产后胎盘植入的MRI诊断与介入治疗的临床研究
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摘要
第一部分正常胎盘的MRI表现及组织学基础
目的
1.分析探讨正常胎盘结构的MRI图像的信号特点与相关组织学之间关系。
2.分析胎儿胎盘成熟度不同分级的MRI表现。
3探讨中晚孕期胎盘成熟度MRI分级与孕周的关系。
资料与方法
1.研究对象
收集2009年4月至2012年4月50例孕19周以上孕妇MRI资料,均先行B超检查排除胎盘病变孕妇,其中妊娠19-23周为5例,24～31周为18例,32-35周19例,36-40周8例,均为单胎妊娠,50例孕妇年龄20-36岁,平均30.2岁。
2.主要仪器与设备
本研究使用Siemens Symphony1.5T超导型核磁共振扫描仪,相控阵线圈,后处理工作站为Siemens公司自带的LEONARDO工作站。
3.检查方法
MR检查方法
腹部常规三维定位采用GRE序列,MRI扫描序列包括：T1WI、T2WI横断、矢状及冠状位扫描,T2WI成像采用HASTE序列,主要参数为：TR:1000ms,TE:74ms,带宽630HZ/PX,层厚6mm,层间距1.8mm, FOV35cm,矩阵164×256,采集次数(NEX=1次),激励次数2次,同时采用脂肪抑制、流动补偿技术,部分病例行Gd-DTPA增强扫描,经肘静脉用高压注射器注入,注药速度2-3ml/s,剂量为0.1mmol/kg.
超声检查方法
孕妇仰卧位,患者检查前适度充盈膀胱,用二维常规腹部扫描,必要时经阴道超声检查,辅以彩色多普勒与三维超声进一步检查。主要测量子宫大小,胎盘大小,胎盘后间隙(子宫肌层低回声)是否存在、胎盘内部及周边血流信号情况。
4.标本处理
胎盘新鲜标本取材于正常人工流产和足月产后置入10%福尔马林液中固定,一次性石蜡包埋,连续切片,常规HE染色,光镜下观察。
5.统计学分析
采用SPSS14.0统计软件数据录入处理,P<0.05有统计学意义,采用Kruskal-Wallis H检验,对各孕周组之间胎盘成熟度MRI分级进行比较。
结果
1.MRI胎盘的分级法是以胎盘的绒毛板、胎盘实质及胎盘的基底层三部分结构的变化作为分级的依据,参照B超Grannum标准对胎盘成熟度进行分级。
2.根据T2WI显示的胎盘结构,本组50例正常中晚期胎盘MRI诊断0级胎盘4例、Ⅰ级胎盘18例、Ⅱ级胎盘23例、Ⅲ级胎盘5例。
3.增强后胎盘MRI特征：注入增强剂快速扫描,胎盘信号增高明显强化,胎盘显影早于邻近子宫肌层；即刻再次扫描,妊娠中期孕妇可显示均匀的胎盘强化,妊娠晚期孕妇可显示2-3CM大小的胎盘小叶强化明显；延迟扫描胎盘及子宫肌层均匀强化。
4.光镜下：中晚期胎盘切片背景清晰,绒毛形状纤细,分支增多变细,正常的绒毛结构内可见少量梗死、钙化灶,滋养层主要是合体细胞,间质为网状结缔组织,实质内血管可分辨区内外膜结构。
结论
1.MR检查图像可以清晰显示胎盘三层结构：胎盘实质,胎盘绒毛膜板,胎盘基底膜。
2.从0级至Ⅲ级,胎盘MR表现具有各自不同特征表现。
3.胎盘成熟为一渐变的过程,其各级成熟度在各孕周分布幅度不同,并有相互交叉重叠现象。
第二部分MRI在产后胎盘植入介入治疗前后的诊断价值
目的：
1.分析临床疑诊胎盘植入行介入治疗的患者MR]资料,评价MRI诊断胎盘植入与手术和/或临床综合诊断标准的相关性.
2.探讨MRI在产后胎盘植入介入治疗前后的影像征象.
资料与方法
1.研究对象
搜集2009年4月至2012年4月间30例妊娠中止或产后患者资料,年龄为21-36岁,平均(30±4)岁,临床发现人流或产后胎盘排出不全或未娩出,阴道不规则出血、临床拟诊为胎盘植入,全部病例均行经皮双侧子宫动脉化疗栓塞介入治疗术,介入治疗前后一周内分别行MRI检查。30例患者中首次分娩为20例,第2次分娩为5例,5例为中妊人流；曾有人流病史为21例,有剖宫产史10例,3例有子宫肌瘤手术史,8例合并有前置胎盘。
2.仪器及检查方法
使用西门子公司生产的Symphony1.5T超导型核磁共振扫描仪,相控阵线圈仰卧位扫描。常规扫描序列FLASH/T1WI (TR/TE:113ms/4.76ms), T2WI采用HASTE序列TR/TE:1000ms/74ms,层厚6mm,层间距1.8mm, NEX1次,FOV35cm,矩阵240-320,分别行横断位、矢状位、冠状位扫描,同时采用脂肪抑制、流动补偿技术,全部病例均行钆喷酸葡胺造影剂Gd-DTPA增强扫描,扫描范围由子宫底上约2cm至耻骨联合下。
3信号强度描述与图像处理
不同组织MRI信号强度均以同序列的子宫肌层信号强度为对照。由两名副高及以上的高年资影像科医师进行诊断分析、诊断之前均不知晓手术与病理结果,诊断观察MRI中胎盘的信号强度、位置、形态、植入部位和子宫肌壁及周围相邻器官可能受累情况等。以临床综合诊断或手术病理结果为标准,评价MRI的诊断价值。
4统计学分析
采用SPSS14.0软件分析处理,采用Kappa统计量评估MRI的检查结果与病理及临床综合诊断标准比较的一致性,P<0.05为差异有统计学意义。
结果
1.MRI诊断胎盘植入与临床或病理结果相关性Kappa=0.733, P=0.000,有统计学意义。
2.粘性性胎盘：MRI显示子宫肌层信号完整,子宫内结合带不规则、模糊或中断,子宫肌层也可局部呈受压改变。
3.植入性胎盘：MRI显示子宫肌层信号不规则或受侵,子宫肌层变薄,子宫结合带信号中断,可有流空血管影穿过肌层。
4.穿透性胎盘：MRI显示胎盘位于子宫肌层信号带外,正常子宫肌层信号局部完全消失,有时可显示膀胱或肠道受侵。
5.增强扫描,表现为明显强化,呈“花环状”或“结节状”强化。
6.介入治疗后复查：胎盘植入残留部分较正常子宫肌层增强信号减低,边界较清晰。
结论
1.MRI诊断胎盘植入准确性较高,结合增强扫描可以准确的判断子宫肌层受侵的情况,与手术和/或临床综合诊断标准有相关性,MRI影像可以反映胎盘植入介入治疗前后的的病理改变,为胎盘植入诊断及介入治疗的疗效评价提供可靠依据及指导,具有较高的临床价值。
2.介入治疗前胎盘植入MRI征象：子宫内结合带不规则、模糊或中断(粘连性胎盘植入)；子宫肌层信号不规则或受侵,子宫肌层变薄(植入性胎盘植入)；正常子宫肌层信号局部完全消失,有时可显示膀胱或肠道受侵(穿透性胎盘植入)
3.介入治疗后胎盘植入MRI征象：植入胎盘与宫壁融合、植入及穿透部分子宫肌层仍可见混杂高信号,增强扫描显示更加清晰,胎盘植入残留部分较正常子宫肌层增强信号减低,边界较清晰.
