用荷兰PILLIPS公司的ARCHIVA1.5超导磁共振机,4例患者采用GE EXCITE3.0超导磁共振进行检查。体部相控阵线圈。
2、扫描方法
28例患者均行MRI平扫及增强扫描,病人仰卧位,平静呼吸,扫描范围包括整个盆腔,先进行MRI平扫,扫描序列包括：T1WI TSE序列,横断位,矢状位；T2W TSE序列横断位、矢状位；横断SPIR压脂序列,然后进行增强扫描,使用(喷替酸葡甲胺)Gd-DTPA,按0.1mmol/kg体重,流率2.0ml/s由肘静脉注射,3-10分钟后进行T1WI SPIR压脂增强横断位,矢状位扫描。视野(FOV)200-300,层厚5mm,层间隔lmm。采集矩阵300-512,重建矩阵：320-512。
2、图像分析
由至少两位MRI室高级医师用双盲法单独阅读首次MRI片,细致观察1)、孕囊着床位于子宫的位置。2)、观察前次手术瘢痕位置。3)、判断孕囊植子宫肌层的情况及其与瘢痕的关系。4)、判断测量孕囊与膀胱之间肌层厚度。意见不一致时,协商后得出结果。术中观察孕囊位置及其孕囊植入子宫肌层情况。术后将清除之胚囊组织及瘢痕组织送病理检查。
结果
1、子宫下段切口瘢痕的影像表现：
28例CSP中手术瘢痕位于子宫下段-子宫峡部前壁者27例,1例瘢痕位于子宫体部前壁,MRI表现为局部子宫肌层连续性中断,局部向内凹陷或变薄,T1WI、及T2WI瘢痕均表现为低信号。
2、孕囊的分型及影像学表现：
1)、囊状孕囊：28例CSP均清楚显示孕囊,孕囊大小10x6x7mm-30x20x16mm不等。其中23例呈囊状信号特征,孕囊在T1WI上表现为边界不清圆形、椭圆形低信号影,在T2WI上表现为一边界清楚囊状高信号,增强后孕囊壁可见环形薄壁强化,23例囊性孕囊中9例孕囊位于子宫肌层,余14例孕囊向子宫肌层浸润同时向宫腔内生长,局部子宫峡部前壁明显变薄。
2)、包块型孕囊：28例中5例孕囊表现为不规则包块影,T1W呈等信号中夹杂局限性高信号,在T2WI上呈等、高混杂信号,5例包块型者宫腔内均见积血。包块向宫腔内生长并向子宫前壁肌层浸润生长,增强后表现为包块内突起状明显强化。
3、孕囊与膀胱的关系
23例囊性孕囊中9例孕囊位于瘢痕周围肌层内,9例中5例孕囊向前方膀胱方向突出生长,14例位于瘢痕处及宫腔内,即：孕囊大部位于瘢痕上方的下段宫腔内,小部分深入瘢痕处；5例包块型者孕囊均位于瘢痕处,2例孕囊向膀胱方向突出生长,突出于子宫轮廓外。3例见子宫前壁肌层浸润,增强后表现为包块内突起状明显强化。孕囊着床的瘢痕处肌层明显变薄,肌层厚度1.1-4Imm。
结论
剖宫产瘢痕妊娠具有一定的MRI特征,正确掌握其影像特征可以对临床治疗起到正确的指导作用。
第二部分MRI对剖宫产瘢痕妊娠的诊断价值及其与超声的对照研究
目的
1、探讨MRI对剖宫产后子宫切口瘢痕妊娠的诊断优势。
2、探讨经阴道超声对剖宫产瘢痕妊娠的诊断优势。
3、MRI、经阴道超声在剖宫产瘢痕妊娠诊断中的价值比较。
方法
1、研究对象
一般资料；收集南方医院、广州市花都区人民医院、广州市花都区妇幼保健院2010年3月-2012年1月期间,经手术证实的28例CSP病例的MRI及经阴道超声资料,年龄21-42岁,平均年龄29岁。临床表现：28例患者停经时间14-90天,尿HCG均阳性,下腹痛伴阴道流血21例；下腹痛5例；其余2例无不适。所有患者有1-3次剖宫产史。距离前次剖宫产时间为3-96个月。
2、仪器设备
MRI仪器：24例患者使用荷兰PILLIPS公司的ARCHIVA1.5超导磁共振机,体部相控阵线圈进行扫描。4例患者采用GE EXCITE3.0超导磁共振、体部相控阵线圈进行扫描。
经阴道超声仪器：28例患者采用经阴道超声采用东芝Xario型超声诊断仪,经阴道探头,频率为5-7MHz。19例患者同时还进行了经阴道彩色多普勒检查,采用阿洛卡SSD-ALPHAS超声诊断仪,经阴道探头,频率7.5Hz。
3、检查方法
MRI扫描方法：28例患者均行MRI平扫及增强扫描,病人仰卧位,平静呼吸,扫描范围包括整个盆腔。先进行MRI平扫,扫描序列包括：T1WI TSE序列,横断位,矢状位；T2W TSE序列横断位、矢状位；横断SPIR压脂序列,然后进行增强扫描,使用(喷替酸葡甲胺)Gd-DTPA,按0.1mmol/kg体重,流率2.0ml/s由肘静脉注射,后进行T1WI SPIR压脂增强横断位,矢状位扫描。视野(FOV)200-300,层厚5mm,层间隔1mm。采集矩阵300-512,重建矩阵：320-512。28例均于经阴道超声检查1—2天内进行MRI检查。
超声检查方法：患者检查前排空膀胱,取膀胱截石位,将阴道探头套上安全套,再缓慢将探头放置于阴道内。
4、MRI、经阴道超声图像分析
由至少两位MRI室、经阴道超声高级医师用双盲法单独阅读首次MRI片,及操作经阴道超声检查,细致观察1)、孕囊大小、性质、着床位于子宫的位置。2)、观察前次手术瘢痕位置。3)、瘢痕厚度、孕囊植入子宫肌层的情况及其与瘢痕的关系。4)、判断测量孕囊与膀胱之间肌层厚度。5)、宫腔出血及孕囊内出血情况。6)、阴道超声孕囊卵黄囊是否存在、胚芽搏动情况。意见不一致时,协商后得出结果。
5、手术方式
28例中19例行经阴道剖宫产瘢痕妊娠切除术,4例经腹孕囊清除及瘢痕切除术；阴式剖宫产瘢痕妊娠切除术采取环形切开阴道前穹窿,分离膀胱与阴道前壁间隙,暴露宫颈峡部瘢痕组织,横行切开瘢痕,观察孕囊位置及其孕囊植入子宫肌层情况,负压吸出孕囊,用中号刮匙搔刮宫腔至粗糙,切除瘢痕组织。内见绒毛；3例无完整孕囊,28例中1例于宫颈下段瘢痕处见蓝紫色突出,约8x8x7cm,阴式剖宫产瘢痕妊娠切除术术中宫腔大量出血,随行全子宫切除术。
结果
1、MRI对孕囊的诊断：
28例中23例孕囊表现为囊性信号,在T1WI上表现为边界不清圆形、椭圆形低信号影。在T2WI上表现为一边界清楚囊状影,可见薄层囊壁,增强后囊壁呈环形均匀强化,其中合并孕囊内出血6例,表现为囊内点状、线状短T1W信号,9例孕囊位于瘢痕周围肌层内,其中5例向前方突出生长,14例位于瘢痕处及宫腔内,即：孕囊大部位于瘢痕上方的下段宫腔内,小部分深入瘢痕处。宫腔内积血13例。
28例中5例表现为包块型,T1W、T2W呈等、高混杂信号,包块型孕囊均位于瘢痕处,增强后可见孕囊向子宫前壁肌层植入,合并宫腔内积血5例。
2、经阴道超声对孕囊的诊断：
28例中经阴道超声诊断23例为囊状回声,内为液性暗区,其中2例囊内见絮状不均质出血回声,12例可见卵黄囊,其中10例见脉管搏动,23例中合并宫腔内积血3例,表现为宫腔分离,并见絮状回声。8例位于子宫瘢痕处肌层内,15例位于瘢痕处及宫腔内。14例同时行经阴道彩色多普勒超声检查,表现为孕囊周边环形血流信号,可测及低阻血流频谱；
28例中5例表现为包块型,包膜皱缩,内为不均质杂乱、中、低回声,合并宫腔内积血5例。5例均同时行经阴道彩色多普勒检查,表现为混合包块内部及包块周边肌层丰富血流信号,2例尚可测及动静脉瘘血流频谱及低阻型血流频谱。
3、经阴道超声、MRI对子宫切口瘢痕的诊断
28例中27例子宫瘢痕位于子宫下段峡部前壁,1例位于子宫体部前壁。经阴道超声表现为子宫肌层连续性中断,局部呈楔形凹陷或变薄,MRI信号T1W、T2W均为低信号,子宫前壁明显变薄,孕囊与膀胱之间子宫肌层的厚度超声为1.3-4mm、MRI判断孕囊与膀胱之间子宫肌层的厚度为1.1—4mm。
4、经阴道超声、MRI对子宫切口瘢痕诊断价值的比较：
MRI及经阴道超声显示囊性孕囊23例,其中MRI诊断孕囊内合并出血6例,经阴道超声发现囊内出血2例,经阴道超声发现卵黄囊12例,其中胚胎存活10例；MRI无法显示卵黄囊及判断胚胎是否存活,MRI显示位于瘢痕处肌层内孕囊9例,其中5例同时向前方突出生长；位于瘢痕处向宫腔方向延伸14例,经阴道超声诊断位于肌层8例,瘢痕及宫腔内15例；包块型孕囊5例,经阴道超声诊断包块内出血3例,MRI诊断5例,MRI诊断包块对子宫肌层浸润5例,经阴道超声无法判断孕囊对子宫肌层的浸润。MRI诊断宫腔内积血18例,经阴道超声诊断6例。
结论
1、经阴道超声在判断卵黄囊着床位置及其胚囊是否存活有优势。
2、MRI在判断孕囊与瘢痕关系、宫腔及孕囊内少量出血方面较经阴道超声有优势。
3、在判断孕囊孕囊大小、瘢痕位置、瘢痕厚度方面无明显差别。
第三部分剖宫产瘢痕妊娠的风险因素分析
目的：
探讨指标：年龄、剖宫产次数、人工流产次数、末次剖宫产时间、末次人流时间与剖宫产瘢痕妊娠发生的相关性。
研究对象：
一、搜集收集南方医院、广州市花都区人民医院、广州市花都区妇幼保健院2010年3月-2012年1月期间,经手术证实的CSP病例28例,收集其临床资料：包括1、年龄2、剖宫产次数、3、人工流产次数。4、最后一次剖宫产或流产距诊断为CSP的时间(末次剖宫/人流时间)。
二、随机抽取广州市花都区人民医院2010年3月-2012年有剖宫产病史,此次顺利生产的住院病人34例,作为对照组,收集其临床资料：包括1、年龄2、剖宫产次数、3、人工流产次数。5、最后一次剖宫/流产距此次妊娠的时间(末次剖宫/人流时间)。