第三部分产后胎盘植入子宫动脉途径介入治疗的临床研究
目的
1.分析产后胎盘植入的子宫动脉途径介入治疗原理、手术操作技巧。
2.探讨产后胎盘植入子宫动脉途径介入治疗的临床疗效、并发症及预后改变。
3.分析绒毛膜促性腺激素(β-hCG)检测值在产后胎盘植入介入治疗前后改变及临床应用价值。
资料与方法
1.研究对象
2009年4月-2012年4月间我院妇产科23例胎盘植入合并产后出血患者,年龄29-45岁(平均34±3)岁,终止妊娠时孕周为25-38周,平均(29±3.6)周。临床表现为产后胎盘未完全排除,阴道流血,均行子宫动脉化疗栓塞术,23例患者分为急诊栓塞组和择期栓塞两组,急诊栓塞组7例,择期栓塞组16例。
胎盘植入诊断标准
1)临床表现,剖宫产或产后发现胎盘部分与肌壁粘连,胎盘组织强行剥离或钳夹仍有残留,剥离面出血、粗糙。
2)B超或MRI检查证实子宫腔内有残留胎盘组织,有侵入性影像学改变,与子宫肌层分界不清。
3)病理检查,产后排出组织证实为坏死性或陈旧性胎盘绒毛组织。
胎盘植入疗效评价标准
1)无效：月经不规则,阴道的流血量无明显减少,复查超声子宫形态仍不规则、肌层较厚,子宫动脉栓塞术治疗后血清中β-HCG水平下降不明显；
2)有效：随访半年,月经周期基本规律,阴道的流血量减少,复查超声子宫形态、肌层接近正常；子宫动脉栓塞术治疗后2周血清中β-HCG水平明显下降,4周后基本接近正常；
3)显效：随访半年,月经周期恢复正常,阴道的流血量显著减少,复查超声子宫形态、肌层恢复正常；子宫动脉栓塞术治疗后2周血清中β-HCG水平迅速下降,4周后转阴。
2.治疗方法子宫动脉化疗灌注栓塞术
术前常规建立静脉通道、留置导尿管,消毒铺中,经右侧股动脉穿刺,行Seldinger技术穿刺插管,选用5.0FCobra管或子宫动脉造影管分别行双侧髂动脉造影,显示子宫动脉后经微导管超选择进入子宫动脉内,胎盘植入处可见不规则的血窦或血管湖,造影剂浓聚,静脉期染色持续存在,明确胎盘病变后灌注30-50m1甲氨喋呤(MTX)加50m1生理盐水,选用明胶海绵栓塞子宫动脉,DSA造影复查至末梢分支血管消失为止,大出血伴休克患者术前输血充分,维持血压稳定,急诊行栓塞治疗。栓塞后一周内在B超引导下行清宫术治疗。
3.术后处理
本组23例患者,术后积极支持对症处理,疼痛患者给予曲马多或杜冷丁止痛,术后3天静脉滴注抗生素给予常规预防感染治疗,记录患者的血压、呼吸、脉搏、体温,术后24小时内观察下肢动脉搏动,术后3天、7天、2周复查血清β-HCG值,定期复查肝肾功能,B超检查监测宫腔内变化。术后观察患者阴道出血量、月经来潮、胎盘排出、住院时间等。
4.统计学分析采用
SPSS14.0统计软件数据录入处理,P<0.05有统计学意义,
(1)急诊栓塞组与择期栓塞组比较：计量资料采用T检验,计数资料采用fisher精确检验。
(2)胎盘植入患者介入治疗前后血清β-hCG变化情况：组内不同时间点血β-hCG的比较使用Kruskal-Wallis H检验,并进一步采用Dunnett,s T3法进行多重比较。
结果
1.本组23例患者介入治疗均手术成功,无1例子宫切除,手术时间50-80分钟,平均(60±5.8)分钟,术中造影见子宫动脉末梢闭塞,术后阴道活动性出血停止,4例失血性休克患者术后生命体征恢复正常,21例清宫术后子宫恢复正常,清出组织含有胎盘蜕膜或绒毛,随访2月余,阴道均无出血。
急诊栓塞组和择期栓塞组在输血(P值=0.004)、出血量(P值=0.00)和住院治疗时间(P值=0.00)有显著差别,平均年龄(P值=0.95)、刮宫产次数(P值=0.83)、清宫术次数(P值=1)、有无前置胎盘(P值=1)无统计学意义。
2.23例产后胎盘植入患者介入治疗前后血清p-hCG变化研究组各个时间点HCG存在差异(卡方=52.576,P=0.00)；研究组治疗前与治疗后3天HCG有统计学差异(P=0.000),治疗前与治疗后7天存在差异(P=0.000)、与治疗后2周有差异(P=0.000),治疗后3天与治疗后7天有差异(P=0.00)、与治疗后2周有差异(P=0.00),治疗后7天与治疗后2周也有差异(P=0.00),总之：治疗前与治疗后3天、治疗后7天、治疗后2周有统计学差异。
3.超声或MRI复查,23例宫腔内均未见胎盘组织残留,但有5例肌壁仍可见残留胎盘组织,复查血清β-HCG值显示在胎盘排出后2-3周后基本恢复正常水平。随访的20例患者中有5例再次怀孕并产下健康婴儿.
4.术后不良反应：恶心、呕吐较常见,疼痛、发热给予支持对症处理。与插管技术相关的并发症主要为血肿。
结论1.MTX灌注联合栓塞介入治疗可完全临时阻断植入胎盘动脉血供,使残余胎盘组织缺血、变性、坏死甚至脱落.
2.产后胎盘植入子宫动脉途径介入治疗成功率高,大多数患者保留了子宫及再次生育的能力,并发症少,术后恢复快,同时可预防植入胎盘导致的大出血或子宫破裂风险；本组病例发现急诊栓塞和择期栓塞在出血量和住院治疗时间有显著差异.