统计学方法：
1、采用病例-病例对照研究,将手术证实的CSP病例28例与随机抽取的有剖宫产病史,此次再次顺利生产的病例34例做对照,
2、分析的风险因素包括1、年龄2、剖宫产次数、3、人工流产次数。4、末次剖宫产时间。
3、纳入标准：
CSP的纳入标准：①、手术证实为瘢痕妊娠。②、有完整临床病史：年龄、剖宫产次数、人工流产次数、末次剖宫/人流时间)
对照组的纳入标准：①、曾有至少一次剖宫产病史。②、再次妊娠为宫内妊娠并顺利生产。③、有本次妊娠产前超声检查资料：④临床资料：剖宫产次数、具体时间、人流次数,具体时间。
对照组排除标准：①、临床资料欠完整。②、本次妊娠发生前置胎盘、胎盘早剥等,未能顺利生产。
4、使用spss13.0进行统计学分析,CSP组与对照组之间风险因素的分析采用两组资料独立样本t检验,以观察两组风险因素之间是否有显著性差异。以年龄,人流次数,剖宫次数,末次剖宫/人流时间四个因素为自变量,以是否发生CSP为应变量,作Logistic回归分析,分析CSP发生的相关风险因素。
5、结果：
1、应用t检验对两组的年龄,人流次数,剖宫次数,末次剖宫/人流时间作了统计分析结果显示两组的年龄没有差别(t=-1.067,P=0.291,P>0.05),人流次数(t=4.643,P=0.000,P<0.05),剖宫次数(t=4.036,P=0.000,P<0.05),末次剖宫/人流时间有差别(t=-4.181,P=0.000,P<0.05)。
2、以年龄,人流次数,剖宫次数,末次剖宫/人流时间四个因素为自变量,以是否发生CSP为应变量,作Logistic回归分析,结果显示：人流次数(p=0.003,OR=0.295),末次剖宫产/人流时间(p=0.040,OR=1.042)对瘢痕有影响。
3、结论：
多次人流、末次剖宫产/人流时间是剖宫产瘢痕妊娠的发生风险因素,应该尽量避免。
Object
1、To explore the MRI signs of cesarean scar.
2、To explore classification types and MRI signs of cesarean scar pregnancy.
Material and Method:
subject:
MRI materials of28patients respectively from Nan Fang hospital affiliated to Southern Medical University, Huadu district hospital affiliated to Southern Medical University and women and children health care centre of Huadu district were studied, Time from March2010to January2012.All cases were confirmed by operation and clinical. The patients age from21-42.The middle age is29.Clinical manifestation as: menopause for14-90days, urine test of HCG is positive in all28cases, lower abdominal pain companied vaginal bleeding in21cases; Only lower abdominal pain in5cases; had no uncomfortable in2cases. All patients had1to3times cesarean delivery experience. Time from the latest cesarean delivery to this time to see doctor is3to96month.
Main instrument and equipment
24patients were examined with ARCHIVA1.5T superconducting magnetic resonance scanner, from PILLIPS Company in Holland.4patients were examined with GE EXCITE3.0T superconducting magnetic resonance scanner, phased array body coil.
Scanning method
28cases patients were all proceeded MRI plane scan and enhanced scan. Patients lie supine, calm breathing, scanning range including whole pelvic, first for MRI plane scan, scan sequence including:axial position and sagittal position of T1WI TSE sequence and T1W TSE sequence, axial position SPIR fat press sequence, then for enhanced scan, using Gd-DTPA, by O.lmmol/kg weight, flow rate2.0ml/s by elbow intravenous,3-10minutes later after injection, Perform T1WI SPIR sequence scanning,in axial and sagittal position. FOV:200-300, slice:5mm, interval gap:1mm. Aqusition matrix:300-512, Reconstruction matrix:320-512.
Image analysis
At least two senior MRI doctors read the first MRI imaging independently, use double blind method, careful observe the followings:1), the implantation position of gestational sac to the uterus.2), observation of the location of previous caesarean scar.3),estimate the degree of gestational sac planting into the muscular layer of the uterus and judge the relationship between gestational sac and the scar.4), measure muscle layer thickness between the pregnancy sac and the bladder. When disagree occur, results can be made after consultations. During operation, observe the position of gestational sac and it implantation into the uterus muscle layer, after operation, the embryo sac tissue and scar tissue were send to pathological examination.
Results:
1、Imaging features of lower uterine segment cesarean scars:
Among28cases of CSP, cesarean scars is in the anterior wall of the lower uterine segment(isthmus of uterus wall) in27cases, in the anterior wall of the uterine body in1case, The MRI signal of local muscular layer of the uterus does not continue, become thinning and collapse inwards, In T1WI,and T2WI sequence showed lower signal.