3.产后胎盘植入介入治疗前后绒毛膜促性腺激素(β-hCG)下降显著,绒毛膜促性腺激素数值监测可以作为胎盘植入介入治疗临床疗效判断的指标之一.
Part1MRI findings and histologic basis of placenta
Object:
1.To analyse the clinic value of MRI findings and histologic basis of normal placenta.
2.Analysis of fetal placental maturity of different grades of MRI, to explore the relationship between MRI classification and the gestational age in the second and third trimester
Material and Method:
1.Subject
From April2009to April2012,50singleton pregnancies of after19gestational age have been collected by MRI,their mean age were30.2years old(rang20-36),the19-23gestational age(GA)for5cases,24～31GA for18cases,32～35GA for19cases,36-40GA for8cases,.
2.Main instrument and equipment
The Symphony1.5T superconducting magnetic resonance scanner of Siemens;phased-array coil with coronal, sagittal, and axial scanning, then were placenta vertical section, sagittal and transverse coronary scanning.Image postprocessing was done through the Functool software of Siemens company's LEONARDO workstation.
3.MR examination method
The3D positioning using GRE sequence, MRI scanning sequences included: T1WI, T2WI (transverse, sagittal and coronal scan)
The parameter of T2WI imaging with HASTE sequence were TR:1000ms, TE:74ms, slice thick6mm, layer spacing1.8mm, FOV:35cm, matrix164×256, NEX1, Incentive2times,with the fat suppression, and flow compensation technique. Some patients were Gd-DTPA enhancement.
Ultrasonic examination method
Gravida supine, patients examined before proper filling of bladder, using two-dimensional routine abdominal scan, when necessary, transvaginal ultrasonography, combined with color Doppler and three-dimensional ultrasound further examination. The main measurement of uterine size, size of the placenta, placenta after clearance (muscular layer of uterus, placenta low echo) the existence of internal and peripheral blood flow signal.
4. Pathology examination
Placenta fresh specimens fixed in10%formalin were obtained from normal full-term pregnancy abortion and postpartum,which were disposable paraffin-embedded、routine HE stainned and observed under Optical microscope.
5. Statistical analysis
Data analyses were performed by SPSS14.0and the statistical differences were considered as statistically significant when P value was<0.05.Applying Kruskal-Wallis H statistic to compare between each gestational weeks placental mature grading by MRI.
Result
1.According to Grannum standard of ultrasonography of placental mature grading, MRI in placenta maturity grading is changes in the villous plate, the placental parenchyma and placental basal layer as the classification basis.
2.According to the placental structure of T2WI,50cases of normal placenta MRI grading included grade o in4cases、grade Ⅰ in18cases、grade Ⅱ in23cases、 gradeⅢ in5cases.
3.The enhanced MRI features of placenta:
a:Immediately after Gd-DTPA enhancement shows lobular placental enhancement;b:then shows homogeneous enhancement of the placenta in the second pregnancy and enhanced obviously placental lobule in third trimester pregnancy. C:Delayed scanning placenta and uterine muscular layer homogeneous enhancement.
4.Optical microscopy:
Placental sections with clear background and villus structure within the normal visible small infarction, calcification.
Conclusion:
1. T2WI images of MRI can clearly show the structure of three layers of placenta:the villous plate、placental parenchyma and placental basal layer。
2. Placental mature being a process of gradual change, the levels of maturity in the gestational age distribute in different extent and exist the mutual overlapping phenomenon.
Part2MRI Evaluation of Placental Adhesive Disorders Treated by Interventional Therapy
Objective:
l.To research MRI data of interventional therapy for patients with clinically suspected PADs and correlation between the evaluation of MRI diagnosis of PADs and operation and/or clinical diagnostic criteria.
2.To explore MRI signs before and after treatment intervention in postpartum PADs.
Material and Method
1. Subject
From2009April to2012April,30patients of interruption of pregnancy or postpartum have been collected, aged21to36years, averaged (30±4) years old, whose placenta were not complete or not delivery,having irregular vaginal bleeding.All patients underwent percutaneous bilateral uterine arterial chemoembolization interventional therapy and MRI examination within a week. In30patients, the first delivery of20cases, second deliveries of5cases,5cases of pregnancy abortion; history of induced abortion in21cases, history of cesarean section in10cases, history of operation of uterine leiomyoma in3cases,8cases complicated with placenta previa.
2. Main instrument and MR examination method
The Symphony1.5T superconducting magnetic resonance scanner of Siemens;phased-array coil with coronal, sagittal, and axial scanning, then were placenta vertical section, sagittal and transverse coronary scanning.
The parameter of T2WI imaging with HASTE sequence were TR:1000ms, TE:74ms, slice thick6mm, layer spacing1.8mm, FOV:35cm, matrix240x320, NEX1, Incentive2times,with the fat suppression, and flow compensation technique.All patients were Gd-DTPA enhancement and scan range from uterine bottom to symphysis pubis.
3.Signal intensity description and Image processing
All tissues of MRI signal intensity with the myometrium as control. Before diagnosis, diagnosis by two over and above high radiologists were not aware of operation and pathology, diagnosis of signal intensity, MRI placental location, morphology, site of implantation and uterine muscle wall and the adjacent organs may be affected. In order to clinical diagnosis and operation pathology results as the standard, to assess the diagnostic value of MRI.
4. Statistical analysis
Data analyses were performed by SPSS14.0and the statistical differences were considered as statistically significant when P value was<0.05.Applying Kappa statistic to compare pathology and clinical diagnosis standard and MRI diagnosis.
Result:
1.There were statistical differences in the correlation between the evaluation of MRI diagnosis of PADs and operation and/or clinical diagnosis,and Kappa=0.733, P=0.000.
2.Placenta accrete:MRI shown the myometrium signal integrity and the endometrial cavitysignal with irregular, fuzzy or discontinuous.
3.Placenta increte:MRI shown the myometrium signal irregular, the endometrial cavitysignal with discontinuous and the vessels through the myometrium.
4.Placenta percrete:MRI shown the myometrium local signal disappeared、the tissue of placenta beyond the myometrium and the adjacent bladder or bowel infiltrated.
5.On Gadolinium-enhanced T1WI,the placental tissue invaded the myometrium in the shape of "garland"or "nodul".
6.After interventional treatment the residual part of placenta implantation was the clear boundary and hypointense signal by comparing normal myometrial signal.
Conclusion
1. MRI features of before interventional therapy of PADs:with no rules, fuzzy or interrupt with the uterus (placenta accrete); uterine myometrium signal irregular or invasion, thin myometrium (placenta increte); normal myometrial local signal disappears completely, sometimes can display the bladder or bowel invasion (placenta percrete).
2MRI features of after interventional therapy of PADs:placenta implants and palace wall fusion, implantation and penetration of the myometrium remains visible mixed high signal, enhanced scan shows more clear, placenta implantation residue than normal myometrium enhanced signal is reduced, the boundary is clear
3. MRI can show the placental implantation site and myometrial invasion degree.There were statistical differences in the correlation between the evaluation of MRI diagnosis of PADs and operation and/or clinical diagnosis.MRI has an important reference value and can accurately evaluate curative effect before and after interventional therapy to placental adhesive disorders.
Part3Clinical study of transcatheter uterine artrey chemoembolization for postpartum placental adhesive disorders
Objective:
1. To explore treatment principle and operation skills by transcatheter uterine artrey chemoembolization for postpartum placental adhesive disorders.
2.To investigate clinical curative effect, complications and prognosis by transcatheter uterine artrey chemoembolization for postpartum placental adhesive disorders.
3. To explore the change of human chorionic gonadotropin-beta(β-hCG) before and after treatment by transcatheter uterine artrey chemoembolization for postpartum placental adhesive disorders.
Material and Method
1. Subject
From2009April to2012April,23patientsof placental adhesive disorders with postpartum hemorrhage have been collected, aged29to45years, averaged (34±3) years old, whose placenta were not complete delivery,having irregular vaginal bleeding.All patients underwent percutaneous uterine arterial chemoembolization interventional therapy。The mean gestational age(GA) was29±3.6weeks(range25-38).The patients were divided into the emergency group(7cases) and selective group(16cases).
Criteria for the diagnosis of PADs
1) the clinical manifestations, cesarean section postpartum placental or part and muscular wall adhesion, placenta forcibly stripping or clamp there is still residual, peeling, rough surface hemorrhage.
2) B ultrasound or MRI confirmed the diagnosis of uterine cavity residual placenta, invasive imaging changes of uterus muscle layer, and the unclear boundaries.
3) pathology, postpartum discharge tissue confirmed necrotic or old placental villus tissue.
Evaluation Criteria of curative effect of PADs
1) novalid:irregular menstruation, vaginal bleeding volume was not reduced, repeated ultrasound uterus shape is irregular, muscle layers thick, uterine artery embolization for the treatment of β-HCG level in the serum decreased significantly;
2) valid:follow-up for half a year, the basic rules of the menstruation, amount of bleeding in vagina reduction, repeated ultrasound uterine morphology, the myometrium close to normal; β-HCG levels in serum decreased significantly2weeks after uterine artery embolization in the treatment of4weeks later, close to the normal results;
3) effective:followed-up for half a year, return to normal menstrual cycle, the amount of vaginal bleeding was significantly reduced, repeated ultrasound uterine morphology, the myometrium returned to normal; β-HCG levels in2weeks in serum decreased rapidly after uterine artery embolization therapy,4weeks after seroconversion.
2. Methods of Treatment
The two groups were firstly treated with bilateral uterine artery angiography and then super selective perfusion of MTX with gelatin sponge embolization of uterine artery.After operation,all patients were observed with body temperature changes、 postoperative vaginal bleeding、menstruation、placenta, hospitalization time.
Routine preoperative establish intravenous access, indwelling catheter, sterilization shop towel, through the right femoral artery puncture, puncture and intubation of the Seldinger technology, using5.0F Cobra tube or uterine artery angiography tube were performed bilateral iliac artery angiography, display uterine artery after a microcatheter into the uterine artery, PADs showed irregular blood sinus or vascular lake, contrast agent concentration, venous phase staining persists, clear placental lesions after perfusion of30-50ML methotrexate (MTX) plus50ml physiological saline, with gelatin sponge embolization of uterine artery, DSA angiography was performed to peripheral arterial branches disappeared, hemorrhage and shock before blood transfusion patients fully, maintain the stability of blood pressure, emergency embolization. Embolism after a week in B ultrasound guided curettage
3.Treatment after Operation
After operation,all patients were given active support for symptomatic treatment, treated with analgesics and intravenous antibiotics,recorded with blood pressure, breath, pulse, body temperature, lower extremity arterial pulsation observed within24hours after operation,monitored with intrauterine change by ultrasound,recorded after3days,7days,2week,4weeks the serumβ-HCG value.
4Statistical analysis
SPSS14statistical software for data processing, P<0.05was statistically significant
(1) the emergency embolization group and selective embolization group: measurement data using T test, count data using Fisher's exact test.
(2) serumβ-hCG changes of patients before and after interventional therapy of PADs:at different time points within groups the use of Kruskal-Wallis H test, and further using Dunnett, s T3test for multiple comparisons.
Result
1.This group of23patients with interventional therapy were successful operation without hysterectomy.The mean operation time was60±5.8minutes(range50-80). We can find intraoperative angiography of uterine artery distal occlusion, vaginal bleeding after operation disappeared, hemorrhagic shock patients postoperatively back to normal、21cases recovered to normal after curettage of uterus.There were no bleeding of vagina by follow-up of2months.
The emergency embolization group and selective embolization group in blood transfusion (P=0.004), the amount of bleeding (P=0.00) and time of hospitalization (P=0.00) had significant difference, the average age of (P=0.95), the number of cesarean section (P=0.83), curettage times (P=1), there is no prefix the placenta (P=1) has no statistical significance.
2.The serum β-hCG change of research group at each time point had significant difference (K=52.576, P=0.00) before and after treatment in23cases; the study group before treatment and after treatment of3days, there were no significant differences in HCG (P=0.000), before treatment and after treatment7days difference (P=0.000), and after treatment2there are differences (P=0.000),3days after treatment and7days after treatment were (P=0.00), and after2weeks of therapy were (P=0.000),7days after treatment and2weeks after treatment also has difference (P=0.00),.
3.After Ultrasound or MRI scan,23cases of uterine cavity were no placental tissue residue, but there were5cases of myometrium is still visible residue of placenta and serump-HCG value returned to normal levels within5-6weeks after the delivery of the placenta. The20patients were followed up in5cases of pregnancy and birth of a healthy child.
4.Postoperative side effects:nausea, vomiting, fever and pain were common, gaven support for symptomatic treatment. The main complications associated with catheterization technique was hematoma.
Conclusion
1.Combining MTX perfusion with chemoembolization could be completely temporary occlusion of placental blood implantation,which could cause residual placental tissue the degeneration and necrosis or even fall-off.
2.Through uterine artery chemoembolization with high success rate,the patients could retain the uterus and fertility ability again, fewer complications, faster postoperative recovery, and can prevent PADs cause bleeding or uterine rupture risk; this group of patients is the emergency embolization and selective embolization in the amount of bleeding and hospitalization time have significant difference.
3.Monitoring chorionic gonadotropin numerical(β-hCG) could be used as one of indexes to judge clinical effect of PADs by chemoembolization therapy before and after operation because human chorionic gonadotropin (β-hCG) decreased significantly.