2、The classification of gestational sac and imaging findings in MRI
1) Cystic gestational sac:28cases of CSP are clearly showed the gestational sac, The sizes of gestational sac ranging from10x6x7mm-30x20x16mm. Among28cases,23cases showed cystic signal features, in T1WI sequence showed round or oval shape lower signal, its boundary does not clear, In T2WI sequence, appear as cystic high signal, Clear in boundary, ring thin-wall enhancement can be seen in pregnancy wall. Among23of Cystic gestational sac cases, Cystic gestational sac is located in uterine muscle layer in9cases, more than14cases gestational sac implant into uterine muscle layer,meanwhile grow towards uterine cavity, The anterior wall of uterus isthmus became significantly thinner.
2) Mass-gestational sac:Among28cases of CSP,5cases present as irregular mass type, they showed medium signal, high signal in T1W and T2W sequence, haemorrhage can be seen in the uterine cavity in5cases. Mass-pregnancy SAC grew towards intrauterine cavity, meanwhile implanted into anterior uterine myometrial tissue. Tree fork structure enhancement can be seen within masses.
4、The relationship between gestational sac and the bladder
Among23cystic gestational sac cases, gestational sac is located within muscle layer of scar in9cases,5cases in9cases grows towards the bladder direction,14cases in the sar and the uterine cavity, that is:gestational sac located at the lower segment uterine cavity, a small part extended deeply into the scars.5cases of mass-gestational sac is within the scar.2cases grow to the direction of bladder, protrudes from the outside contour of the uterus.3cases can be seen implanted into uterine wall myometrial, Tree fork structure enhancement can be seen within masses. Scar muscular layer becomes apparently thinner, muscle thickness1.1-4mm.
Conclusions:
Cesarean section scar pregnancy has certain MRI features, Correctly grasp its image features can give the correct guiding effect on clinical treatment
PART TWO
A comparative study of the Value of MRI in the diagnosis of Cesarean sac pregnancy and transvaginal ultrasound
Object:
1、Explore the value of MRI in the diagnosis of Cesarean scar pregnancy.
2、Explore the value of Transvaginal ultrasound in the diagnosis of Cesarean scar pregnancy.
3、Comparison of MRI and Transvaginal ultrasound in the diagnosis of Cesarean scar pregnancy.
subject:
MRI materials of28patients respectively from Nan Fang hospital affiliated to Southern Medical University, Huadu district hospital affiliated to Southern Medical University and women and children health care centre of Huadu district were studied, Time from March2010to January2012.All cases were confirmed by operation and clinical. The patients age from21-42.The middle age is29.Clinical manifestation as: menopause for14-90days, urine test of HCG is positive in all28cases, lower abdominal pain companied vaginal bleeding in21cases; Only lower abdominal pain in5cases; had no uncomfortable in2cases. All patients had1to3times cesarean delivery experience. Time from the latest cesarean delivery to this time to see doctor is3to96months.
Main instrument and equipment
24patients were examined with ARCHIVA1.5T superconducting magnetic resonance scanner, from PILLIPS Company in Holland.4patients were examined with GE EXCITE3.0T superconducting magnetic resonance scanner, phased array body coil.
Transvaginal ultrasound apparatus:28cases were examined by using Oshiba Xario ultrasound transvaginal instrument. transvaginal ultrasound probe, frequency is5-7MHz.19cases were also examined by using transvaginal color Doppler ultrasound instrument, The instrument sty is Aluoka SSD-ALPHAS, transvaginal probe, frequency is7.5Hz. Scanning method
28cases patients were all proceeded MRI plane scan and enhanced scan. Patients lie supine, calm breathing, scanning range including whole pelvic, first for MRI plane scan, scan sequence including:axial position and sagittal position of T1WI TSE sequence and T1W TSE sequence, axial position SPIR fat press sequence, then for enhanced scan, using Gd-DTPA, by0.1mmol/kg weight, flow rate2.0ml/s by elbow intravenous,3-10minutes later after injection, Perform T1WI SPIR sequence scanning,in axial and sagittal position. FOV:200-300, slice:5mm, interval gap:1mm. Aqusition matrix:300-512, Reconstruction matrix:320-512. All28Patients were examined within1-2days of ultrasound examination.
Ultrasound examination:Before examine tell patients empty their bladder.lie in the dorsal lithotomy position, put condom on the surface of probe, then slowly put the probe into vagina.
4、MRI and Transvaginal ultrasound image analysis At least two senior MRI doctors read first MRI results, two transvaginal ultrasound doctors examine patients with double-blind method. Observe the followings:1)、 gestational sac size, nature, implantation position of gestational sac;2X Observation of the previous caesarean scar location;3)、Implantation of gestational sac into muscle layer of the uterus and its relationship with the scar.4)、caesarean scar thickness.5)、haemorrhage in uterus cavity and in gestational sac.6)s if gestational sac、yolk sac exist, observe the beating of the embryo. When disagree occur, results can be made after consultations.
5、Surgical procedure
21of28cases experience gestation sac excision、cesarean scar excision through vaginal.1cases experience hysterectomy,6cases operation procedure was not known. Slice open the front of Vaginal fornix separate the bladder and vaginal anterior wall, expose cervical isthmus scar tissue, incision scars in transverse direction, observe the position of gestation sac implanting to the muscular layer of the uterus, vacuum out the gestation sac, scratched the uterine wall with medium curettes to rough in the local tissue, Cut off scar tissue. Among27cases, gestation sacs were integrity in24cases, pathology results:down can be seen in gestation sacs. Without integrity gestation sacs in3cases, blue and purple highlights can be seen in1of28cases in the scar under, about8x8x7cm size, uterine bleeding was found in procedure of operation then the uterus was removed.
Results
1、MRI findings of gestation sac
Among28cases, gestation sacs showed cystic signal in23cases, in T1WI sequence showed round or oval shape lower signal, its boundary does not clear, In T2WI sequence, appear as cystic high signal, Clear in boundary, ring thin-wall enhancement can be seen in pregnancy wall, hemorrhage can be seen within gestation sacs, present as line ship,short T1W signal. Among23of Cystic gestational sac cases, Cystic gestational sac is located in uterine muscle layer in9cases, more than14cases gestational sac implant into uterine muscle layer,meanwhile grow towards uterine cavity, The anterior wall of uterus isthmus became significantly thinner. Hemorrhage in uterine cavity in13cases.
2、Transvaginal ultrasonography in diagnosing pregnancy sac
Among28cases, cystic echo of liquid was found by transvaginal Sonography in23cases, in which2cases were found cotton like echo, that is hemorrhage echo, yolk sac can be seen in12cases,10case of them vascular pulsation can be seen,3in23cases with intrauterine hemorrhage, that is:depart of the uterus cavity and flocculent echo were detect. In8cases、gestational sac were at muscle layer of uterine scarring, in15cases, is at the scar and the uterine cavity.14cases at the same time had transvaginal color Doppler ultrasonic examination, performance for the pregnancy sac surrounding by annular flow signal, low resistance flow pattern.
Among28cases,5cases present for the package block type, envelope wrinkling, heterogeneity clutter, medium and low echoes, combined with intrauterine hemorrhage in5cases. Transvaginal colour Doppler were conducted in the5cases. Characterized by mixed masses and rich blood flow signal surrounding the local muscular layer, arteriovenous fistula blood flow and a low resistance of blood flow spectrum can be measured in2cases.
3、Transvaginal ultrasound and MRI findings of cesarean scars
In27of28cases, the uterine scar is located in lower uterine segment anterior wall of isthmus,1case is located in the anterior wall of uterine body. Muscular layer of the uterus were not continue in Transvaginal ultrasound, wedge-shaped depressions or thinning, MRI signal in T1W, T2W is low signal, anterior uterine wall significantly thinned, gestational sac between the bladder and womb muscle layer were thickness,1.3-4mm by ultrasonic,1.1-4mm by MRI.
4、Comparetion of Transvaginal ultrasound and MRI in the diagnosis of cesarean scar pregnancy.