目的
1.分析探讨正常胎盘结构的MRI图像的信号特点与相关组织学之间关系。
2.分析胎儿胎盘成熟度不同分级的MRI表现。
3探讨中晚孕期胎盘成熟度MRI分级与孕周的关系。
资料与方法
1.研究对象
收集2009年4月至2012年4月50例孕19周以上孕妇MRI资料,均先行B超检查排除胎盘病变孕妇,其中妊娠19-23周为5例,24～31周为18例,32-35周19例,36-40周8例,均为单胎妊娠,50例孕妇年龄20-36岁,平均30.2岁。
2.主要仪器与设备
本研究使用Siemens Symphony1.5T超导型核磁共振扫描仪,相控阵线圈,后处理工作站为Siemens公司自带的LEONARDO工作站。
3.检查方法
MR检查方法
腹部常规三维定位采用GRE序列,MRI扫描序列包括：T1WI、T2WI横断、矢状及冠状位扫描,T2WI成像采用HASTE序列,主要参数为：TR:1000ms,TE:74ms,带宽630HZ/PX,层厚6mm,层间距1.8mm, FOV35cm,矩阵164×256,采集次数(NEX=1次),激励次数2次,同时采用脂肪抑制、流动补偿技术,部分病例行Gd-DTPA增强扫描,经肘静脉用高压注射器注入,注药速度2-3ml/s,剂量为0.1mmol/kg.
超声检查方法
孕妇仰卧位,患者检查前适度充盈膀胱,用二维常规腹部扫描,必要时经阴道超声检查,辅以彩色多普勒与三维超声进一步检查。主要测量子宫大小,胎盘大小,胎盘后间隙(子宫肌层低回声)是否存在、胎盘内部及周边血流信号情况。
4.标本处理
胎盘新鲜标本取材于正常人工流产和足月产后置入10%福尔马林液中固定,一次性石蜡包埋,连续切片,常规HE染色,光镜下观察。
5.统计学分析
采用SPSS14.0统计软件数据录入处理,P<0.05有统计学意义,采用Kruskal-Wallis H检验,对各孕周组之间胎盘成熟度MRI分级进行比较。
结果
1.MRI胎盘的分级法是以胎盘的绒毛板、胎盘实质及胎盘的基底层三部分结构的变化作为分级的依据,参照B超Grannum标准对胎盘成熟度进行分级。
2.根据T2WI显示的胎盘结构,本组50例正常中晚期胎盘MRI诊断0级胎盘4例、Ⅰ级胎盘18例、Ⅱ级胎盘23例、Ⅲ级胎盘5例。
3.增强后胎盘MRI特征：注入增强剂快速扫描,胎盘信号增高明显强化,胎盘显影早于邻近子宫肌层；即刻再次扫描,妊娠中期孕妇可显示均匀的胎盘强化,妊娠晚期孕妇可显示2-3CM大小的胎盘小叶强化明显；延迟扫描胎盘及子宫肌层均匀强化。
4.光镜下：中晚期胎盘切片背景清晰,绒毛形状纤细,分支增多变细,正常的绒毛结构内可见少量梗死、钙化灶,滋养层主要是合体细胞,间质为网状结缔组织,实质内血管可分辨区内外膜结构。
结论
1.MR检查图像可以清晰显示胎盘三层结构：胎盘实质,胎盘绒毛膜板,胎盘基底膜。
2.从0级至Ⅲ级,胎盘MR表现具有各自不同特征表现。
3.胎盘成熟为一渐变的过程,其各级成熟度在各孕周分布幅度不同,并有相互交叉重叠现象。
第二部分MRI在产后胎盘植入介入治疗前后的诊断价值
目的：
1.分析临床疑诊胎盘植入行介入治疗的患者MR]资料,评价MRI诊断胎盘植入与手术和/或临床综合诊断标准的相关性.
2.探讨MRI在产后胎盘植入介入治疗前后的影像征象.
资料与方法
1.研究对象
搜集2009年4月至2012年4月间30例妊娠中止或产后患者资料,年龄为21-36岁,平均(30±4)岁,临床发现人流或产后胎盘排出不全或未娩出,阴道不规则出血、临床拟诊为胎盘植入,全部病例均行经皮双侧子宫动脉化疗栓塞介入治疗术,介入治疗前后一周内分别行MRI检查。30例患者中首次分娩为20例,第2次分娩为5例,5例为中妊人流；曾有人流病史为21例,有剖宫产史10例,3例有子宫肌瘤手术史,8例合并有前置胎盘。
2.仪器及检查方法
使用西门子公司生产的Symphony1.5T超导型核磁共振扫描仪,相控阵线圈仰卧位扫描。常规扫描序列FLASH/T1WI (TR/TE:113ms/4.76ms), T2WI采用HASTE序列TR/TE:1000ms/74ms,层厚6mm,层间距1.8mm, NEX1次,FOV35cm,矩阵240-320,分别行横断位、矢状位、冠状位扫描,同时采用脂肪抑制、流动补偿技术,全部病例均行钆喷酸葡胺造影剂Gd-DTPA增强扫描,扫描范围由子宫底上约2cm至耻骨联合下。
3信号强度描述与图像处理
不同组织MRI信号强度均以同序列的子宫肌层信号强度为对照。由两名副高及以上的高年资影像科医师进行诊断分析、诊断之前均不知晓手术与病理结果,诊断观察MRI中胎盘的信号强度、位置、形态、植入部位和子宫肌壁及周围相邻器官可能受累情况等。以临床综合诊断或手术病理结果为标准,评价MRI的诊断价值。
4统计学分析
采用SPSS14.0软件分析处理,采用Kappa统计量评估MRI的检查结果与病理及临床综合诊断标准比较的一致性,P<0.05为差异有统计学意义。
结果
1.MRI诊断胎盘植入与临床或病理结果相关性Kappa=0.733, P=0.000,有统计学意义。
2.粘性性胎盘：MRI显示子宫肌层信号完整,子宫内结合带不规则、模糊或中断,子宫肌层也可局部呈受压改变。
3.植入性胎盘：MRI显示子宫肌层信号不规则或受侵,子宫肌层变薄,子宫结合带信号中断,可有流空血管影穿过肌层。
4.穿透性胎盘：MRI显示胎盘位于子宫肌层信号带外,正常子宫肌层信号局部完全消失,有时可显示膀胱或肠道受侵。
5.增强扫描,表现为明显强化,呈“花环状”或“结节状”强化。
6.介入治疗后复查：胎盘植入残留部分较正常子宫肌层增强信号减低,边界较清晰。
结论
1.MRI诊断胎盘植入准确性较高,结合增强扫描可以准确的判断子宫肌层受侵的情况,与手术和/或临床综合诊断标准有相关性,MRI影像可以反映胎盘植入介入治疗前后的的病理改变,为胎盘植入诊断及介入治疗的疗效评价提供可靠依据及指导,具有较高的临床价值。
2.介入治疗前胎盘植入MRI征象：子宫内结合带不规则、模糊或中断(粘连性胎盘植入)；子宫肌层信号不规则或受侵,子宫肌层变薄(植入性胎盘植入)；正常子宫肌层信号局部完全消失,有时可显示膀胱或肠道受侵(穿透性胎盘植入)
3.介入治疗后胎盘植入MRI征象：植入胎盘与宫壁融合、植入及穿透部分子宫肌层仍可见混杂高信号,增强扫描显示更加清晰,胎盘植入残留部分较正常子宫肌层增强信号减低,边界较清晰.