MRI and transvaginal ultrasound shows23cases of cystic pregnancy sac, in which MRI found cyst pregnancy sac complicated with hemorrhage in6cases; transvaginal ultrasound found2cases of cyst hemorrhage; found yolk sac in12cases, embryo survival in10cases. MRI cannot display the yolk sac and determine whether the embryo survival, MRI shows pregnancy sac at muscular layer scar in9cases, extending to the uterine cavity in14cases, transvaginal ultrasonic found in muscle in8cases, and within intrauterine scar grow towards uterine cavity in15cases.
Masses pregnancy sac in5cases, transvaginal ultrasonography found hemorrhage in the mass in3cases; and MRI found in5cases, MRI found implanting to the myometrium in5cases, transvaginal ultrasound cannot judge the pregnancy sac implanting. MRI found intrauterine hemorrhage in18cases, transvaginal ultrasound found intrauterine hemorrhage in6cases.
Conclusions:
1、Transvaginal ultrasonography has advantage in judging of implantation of yolk sac and embryo sac survival.
2、MRI has more advantages than vaginal ultrasound in judging the relationship of pregnancy sac with scars, bleeding in in the uterine cavity
3、There is no significant difference in judging the pregnancy sac size, location of the scar and the scar thickness
Part Three Analysis of risk factors of Cesarean scar pregnancy
Object:
Discussion on indicators:the correlation between the occurrence of Cesarean scar pregnancy and age, position of the uterus (the forward and the backward), the number of Cesarean, the number of abortion, the latest time of cesarean section, the latest time of abortion.
Study object:
Collecting the clinical data of28CPS cases confirmed by Southern Medical University, Huadu district hospital affiliated to Southern Medical University and women and children health care centre of Huadu district, March2010-January2012,which includes1-. Age2, uterus position (forward or backward)3,the number of cesarean section,4the number of abortions5, Cesarean delivery or abortion for the last time from diagnosis to the CSP time (last time of Cesarean)
Randomly select34patients from Haudu hospital affiliated to Southern Medical University who have cesarean delivery history, deliver baby smoothly this time, during March2010-January2012period as contrast. Collecting the clinical data,includes:1、Age.2、uterus position (forward or backward)3、the number of cesarean section,4the number of abortions5,The time from the latest Cesarean delivery to the time of this delivery.
Statistical methods
1、Case-case contrast method was used, comparative study between CSP in28cases confirmed by the operation and random selected cases that have a history of Cesarean section in34cases with successful deliveries.
2、Risk factors analyzed:1、Age2, uterus position (forward or backward)3,the number of cesarean section,4the number of abortions5,the last time of Cesarean
3、 Accepting Standard of CSP:1、Operation confirmed as scar pregnancy;2、A complete clinical history:age、uterus position、the number of cesarean section、 the number of abortions、the last time of Cesarean Accepting Standard of contrast group:1、there have been at least a history of Cesarean section;2、Pregnancy is intrauterine pregnancy again and smoothly delivery;3、ultrasound examination information in the early of pregnancy:provide uterus position (forward or backward);4、Clinical dates:the number of Cesarean section, specific time, the number of abortion Exclusion criteria of contrast group:1、 clinical information incomplete.2、the gestation failed to due to placenta previa, placental abruption
4、used two sets of information for independent samples t test and observed if there is significant difference in terms of risk between the two groups
5、analyzed the CSP-related risk factors by using Logist regression
1、T tested and analyzed on two groups of age, the number of abortion, the number of Cesarean, cesarean section at the end time, the result shows that there is no difference on ages (t=-1.067, P=0.29, p>0.05), the number of abortion (t=4.643, P.=0.000, p<0.05), the number of Cesarean (t=4.036, P.=0.000, p<0.05), the last time of Cesarean differentiated (t=-4.181, P=0.000, p<0.05)
2、Logistic regression analysis on ages, the number of abortion, the number of Cesarean and the last time of cesarean section shows that effects are caused on SCAR based on the number of abortion, the last time of Cesarean.
Conclusion:Multiple abortions and the last time of Cesarean are the risk factors that lead to cesarean scar pregnancy; multiple abortions and repeated cesarean sections should be avoided.
引文
[1]Larsen JV, Solomon MH. Pregnacy in uterine sacculus an unusual cause of postabortal haemorrhage. S Afr med J,1978,53:142-143
[2]Fylstra DL, Pound-Chang T, Miller MG, Cooper A, Miller KM. Ectopic pregnancy within a cesarean delivery scar:a case report. Am J Obstet Gynecol 2002 Aug;187(2):302-304.
[3]Jurkovic D, Hillaby K, Woelfer B, et al. Fimt-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar [J].Ultrasound Obstet Gyneeol,2003,21(3):220-227.
[4]Seow KM, Huang LW, Lin YH, et al. Cesarean scar pregnancy:Issues in management[J].Ultrasound Obstet Gynecol,2004,23(3):247-253.
[5]任彤,赵俊,万希润等,剖宫产瘢痕妊娠的诊断及处理[J].现代妇产科进展,2007,16(6)：433-436
[6]宋玲,龚明,余本英。经腹及经阴道超声联合应用对剖宫产术后切口瘢痕妊娠的诊断价值。中国超声医学杂志,2010,26(6)570—572
[7]Einenkel J, Stumpp P,Ksling S,et al. A misdiagnosed case of caesarean scar pregnancy[J].Arch Gynecol Obstet,2005,271(2):178-181.
[8]Shih JC. Cesarean sear pregnancy:diagnosis with three-dimensional(3D) ultrasound and 3D power Doppler[J].Ultrasound Obstet Gynecol,2004,23 (3):306-307.
[9]Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar [J].Ultra-sound Obstet Gynecol,2000,16(6):592-593.
[10]Maymon R, Halperin R,Mendlovic S, et al. Ectopic pregnancies in a caesarean scar:review of the medical approach to an iatrogenic complication [J]. Hum Reprod Update,2004,10(6):515-523.
[11]Bih-Chwen Hsieh, Jiann-Loung Hwang, Hun-Shan Pan, et al. Heterotopic Caesarean scar pregnancy combined with intrauterine pregnancy successfully treated with embryo aspiration for selected embryo reduction:Case report. Human Reproduction,2004,19(2):285-287.
[12]Solomon LJ, Femandez H, Chauveaud A, et al. Succesful management of a heterotopic of the intrauterine gestation:Case report. Human Reproduction, 2003,18(1):189-191
[1]李胜利主编胎儿畸形产前超声诊断学人民军医出版社2007 5ISBN978-80194-108-4
[2]席焕久主编 新编人体解剖学。人民军医出版社,2008,8ISBN978-7-5091-2030-9
[3]P. A. Godin, S. Bassil, and J. Donnez, An ectopic pregnancy developing in a previous caesarian section scar, Fertility and Sterility,1997,67, (2) 398-400
[4]焦澜舟向阳剖宫产术后子宫瘢痕妊娠.中华妇产科杂志2008,43(12)947-950
[5]Seow KM, Hwang JL, Tsai YL, et al. Ultrasound diagnosis of a pregnancy in a cesarean scar. Ultrasound Obstet Gynecol 2001,18:547
[6]Hyun-Sun Ko, Young Lee, Hee-Joong Lee, et al. Sonographic and MR Findings in 2 Cases of Intramural Pregnancy Treated Conservatively. JOURNAL OF CLINICAL ULTRASOUND 2006,34(7)356-359
[7]C. J. C. M. Hamilton, J. Legarth, and K. A. Jaroudi, Intramural pregnancy after in vitro fertilization and embryo transfer, Fertility and Sterility,1992,57 (1) 215-217
[8]Maymon R, Halberman R, Mendlovic S, et al. Ectopic pregnancies in a caesarean scar:reviw of the medical approach to an iatrogenic complication. Hum Reprod Update,2004,10:515-523 。 PMID:15375087
[9]A. Al-Nazer, L. Omar, M. Wahba, T. Abbas, et al, Ectopic intramural pregnancy developing at the site of a cesarean section scar:a case report, Cases Journa,2009.2(12),9404
[10]金力,范光升,郎景和,剖宫产术后瘢痕妊娠的早期诊断与治疗。生殖与避孕,2005,25(10)630—633
[11]李莉(综述),李永强(审校)剖官产术后子官切口瘸痕妊娠的诊治新进 展医学综述,201218(9),1346—1349
[12]Rotas MA, Haberman S, Levgur M, Caesarean scar ectopic pregnancies: etiology,diagnosis and management.[J] Obstet Gynecol 2006,107:1373-1381
[13]程志厚剖宫产及相关问题北京：北京出版社,1991：199-201
[14]张燕科,吴瑞瑾综述,林俊审校。剖宫产瘢痕妊娠的诊治现状。国际妇产科学杂志2008,35(5)370-373
[15]袁岩,戴晴,蔡胜等.超声对剖宫产瘢痕妊娠的诊断价值.中华超声影像学杂志,2010,19(4)321-324
[16]KO HS, Lee Y, Lee HJ, et al. Sonographic and MR findings in 2 cases of intramural pregnancy treated conservatively. J Clin Ultrasound.2006, 34:356-360
[17]Ha HK, Jung JK, Kang SJ, et al. MR imaging in the diagnosis of rare forms of ectopic pregnancy. AJR Am J Roentgenol,1993; 160:1229-1232.