第三部分产后胎盘植入子宫动脉途径介入治疗的临床研究
目的
1.分析产后胎盘植入的子宫动脉途径介入治疗原理、手术操作技巧。
2.探讨产后胎盘植入子宫动脉途径介入治疗的临床疗效、并发症及预后改变。
3.分析绒毛膜促性腺激素(β-hCG)检测值在产后胎盘植入介入治疗前后改变及临床应用价值。
资料与方法
1.研究对象
2009年4月-2012年4月间我院妇产科23例胎盘植入合并产后出血患者,年龄29-45岁(平均34±3)岁,终止妊娠时孕周为25-38周,平均(29±3.6)周。临床表现为产后胎盘未完全排除,阴道流血,均行子宫动脉化疗栓塞术,23例患者分为急诊栓塞组和择期栓塞两组,急诊栓塞组7例,择期栓塞组16例。
胎盘植入诊断标准
1)临床表现,剖宫产或产后发现胎盘部分与肌壁粘连,胎盘组织强行剥离或钳夹仍有残留,剥离面出血、粗糙。
2)B超或MRI检查证实子宫腔内有残留胎盘组织,有侵入性影像学改变,与子宫肌层分界不清。
3)病理检查,产后排出组织证实为坏死性或陈旧性胎盘绒毛组织。
胎盘植入疗效评价标准
1)无效：月经不规则,阴道的流血量无明显减少,复查超声子宫形态仍不规则、肌层较厚,子宫动脉栓塞术治疗后血清中β-HCG水平下降不明显；
2)有效：随访半年,月经周期基本规律,阴道的流血量减少,复查超声子宫形态、肌层接近正常；子宫动脉栓塞术治疗后2周血清中β-HCG水平明显下降,4周后基本接近正常；
3)显效：随访半年,月经周期恢复正常,阴道的流血量显著减少,复查超声子宫形态、肌层恢复正常；子宫动脉栓塞术治疗后2周血清中β-HCG水平迅速下降,4周后转阴。
2.治疗方法子宫动脉化疗灌注栓塞术
术前常规建立静脉通道、留置导尿管,消毒铺中,经右侧股动脉穿刺,行Seldinger技术穿刺插管,选用5.0FCobra管或子宫动脉造影管分别行双侧髂动脉造影,显示子宫动脉后经微导管超选择进入子宫动脉内,胎盘植入处可见不规则的血窦或血管湖,造影剂浓聚,静脉期染色持续存在,明确胎盘病变后灌注30-50m1甲氨喋呤(MTX)加50m1生理盐水,选用明胶海绵栓塞子宫动脉,DSA造影复查至末梢分支血管消失为止,大出血伴休克患者术前输血充分,维持血压稳定,急诊行栓塞治疗。栓塞后一周内在B超引导下行清宫术治疗。
3.术后处理
本组23例患者,术后积极支持对症处理,疼痛患者给予曲马多或杜冷丁止痛,术后3天静脉滴注抗生素给予常规预防感染治疗,记录患者的血压、呼吸、脉搏、体温,术后24小时内观察下肢动脉搏动,术后3天、7天、2周复查血清β-HCG值,定期复查肝肾功能,B超检查监测宫腔内变化。术后观察患者阴道出血量、月经来潮、胎盘排出、住院时间等。
4.统计学分析采用
SPSS14.0统计软件数据录入处理,P<0.05有统计学意义,
(1)急诊栓塞组与择期栓塞组比较：计量资料采用T检验,计数资料采用fisher精确检验。
(2)胎盘植入患者介入治疗前后血清β-hCG变化情况：组内不同时间点血β-hCG的比较使用Kruskal-Wallis H检验,并进一步采用Dunnett,s T3法进行多重比较。
结果
1.本组23例患者介入治疗均手术成功,无1例子宫切除,手术时间50-80分钟,平均(60±5.8)分钟,术中造影见子宫动脉末梢闭塞,术后阴道活动性出血停止,4例失血性休克患者术后生命体征恢复正常,21例清宫术后子宫恢复正常,清出组织含有胎盘蜕膜或绒毛,随访2月余,阴道均无出血。
急诊栓塞组和择期栓塞组在输血(P值=0.004)、出血量(P值=0.00)和住院治疗时间(P值=0.00)有显著差别,平均年龄(P值=0.95)、刮宫产次数(P值=0.83)、清宫术次数(P值=1)、有无前置胎盘(P值=1)无统计学意义。
2.23例产后胎盘植入患者介入治疗前后血清p-hCG变化研究组各个时间点HCG存在差异(卡方=52.576,P=0.00)；研究组治疗前与治疗后3天HCG有统计学差异(P=0.000),治疗前与治疗后7天存在差异(P=0.000)、与治疗后2周有差异(P=0.000),治疗后3天与治疗后7天有差异(P=0.00)、与治疗后2周有差异(P=0.00),治疗后7天与治疗后2周也有差异(P=0.00),总之：治疗前与治疗后3天、治疗后7天、治疗后2周有统计学差异。
3.超声或MRI复查,23例宫腔内均未见胎盘组织残留,但有5例肌壁仍可见残留胎盘组织,复查血清β-HCG值显示在胎盘排出后2-3周后基本恢复正常水平。随访的20例患者中有5例再次怀孕并产下健康婴儿.
4.术后不良反应：恶心、呕吐较常见,疼痛、发热给予支持对症处理。与插管技术相关的并发症主要为血肿。
结论1.MTX灌注联合栓塞介入治疗可完全临时阻断植入胎盘动脉血供,使残余胎盘组织缺血、变性、坏死甚至脱落.
2.产后胎盘植入子宫动脉途径介入治疗成功率高,大多数患者保留了子宫及再次生育的能力,并发症少,术后恢复快,同时可预防植入胎盘导致的大出血或子宫破裂风险；本组病例发现急诊栓塞和择期栓塞在出血量和住院治疗时间有显著差异.