[18]Vialt Y, Petignat P, Hohlfeld P. Pregnancy in a caesarean scar Ultrasound Obstet Gynecol,2000,16:592-593.
[19]刘欣燕范光升金征宇等,子宫下段妊娠人工流产术中大出血临床分析,中华妇产科杂志,2003,38；163.
[20]Godin PA, Bassi S, Donner J. An ectopic pregnancy developing in a previous caesarean section scar. Ferm Sterill,1997,67;398-400.
[21]张弦,代敏,严志汉等, MRI对剖宫产子宫瘢痕妊娠的影像分析。实用放射学杂志2011,27(9)1380—1382
[1]王玉,子宫剖宫产瘢痕妊娠诊断与治疗进展.中国医药导报2011 8(20)7-9
[2]张英陈义松王佳佳等.剖宫产后子宫瘢痕部位妊娠96例临床分析.中华妇产科杂志,201045(9)664-667.
[3]Rotas MA, Haberman S, Levgur M. Cesarean scar ectopie pregnancies etiology, diagnosis, and maltagement. Obstet Gynecol,2006,107: 1373-1377.
[4]Fyhtra DL. Eetopic pregnancy within a cesarean scar:a review[J]. Obstet Gynecol Surv,2002,57(8):537-543.
[5]Jurkovic D, Hillaby K, Woelfer B, et al. Fimt-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar[J]. Ultrasound Obstet Gyneeol,2003,21(3):220-227.
[6]焦光琼,凌梅立,钱尚萍。经阴道超声在诊断剖宫产子宫瘢痕妊娠中的价值。上海医学影像杂志,2004,13(1)16
[7]黄莉经阴道彩色多普勒超声对剖宫产切口瘢痕妊娠的诊断价值.中国医学影像学杂志.332-333
[8]焦澜舟向阳剖宫产术后子宫瘢痕妊娠.中华妇产科杂志2008 43(12)947-950
[9]Seow KM, Hwang JL, Tsai YL, et al. Ultrasound diagnosis of a pregnancy in a cesarean scar. Ultrasound Obstet Gynecol 2001,18:547
[10]张向群许乙凯罗小琴子宫切口瘢痕妊娠的MR影像分析.中华放射学杂 志201246(9)812-816
[11]袁岩戴晴蔡胜等.超声对剖宫产瘢痕妊娠的诊断价值.中华超声影像学杂志.2010 19(4)321-324
[12]白洁,黄丹萍,李姣玲。彩色多普勒超声诊断及治疗子宫瘢痕妊娠。中国医学影像技术,2010,26(1)113-115
[13]Hyun-Sun Ko, Young Lee, Hee-Joong Lee, et al. Sonographic and MR Findings in 2 Cases of Intramural Pregnancy Treated Conservatively. JOURNAL OF CLINICAL ULTRASOUND 2006,34(7)356-359
[14]Ha HK, Jung JK, Kang SJ,et al.MR imaging in the diagnosis of rare forms of ectopic pregnancy.AJR Am J Roentgenol 1993; 160:1229
[15]张立华,李帅卢珊等,剖宫产切口妊娠超声与MRI诊断比较,中国医学影像学杂志,2012,20(12)936-939
[16]张燕科吴瑞瑾林俊剖宫产瘢痕妊娠的诊治现状。国际妇产科学杂志,200835(5)370-373
[17]Ash A, Smith A, MaxweU D. Caesarean scar pregnancy [J]. BJOG,2007, 114(3):253-263.
[18]Flystra DL, Pound-Chang T, Miller MG, et al. Ectopic pregnancy within a cesarean delivery scar:a review [J]. Obstet Gynecol Surv,2002,57(8):537-543
[19]任丽娜,孟涛剖宫产瘢痕妊娠的诊断及治疗进展.大连医科大学学报201032 (2)223—226
[1]Seow KM, Hwang JL, Tsai YL, et al. Ultrasound diagnosis of a pregnancy in a cesarean scar. Ultrasound Obstet Gynecol 2001,18:547
[2]Hyun-Sun Ko, Young Lee, Hee-Joong Lee, et al. Sonographic and MR Findings in 2 Cases of Intramural Pregnancy Treated Conservatively. JOURNAL OF CLINICAL ULTRASOUND 2006,34(7)356-359
[3]C. J. C. M. Hamilton, J. Legarth, and K. A. Jaroudi, Intramural pregnancy after in vitro fertilization and embryo transfer, Fertility and Sterility,1992,57 (1) 215-217
[4]焦澜舟向阳剖宫产术后子宫瘢痕妊娠.中华妇产科杂志2008 43(12)947-950
[5]Einenkel J, Stumpp P, Ksling S, et al. A misdiagnosed case of caesarean scar pregnancy[J]. Arch Gynecol Obstet,2005,271(2):178-181.
[6]Shih JC. Cesarean sear pregnancy diagnosis with three-dimensional (3D) ultrasound and 3D power Doppler[J]. Ultrasound Obstet Gynecol, 2004,23(3):306-307.
[7]Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar [J]. Ultrasound Obstet Gynecol,2000,16(6):592-593.
[8]Maymon R, Halperin R, Mendlovic S, et al. Ectopic pregnancies in a caesarean scar:review of the medical approach to an iatrogenic complication[J]. Hum Reprod Update,2004,10(6):515-523.
[9]肖碧芳杨彩群葛利平。超声对剖宫产子宫切口愈合不良监测的意义。中国超声医学杂志。2009,25(10)983-985
[10]Qureshi, Inafuku K, Qshima, et al. Ultrasonsgraphic evaluation of lower uterine segment to predict the integrity and quality of cesarean scar during pregnancy:a prosepective study.Tohoku J Exp Med,1997,183:55-65
[11]Regnard C, Nosbusch M, Fellemans C, et al. Cesarean section scar evaluation by saline sonohysterogrophy. Ultrasound Obstet Gynecol,2004,23(3):289-292
[12]孙清娟,超声对剖宫产子宫切口愈合情况的观察。河北医药,2012,34(11)1704
[13]程志厚剖宫产及相关问题北京：北京出版社,1991：199-201
[14]Ash A, Smith A, MaxweU D. Caesarean scar pregnancy[J]. BJOG,2007, 114(3):253-263.
[15]Jurkovic D, Hillaby K, Woelfer B, et al. First- trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar [J]. ltrasound Obstet Gynecol,2003,21(3):220-227
[16]Rotas MA, Haberman S, Levgur M. Cesarean scar ectopie pregnancies etiology, diagnosis, and maltagement. Obstet Gynecol,2006,107: 1373-1377.
[17]蒋英,王淑珍。再次剖宫产时对原子宫切口愈合情况相关因素分析。实用妇产科杂志。2006,22(7)430-432
[18]Maymon R, Halperin R, Mendlovic S, et al. Ectopic pregnancies in a Caesarean scar:review of the medical approach to an iatrogenic complication [J]. HumReprod Update,2004,10(6):515-523
[19]Tan G, Chong YS, Biswas A. Caesarean scar pregnancy:a diagnosis to consider carefully in patients with risk factors[J]. Ann Acad Med Singapore,2005,34(2):216-219
[20]任彤,赵俊,万希润等,剖宫产瘢痕妊娠的诊断及处理[J].现代妇产科进展,2007,16(6)：433-436
[21]Maymom R, Halperin R, Mendlovic S,et al. Ectopie pregnancies in the cesarean scars:the 8 year experience of one medical centre. Hum Reprod, 2004,19:278-284.
[1]Larsen JV, Solomon MH. Pregnacy in uterine sacculus an unusual cause of postabortal haemorrhage. S Afr med J,1978,53:142-143
[2]Fylstra DL, Pound-Chang T, Miller MG, Cooper A, Miller KM. Ectopic pregnancy within a cesarean delivery scar:a case report. Am J Obstet Gynecol 2002 Aug;187(2):302-304.
[3]Jurkovic D, Hillaby K, Woelfer B, et al. Fimt-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar[J].Ultrasound Obstet Gyneeol,2003,21(3):220-227.
[4]Seow KM, Huang LW, Lin YH, et al. Cesarean scar pregnancy:Issues in management[J].Ultrasound Obstet Gynecol,2004,23(3):247-253.
[5]任彤,赵俊,万希润等,剖宫产瘢痕妊娠的诊断及处理[J].现代妇产科进展,2007,16(6)：433-436
[6]李胜利主编胎儿畸形产前超声诊断学人民军医出版社2007 5 ISBN978-80194-108-4
[7]Einenkel J, Stumpp P,Ksling S,et al. A misdiagnosed case of caesarean scar pregnancy [J]. Arch Gynecol Obstet,2005,271(2):178-181.
[8]Shih JC. Cesarean sear pregnancy:diagnosis with three-dimensional(3D) ultrasound and 3D power Doppler[J].Ultrasound Obstet Gynecol,2004,23 (3):306-307.
[9]Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar[J].Ultra-sound Obstet Gynecol,2000,16(6):592-593.
[10]Maymon R, Halperin R,Mendlovic S, et al. Ectopic pregnancies in a caesarean scar:review of the medical approach to an iatrogenic complication[J].Hum Reprod Update,2004,10(6):515-523.
[11]Bih-Chwen Hsieh, Jiann-Loung Hwang, Hun-Shan Pan, et al. Heterotopic Caesarean scar pregnancy combined with intrauterine pregnancy successfully treated with embryo aspiration for selected embryo reduction:Case report. Human Reproduction,2004,19(2):285-287.
[12]Solomon LJ, Fernandez H, Chauveaud A, et al. Succesful management of a heterotopic of the intrauterine gestation:Case report. Human Reproduction, 2003,18(1):189-191
[13]Vial Y, Petignat P, Hohlfeld P.Pregnancy in a cesarean scar[J].Ultrasound Obstet Gynecol,2000,16(6):592-593.
[14]左文莉,子宫剖宫产瘢痕妊娠,中国计划生育杂志,2009,7：433—445
[15]Rotas MA, Haberman S, Levgur M. Cesarean scar ectopie pregnancies etiology, diagnosis, and maltagement. Obstet Gynecol,2006,107: 1373-1377.
[16]任彤,赵俊,万希润等,剖宫产瘢痕妊娠的诊断及处理[J].现代妇产科进展,2007,16(6)：433-436
[17]Maymom R, Halperin R, Mendlovic S,et al. Ectopie pregnancies in the cesarean scars:the 8 year experience of one medical centre. Hum Reprod,2004, 19:278-284.
[18]Ash A, Smith A, Maxwell D.Cesarean scar pregnancy. BJOG,2007, 114(3):253-263
[19]孙清娟超声对剖宫产子宫切口愈合情况的观察。河北医药2012,34(11)：1074
[20]程志厚剖宫产及相关问题北京：北京出版社,1991：199-201
[21]Rotas MA, Haberman S, Levgur M, Caesarean scar ectopic pregnancies: etiology,diagnosis and management.[J] Obstet Gynecol 2006,107:1373-1381
[22]金力,范光升,郎景和,剖宫产术后瘢痕妊娠的早期诊断与治疗。生殖与避孕,2005,25(10)630—633
[23]李莉(综述),李永强(审校)剖宫产术后子官切口瘸痕妊娠的诊治新进展医学综述,201218(9),1346—1349
[24]Einenkel J, Stumpp P, Kosling S et al. A misdiagnosed case of cesarean scar pregnancy. Arch Gynecol Obstet,2005,271:178-181
[25]黄莉经阴道彩色多普勒超声对剖宫产切口瘢痕妊娠的诊断价值。中国医学影像学杂志,2010年第4期332-333
[26]Godin PA, Bassil S,Donner J. An ectopic pregnancy developing in a previous caesarean scar. Ferm Steril,1997,67(2):398-400
[27]张向群许乙凯罗小琴,子宫切口瘢痕内妊娠的MR影像分析。中华放射学杂志。2012,46(9)812-816
[28]袁岩戴晴蔡胜等.超声对剖宫产瘢痕妊娠的诊断价值.中华超声影像学杂志.2010 19(4)321-324
[29]石华亮庞倩芸卢再鸣,剖宫产瘢痕妊娠的MRI特点及MRI对其诊治指导价值。中国临床医学影像杂志,2011,22(1)51-54
[30]KO HS, Lee Y, Lee HJ, et al. Sonographic and MR findings in 2 cases of intramural pregnancy treated conservatively. J Clin Ultrasound.2006, 34:356-360
[31]Ha HK, Jung JK, Kang SJ, et al. MR imaging in the diagnosis of rare forms of ectopic pregnancy. AJR Am J Roentgenol,1993; 160:1229-1232.
[32]水旭娟,彩色多普勒超声在诊断子宫瘢痕妊娠中应用。中华超声影像学杂志,2005,14：636-637
[33]张弦,代敏,严志汉等, MRI对剖宫产子宫瘢痕妊娠的影像分析。实用放射学杂志2011,27(9)1380—1382
[2]Fylstra DL, Pound-Chang T, Miller MG, Cooper A, Miller KM. Ectopic pregnancy within a cesarean delivery scar:a case report. Am J Obstet Gynecol 2002 Aug;187(2):302-304.
[3]Jurkovic D, Hillaby K, Woelfer B, et al. Fimt-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar [J].Ultrasound Obstet Gyneeol,2003,21(3):220-227.
[4]Seow KM, Huang LW, Lin YH, et al. Cesarean scar pregnancy:Issues in management[J].Ultrasound Obstet Gynecol,2004,23(3):247-253.
[5]任彤,赵俊,万希润等,剖宫产瘢痕妊娠的诊断及处理[J].现代妇产科进展,2007,16(6)：433-436
[6]宋玲,龚明,余本英。经腹及经阴道超声联合应用对剖宫产术后切口瘢痕妊娠的诊断价值。中国超声医学杂志,2010,26(6)570—572
[7]Einenkel J, Stumpp P,Ksling S,et al. A misdiagnosed case of caesarean scar pregnancy[J].Arch Gynecol Obstet,2005,271(2):178-181.
[8]Shih JC. Cesarean sear pregnancy:diagnosis with three-dimensional(3D) ultrasound and 3D power Doppler[J].Ultrasound Obstet Gynecol,2004,23 (3):306-307.
[9]Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar [J].Ultra-sound Obstet Gynecol,2000,16(6):592-593.
[10]Maymon R, Halperin R,Mendlovic S, et al. Ectopic pregnancies in a caesarean scar:review of the medical approach to an iatrogenic complication [J]. Hum Reprod Update,2004,10(6):515-523.
[11]Bih-Chwen Hsieh, Jiann-Loung Hwang, Hun-Shan Pan, et al. Heterotopic Caesarean scar pregnancy combined with intrauterine pregnancy successfully treated with embryo aspiration for selected embryo reduction:Case report. Human Reproduction,2004,19(2):285-287.