3.产后胎盘植入介入治疗前后绒毛膜促性腺激素(β-hCG)下降显著,绒毛膜促性腺激素数值监测可以作为胎盘植入介入治疗临床疗效判断的指标之一.
Part1MRI findings and histologic basis of placenta
Object:
1.To analyse the clinic value of MRI findings and histologic basis of normal placenta.
2.Analysis of fetal placental maturity of different grades of MRI, to explore the relationship between MRI classification and the gestational age in the second and third trimester
Material and Method:
1.Subject
From April2009to April2012,50singleton pregnancies of after19gestational age have been collected by MRI,their mean age were30.2years old(rang20-36),the19-23gestational age(GA)for5cases,24～31GA for18cases,32～35GA for19cases,36-40GA for8cases,.
2.Main instrument and equipment
The Symphony1.5T superconducting magnetic resonance scanner of Siemens;phased-array coil with coronal, sagittal, and axial scanning, then were placenta vertical section, sagittal and transverse coronary scanning.Image postprocessing was done through the Functool software of Siemens company's LEONARDO workstation.
3.MR examination method
The3D positioning using GRE sequence, MRI scanning sequences included: T1WI, T2WI (transverse, sagittal and coronal scan)
The parameter of T2WI imaging with HASTE sequence were TR:1000ms, TE:74ms, slice thick6mm, layer spacing1.8mm, FOV:35cm, matrix164×256, NEX1, Incentive2times,with the fat suppression, and flow compensation technique. Some patients were Gd-DTPA enhancement.
Ultrasonic examination method
Gravida supine, patients examined before proper filling of bladder, using two-dimensional routine abdominal scan, when necessary, transvaginal ultrasonography, combined with color Doppler and three-dimensional ultrasound further examination. The main measurement of uterine size, size of the placenta, placenta after clearance (muscular layer of uterus, placenta low echo) the existence of internal and peripheral blood flow signal.
4. Pathology examination
Placenta fresh specimens fixed in10%formalin were obtained from normal full-term pregnancy abortion and postpartum,which were disposable paraffin-embedded、routine HE stainned and observed under Optical microscope.
5. Statistical analysis
Data analyses were performed by SPSS14.0and the statistical differences were considered as statistically significant when P value was<0.05.Applying Kruskal-Wallis H statistic to compare between each gestational weeks placental mature grading by MRI.
Result
1.According to Grannum standard of ultrasonography of placental mature grading, MRI in placenta maturity grading is changes in the villous plate, the placental parenchyma and placental basal layer as the classification basis.
2.According to the placental structure of T2WI,50cases of normal placenta MRI grading included grade o in4cases、grade Ⅰ in18cases、grade Ⅱ in23cases、 gradeⅢ in5cases.
3.The enhanced MRI features of placenta:
a:Immediately after Gd-DTPA enhancement shows lobular placental enhancement;b:then shows homogeneous enhancement of the placenta in the second pregnancy and enhanced obviously placental lobule in third trimester pregnancy. C:Delayed scanning placenta and uterine muscular layer homogeneous enhancement.
4.Optical microscopy:
Placental sections with clear background and villus structure within the normal visible small infarction, calcification.
Conclusion:
1. T2WI images of MRI can clearly show the structure of three layers of placenta:the villous plate、placental parenchyma and placental basal layer。
2. Placental mature being a process of gradual change, the levels of maturity in the gestational age distribute in different extent and exist the mutual overlapping phenomenon.
Part2MRI Evaluation of Placental Adhesive Disorders Treated by Interventional Therapy
Objective:
l.To research MRI data of interventional therapy for patients with clinically suspected PADs and correlation between the evaluation of MRI diagnosis of PADs and operation and/or clinical diagnostic criteria.
2.To explore MRI signs before and after treatment intervention in postpartum PADs.
Material and Method
1. Subject
From2009April to2012April,30patients of interruption of pregnancy or postpartum have been collected, aged21to36years, averaged (30±4) years old, whose placenta were not complete or not delivery,having irregular vaginal bleeding.All patients underwent percutaneous bilateral uterine arterial chemoembolization interventional therapy and MRI examination within a week. In30patients, the first delivery of20cases, second deliveries of5cases,5cases of pregnancy abortion; history of induced abortion in21cases, history of cesarean section in10cases, history of operation of uterine leiomyoma in3cases,8cases complicated with placenta previa.
2. Main instrument and MR examination method
The Symphony1.5T superconducting magnetic resonance scanner of Siemens;phased-array coil with coronal, sagittal, and axial scanning, then were placenta vertical section, sagittal and transverse coronary scanning.
The parameter of T2WI imaging with HASTE sequence were TR:1000ms, TE:74ms, slice thick6mm, layer spacing1.8mm, FOV:35cm, matrix240x320, NEX1, Incentive2times,with the fat suppression, and flow compensation technique.All patients were Gd-DTPA enhancement and scan range from uterine bottom to symphysis pubis.
3.Signal intensity description and Image processing
All tissues of MRI signal intensity with the myometrium as control. Before diagnosis, diagnosis by two over and above high radiologists were not aware of operation and pathology, diagnosis of signal intensity, MRI placental location, morphology, site of implantation and uterine muscle wall and the adjacent organs may be affected. In order to clinical diagnosis and operation pathology results as the standard, to assess the diagnostic value of MRI.
4. Statistical analysis
Data analyses were performed by SPSS14.0and the statistical differences were considered as statistically significant when P value was<0.05.Applying Kappa statistic to compare pathology and clinical diagnosis standard and MRI diagnosis.
Result:
1.There were statistical differences in the correlation between the evaluation of MRI diagnosis of PADs and operation and/or clinical diagnosis,and Kappa=0.733, P=0.000.
2.Placenta accrete:MRI shown the myometrium signal integrity and the endometrial cavitysignal with irregular, fuzzy or discontinuous.
3.Placenta increte:MRI shown the myometrium signal irregular, the endometrial cavitysignal with discontinuous and the vessels through the myometrium.
4.Placenta percrete:MRI shown the myometrium local signal disappeared、the tissue of placenta beyond the myometrium and the adjacent bladder or bowel infiltrated.
5.On Gadolinium-enhanced T1WI,the placental tissue invaded the myometrium in the shape of "garland"or "nodul".
6.After interventional treatment the residual part of placenta implantation was the clear boundary and hypointense signal by comparing normal myometrial signal.
Conclusion
1. MRI features of before interventional therapy of PADs:with no rules, fuzzy or interrupt with the uterus (placenta accrete); uterine myometrium signal irregular or invasion, thin myometrium (placenta increte); normal myometrial local signal disappears completely, sometimes can display the bladder or bowel invasion (placenta percrete).