[12]Solomon LJ, Femandez H, Chauveaud A, et al. Succesful management of a heterotopic of the intrauterine gestation:Case report. Human Reproduction, 2003,18(1):189-191
[1]李胜利主编胎儿畸形产前超声诊断学人民军医出版社2007 5ISBN978-80194-108-4
[2]席焕久主编 新编人体解剖学。人民军医出版社,2008,8ISBN978-7-5091-2030-9
[3]P. A. Godin, S. Bassil, and J. Donnez, An ectopic pregnancy developing in a previous caesarian section scar, Fertility and Sterility,1997,67, (2) 398-400
[4]焦澜舟向阳剖宫产术后子宫瘢痕妊娠.中华妇产科杂志2008,43(12)947-950
[5]Seow KM, Hwang JL, Tsai YL, et al. Ultrasound diagnosis of a pregnancy in a cesarean scar. Ultrasound Obstet Gynecol 2001,18:547
[6]Hyun-Sun Ko, Young Lee, Hee-Joong Lee, et al. Sonographic and MR Findings in 2 Cases of Intramural Pregnancy Treated Conservatively. JOURNAL OF CLINICAL ULTRASOUND 2006,34(7)356-359
[7]C. J. C. M. Hamilton, J. Legarth, and K. A. Jaroudi, Intramural pregnancy after in vitro fertilization and embryo transfer, Fertility and Sterility,1992,57 (1) 215-217
[8]Maymon R, Halberman R, Mendlovic S, et al. Ectopic pregnancies in a caesarean scar:reviw of the medical approach to an iatrogenic complication. Hum Reprod Update,2004,10:515-523 。 PMID:15375087
[9]A. Al-Nazer, L. Omar, M. Wahba, T. Abbas, et al, Ectopic intramural pregnancy developing at the site of a cesarean section scar:a case report, Cases Journa,2009.2(12),9404
[10]金力,范光升,郎景和,剖宫产术后瘢痕妊娠的早期诊断与治疗。生殖与避孕,2005,25(10)630—633
[11]李莉(综述),李永强(审校)剖官产术后子官切口瘸痕妊娠的诊治新进 展医学综述,201218(9),1346—1349
[12]Rotas MA, Haberman S, Levgur M, Caesarean scar ectopic pregnancies: etiology,diagnosis and management.[J] Obstet Gynecol 2006,107:1373-1381
[13]程志厚剖宫产及相关问题北京：北京出版社,1991：199-201
[14]张燕科,吴瑞瑾综述,林俊审校。剖宫产瘢痕妊娠的诊治现状。国际妇产科学杂志2008,35(5)370-373
[15]袁岩,戴晴,蔡胜等.超声对剖宫产瘢痕妊娠的诊断价值.中华超声影像学杂志,2010,19(4)321-324
[16]KO HS, Lee Y, Lee HJ, et al. Sonographic and MR findings in 2 cases of intramural pregnancy treated conservatively. J Clin Ultrasound.2006, 34:356-360
[17]Ha HK, Jung JK, Kang SJ, et al. MR imaging in the diagnosis of rare forms of ectopic pregnancy. AJR Am J Roentgenol,1993; 160:1229-1232.
[18]Vialt Y, Petignat P, Hohlfeld P. Pregnancy in a caesarean scar Ultrasound Obstet Gynecol,2000,16:592-593.
[19]刘欣燕范光升金征宇等,子宫下段妊娠人工流产术中大出血临床分析,中华妇产科杂志,2003,38；163.
[20]Godin PA, Bassi S, Donner J. An ectopic pregnancy developing in a previous caesarean section scar. Ferm Sterill,1997,67;398-400.
[21]张弦,代敏,严志汉等, MRI对剖宫产子宫瘢痕妊娠的影像分析。实用放射学杂志2011,27(9)1380—1382
[1]王玉,子宫剖宫产瘢痕妊娠诊断与治疗进展.中国医药导报2011 8(20)7-9
[2]张英陈义松王佳佳等.剖宫产后子宫瘢痕部位妊娠96例临床分析.中华妇产科杂志,201045(9)664-667.
[3]Rotas MA, Haberman S, Levgur M. Cesarean scar ectopie pregnancies etiology, diagnosis, and maltagement. Obstet Gynecol,2006,107: 1373-1377.
[4]Fyhtra DL. Eetopic pregnancy within a cesarean scar:a review[J]. Obstet Gynecol Surv,2002,57(8):537-543.
[5]Jurkovic D, Hillaby K, Woelfer B, et al. Fimt-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar[J]. Ultrasound Obstet Gyneeol,2003,21(3):220-227.
[6]焦光琼,凌梅立,钱尚萍。经阴道超声在诊断剖宫产子宫瘢痕妊娠中的价值。上海医学影像杂志,2004,13(1)16
[7]黄莉经阴道彩色多普勒超声对剖宫产切口瘢痕妊娠的诊断价值.中国医学影像学杂志.332-333
[8]焦澜舟向阳剖宫产术后子宫瘢痕妊娠.中华妇产科杂志2008 43(12)947-950
[9]Seow KM, Hwang JL, Tsai YL, et al. Ultrasound diagnosis of a pregnancy in a cesarean scar. Ultrasound Obstet Gynecol 2001,18:547
[10]张向群许乙凯罗小琴子宫切口瘢痕妊娠的MR影像分析.中华放射学杂 志201246(9)812-816
[11]袁岩戴晴蔡胜等.超声对剖宫产瘢痕妊娠的诊断价值.中华超声影像学杂志.2010 19(4)321-324
[12]白洁,黄丹萍,李姣玲。彩色多普勒超声诊断及治疗子宫瘢痕妊娠。中国医学影像技术,2010,26(1)113-115
[13]Hyun-Sun Ko, Young Lee, Hee-Joong Lee, et al. Sonographic and MR Findings in 2 Cases of Intramural Pregnancy Treated Conservatively. JOURNAL OF CLINICAL ULTRASOUND 2006,34(7)356-359
[14]Ha HK, Jung JK, Kang SJ,et al.MR imaging in the diagnosis of rare forms of ectopic pregnancy.AJR Am J Roentgenol 1993; 160:1229
[15]张立华,李帅卢珊等,剖宫产切口妊娠超声与MRI诊断比较,中国医学影像学杂志,2012,20(12)936-939
[16]张燕科吴瑞瑾林俊剖宫产瘢痕妊娠的诊治现状。国际妇产科学杂志,200835(5)370-373
[17]Ash A, Smith A, MaxweU D. Caesarean scar pregnancy [J]. BJOG,2007, 114(3):253-263.
[18]Flystra DL, Pound-Chang T, Miller MG, et al. Ectopic pregnancy within a cesarean delivery scar:a review [J]. Obstet Gynecol Surv,2002,57(8):537-543
[19]任丽娜,孟涛剖宫产瘢痕妊娠的诊断及治疗进展.大连医科大学学报201032 (2)223—226
[1]Seow KM, Hwang JL, Tsai YL, et al. Ultrasound diagnosis of a pregnancy in a cesarean scar. Ultrasound Obstet Gynecol 2001,18:547
[2]Hyun-Sun Ko, Young Lee, Hee-Joong Lee, et al. Sonographic and MR Findings in 2 Cases of Intramural Pregnancy Treated Conservatively. JOURNAL OF CLINICAL ULTRASOUND 2006,34(7)356-359
[3]C. J. C. M. Hamilton, J. Legarth, and K. A. Jaroudi, Intramural pregnancy after in vitro fertilization and embryo transfer, Fertility and Sterility,1992,57 (1) 215-217
[4]焦澜舟向阳剖宫产术后子宫瘢痕妊娠.中华妇产科杂志2008 43(12)947-950
[5]Einenkel J, Stumpp P, Ksling S, et al. A misdiagnosed case of caesarean scar pregnancy[J]. Arch Gynecol Obstet,2005,271(2):178-181.
[6]Shih JC. Cesarean sear pregnancy diagnosis with three-dimensional (3D) ultrasound and 3D power Doppler[J]. Ultrasound Obstet Gynecol, 2004,23(3):306-307.