2MRI features of after interventional therapy of PADs:placenta implants and palace wall fusion, implantation and penetration of the myometrium remains visible mixed high signal, enhanced scan shows more clear, placenta implantation residue than normal myometrium enhanced signal is reduced, the boundary is clear
3. MRI can show the placental implantation site and myometrial invasion degree.There were statistical differences in the correlation between the evaluation of MRI diagnosis of PADs and operation and/or clinical diagnosis.MRI has an important reference value and can accurately evaluate curative effect before and after interventional therapy to placental adhesive disorders.
Part3Clinical study of transcatheter uterine artrey chemoembolization for postpartum placental adhesive disorders
Objective:
1. To explore treatment principle and operation skills by transcatheter uterine artrey chemoembolization for postpartum placental adhesive disorders.
2.To investigate clinical curative effect, complications and prognosis by transcatheter uterine artrey chemoembolization for postpartum placental adhesive disorders.
3. To explore the change of human chorionic gonadotropin-beta(β-hCG) before and after treatment by transcatheter uterine artrey chemoembolization for postpartum placental adhesive disorders.
Material and Method
1. Subject
From2009April to2012April,23patientsof placental adhesive disorders with postpartum hemorrhage have been collected, aged29to45years, averaged (34±3) years old, whose placenta were not complete delivery,having irregular vaginal bleeding.All patients underwent percutaneous uterine arterial chemoembolization interventional therapy。The mean gestational age(GA) was29±3.6weeks(range25-38).The patients were divided into the emergency group(7cases) and selective group(16cases).
Criteria for the diagnosis of PADs
1) the clinical manifestations, cesarean section postpartum placental or part and muscular wall adhesion, placenta forcibly stripping or clamp there is still residual, peeling, rough surface hemorrhage.
2) B ultrasound or MRI confirmed the diagnosis of uterine cavity residual placenta, invasive imaging changes of uterus muscle layer, and the unclear boundaries.
3) pathology, postpartum discharge tissue confirmed necrotic or old placental villus tissue.
Evaluation Criteria of curative effect of PADs
1) novalid:irregular menstruation, vaginal bleeding volume was not reduced, repeated ultrasound uterus shape is irregular, muscle layers thick, uterine artery embolization for the treatment of β-HCG level in the serum decreased significantly;
2) valid:follow-up for half a year, the basic rules of the menstruation, amount of bleeding in vagina reduction, repeated ultrasound uterine morphology, the myometrium close to normal; β-HCG levels in serum decreased significantly2weeks after uterine artery embolization in the treatment of4weeks later, close to the normal results;
3) effective:followed-up for half a year, return to normal menstrual cycle, the amount of vaginal bleeding was significantly reduced, repeated ultrasound uterine morphology, the myometrium returned to normal; β-HCG levels in2weeks in serum decreased rapidly after uterine artery embolization therapy,4weeks after seroconversion.
2. Methods of Treatment
The two groups were firstly treated with bilateral uterine artery angiography and then super selective perfusion of MTX with gelatin sponge embolization of uterine artery.After operation,all patients were observed with body temperature changes、 postoperative vaginal bleeding、menstruation、placenta, hospitalization time.
Routine preoperative establish intravenous access, indwelling catheter, sterilization shop towel, through the right femoral artery puncture, puncture and intubation of the Seldinger technology, using5.0F Cobra tube or uterine artery angiography tube were performed bilateral iliac artery angiography, display uterine artery after a microcatheter into the uterine artery, PADs showed irregular blood sinus or vascular lake, contrast agent concentration, venous phase staining persists, clear placental lesions after perfusion of30-50ML methotrexate (MTX) plus50ml physiological saline, with gelatin sponge embolization of uterine artery, DSA angiography was performed to peripheral arterial branches disappeared, hemorrhage and shock before blood transfusion patients fully, maintain the stability of blood pressure, emergency embolization. Embolism after a week in B ultrasound guided curettage
3.Treatment after Operation
After operation,all patients were given active support for symptomatic treatment, treated with analgesics and intravenous antibiotics,recorded with blood pressure, breath, pulse, body temperature, lower extremity arterial pulsation observed within24hours after operation,monitored with intrauterine change by ultrasound,recorded after3days,7days,2week,4weeks the serumβ-HCG value.
4Statistical analysis
SPSS14statistical software for data processing, P<0.05was statistically significant
(1) the emergency embolization group and selective embolization group: measurement data using T test, count data using Fisher's exact test.
(2) serumβ-hCG changes of patients before and after interventional therapy of PADs:at different time points within groups the use of Kruskal-Wallis H test, and further using Dunnett, s T3test for multiple comparisons.
Result
1.This group of23patients with interventional therapy were successful operation without hysterectomy.The mean operation time was60±5.8minutes(range50-80). We can find intraoperative angiography of uterine artery distal occlusion, vaginal bleeding after operation disappeared, hemorrhagic shock patients postoperatively back to normal、21cases recovered to normal after curettage of uterus.There were no bleeding of vagina by follow-up of2months.
The emergency embolization group and selective embolization group in blood transfusion (P=0.004), the amount of bleeding (P=0.00) and time of hospitalization (P=0.00) had significant difference, the average age of (P=0.95), the number of cesarean section (P=0.83), curettage times (P=1), there is no prefix the placenta (P=1) has no statistical significance.
2.The serum β-hCG change of research group at each time point had significant difference (K=52.576, P=0.00) before and after treatment in23cases; the study group before treatment and after treatment of3days, there were no significant differences in HCG (P=0.000), before treatment and after treatment7days difference (P=0.000), and after treatment2there are differences (P=0.000),3days after treatment and7days after treatment were (P=0.00), and after2weeks of therapy were (P=0.000),7days after treatment and2weeks after treatment also has difference (P=0.00),.
3.After Ultrasound or MRI scan,23cases of uterine cavity were no placental tissue residue, but there were5cases of myometrium is still visible residue of placenta and serump-HCG value returned to normal levels within5-6weeks after the delivery of the placenta. The20patients were followed up in5cases of pregnancy and birth of a healthy child.
4.Postoperative side effects:nausea, vomiting, fever and pain were common, gaven support for symptomatic treatment. The main complications associated with catheterization technique was hematoma.
Conclusion
1.Combining MTX perfusion with chemoembolization could be completely temporary occlusion of placental blood implantation,which could cause residual placental tissue the degeneration and necrosis or even fall-off.
2.Through uterine artery chemoembolization with high success rate,the patients could retain the uterus and fertility ability again, fewer complications, faster postoperative recovery, and can prevent PADs cause bleeding or uterine rupture risk; this group of patients is the emergency embolization and selective embolization in the amount of bleeding and hospitalization time have significant difference.
3.Monitoring chorionic gonadotropin numerical(β-hCG) could be used as one of indexes to judge clinical effect of PADs by chemoembolization therapy before and after operation because human chorionic gonadotropin (β-hCG) decreased significantly.
引文
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