[7]Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar [J]. Ultrasound Obstet Gynecol,2000,16(6):592-593.
[8]Maymon R, Halperin R, Mendlovic S, et al. Ectopic pregnancies in a caesarean scar:review of the medical approach to an iatrogenic complication[J]. Hum Reprod Update,2004,10(6):515-523.
[9]肖碧芳杨彩群葛利平。超声对剖宫产子宫切口愈合不良监测的意义。中国超声医学杂志。2009,25(10)983-985
[10]Qureshi, Inafuku K, Qshima, et al. Ultrasonsgraphic evaluation of lower uterine segment to predict the integrity and quality of cesarean scar during pregnancy:a prosepective study.Tohoku J Exp Med,1997,183:55-65
[11]Regnard C, Nosbusch M, Fellemans C, et al. Cesarean section scar evaluation by saline sonohysterogrophy. Ultrasound Obstet Gynecol,2004,23(3):289-292
[12]孙清娟,超声对剖宫产子宫切口愈合情况的观察。河北医药,2012,34(11)1704
[13]程志厚剖宫产及相关问题北京：北京出版社,1991：199-201
[14]Ash A, Smith A, MaxweU D. Caesarean scar pregnancy[J]. BJOG,2007, 114(3):253-263.
[15]Jurkovic D, Hillaby K, Woelfer B, et al. First- trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar [J]. ltrasound Obstet Gynecol,2003,21(3):220-227
[16]Rotas MA, Haberman S, Levgur M. Cesarean scar ectopie pregnancies etiology, diagnosis, and maltagement. Obstet Gynecol,2006,107: 1373-1377.
[17]蒋英,王淑珍。再次剖宫产时对原子宫切口愈合情况相关因素分析。实用妇产科杂志。2006,22(7)430-432
[18]Maymon R, Halperin R, Mendlovic S, et al. Ectopic pregnancies in a Caesarean scar:review of the medical approach to an iatrogenic complication [J]. HumReprod Update,2004,10(6):515-523
[19]Tan G, Chong YS, Biswas A. Caesarean scar pregnancy:a diagnosis to consider carefully in patients with risk factors[J]. Ann Acad Med Singapore,2005,34(2):216-219
[20]任彤,赵俊,万希润等,剖宫产瘢痕妊娠的诊断及处理[J].现代妇产科进展,2007,16(6)：433-436
[21]Maymom R, Halperin R, Mendlovic S,et al. Ectopie pregnancies in the cesarean scars:the 8 year experience of one medical centre. Hum Reprod, 2004,19:278-284.
[1]Larsen JV, Solomon MH. Pregnacy in uterine sacculus an unusual cause of postabortal haemorrhage. S Afr med J,1978,53:142-143
[2]Fylstra DL, Pound-Chang T, Miller MG, Cooper A, Miller KM. Ectopic pregnancy within a cesarean delivery scar:a case report. Am J Obstet Gynecol 2002 Aug;187(2):302-304.
[3]Jurkovic D, Hillaby K, Woelfer B, et al. Fimt-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar[J].Ultrasound Obstet Gyneeol,2003,21(3):220-227.
[4]Seow KM, Huang LW, Lin YH, et al. Cesarean scar pregnancy:Issues in management[J].Ultrasound Obstet Gynecol,2004,23(3):247-253.
[5]任彤,赵俊,万希润等,剖宫产瘢痕妊娠的诊断及处理[J].现代妇产科进展,2007,16(6)：433-436
[6]李胜利主编胎儿畸形产前超声诊断学人民军医出版社2007 5 ISBN978-80194-108-4
[7]Einenkel J, Stumpp P,Ksling S,et al. A misdiagnosed case of caesarean scar pregnancy [J]. Arch Gynecol Obstet,2005,271(2):178-181.
[8]Shih JC. Cesarean sear pregnancy:diagnosis with three-dimensional(3D) ultrasound and 3D power Doppler[J].Ultrasound Obstet Gynecol,2004,23 (3):306-307.
[9]Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar[J].Ultra-sound Obstet Gynecol,2000,16(6):592-593.
[10]Maymon R, Halperin R,Mendlovic S, et al. Ectopic pregnancies in a caesarean scar:review of the medical approach to an iatrogenic complication[J].Hum Reprod Update,2004,10(6):515-523.
[11]Bih-Chwen Hsieh, Jiann-Loung Hwang, Hun-Shan Pan, et al. Heterotopic Caesarean scar pregnancy combined with intrauterine pregnancy successfully treated with embryo aspiration for selected embryo reduction:Case report. Human Reproduction,2004,19(2):285-287.
[12]Solomon LJ, Fernandez H, Chauveaud A, et al. Succesful management of a heterotopic of the intrauterine gestation:Case report. Human Reproduction, 2003,18(1):189-191
[13]Vial Y, Petignat P, Hohlfeld P.Pregnancy in a cesarean scar[J].Ultrasound Obstet Gynecol,2000,16(6):592-593.
[14]左文莉,子宫剖宫产瘢痕妊娠,中国计划生育杂志,2009,7：433—445
[15]Rotas MA, Haberman S, Levgur M. Cesarean scar ectopie pregnancies etiology, diagnosis, and maltagement. Obstet Gynecol,2006,107: 1373-1377.
[16]任彤,赵俊,万希润等,剖宫产瘢痕妊娠的诊断及处理[J].现代妇产科进展,2007,16(6)：433-436
[17]Maymom R, Halperin R, Mendlovic S,et al. Ectopie pregnancies in the cesarean scars:the 8 year experience of one medical centre. Hum Reprod,2004, 19:278-284.
[18]Ash A, Smith A, Maxwell D.Cesarean scar pregnancy. BJOG,2007, 114(3):253-263
[19]孙清娟超声对剖宫产子宫切口愈合情况的观察。河北医药2012,34(11)：1074
[20]程志厚剖宫产及相关问题北京：北京出版社,1991：199-201
[21]Rotas MA, Haberman S, Levgur M, Caesarean scar ectopic pregnancies: etiology,diagnosis and management.[J] Obstet Gynecol 2006,107:1373-1381
[22]金力,范光升,郎景和,剖宫产术后瘢痕妊娠的早期诊断与治疗。生殖与避孕,2005,25(10)630—633
[23]李莉(综述),李永强(审校)剖宫产术后子官切口瘸痕妊娠的诊治新进展医学综述,201218(9),1346—1349
[24]Einenkel J, Stumpp P, Kosling S et al. A misdiagnosed case of cesarean scar pregnancy. Arch Gynecol Obstet,2005,271:178-181
[25]黄莉经阴道彩色多普勒超声对剖宫产切口瘢痕妊娠的诊断价值。中国医学影像学杂志,2010年第4期332-333
[26]Godin PA, Bassil S,Donner J. An ectopic pregnancy developing in a previous caesarean scar. Ferm Steril,1997,67(2):398-400
[27]张向群许乙凯罗小琴,子宫切口瘢痕内妊娠的MR影像分析。中华放射学杂志。2012,46(9)812-816
[28]袁岩戴晴蔡胜等.超声对剖宫产瘢痕妊娠的诊断价值.中华超声影像学杂志.2010 19(4)321-324
[29]石华亮庞倩芸卢再鸣,剖宫产瘢痕妊娠的MRI特点及MRI对其诊治指导价值。中国临床医学影像杂志,2011,22(1)51-54
[30]KO HS, Lee Y, Lee HJ, et al. Sonographic and MR findings in 2 cases of intramural pregnancy treated conservatively. J Clin Ultrasound.2006, 34:356-360
[31]Ha HK, Jung JK, Kang SJ, et al. MR imaging in the diagnosis of rare forms of ectopic pregnancy. AJR Am J Roentgenol,1993; 160:1229-1232.
[32]水旭娟,彩色多普勒超声在诊断子宫瘢痕妊娠中应用。中华超声影像学杂志,2005,14：636-637
[33]张弦,代敏,严志汉等, MRI对剖宫产子宫瘢痕妊娠的影像分析。实用放射学杂志2011,27(9)1380—1382