First-trimester versus second- and third-trimester pregnancy in prenatal ultrasonographic features of placenta accreta
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摘要:目的 比较孕早期和孕中晚期胎盘植入的产前超声特点及预后影响因素。方法 回顾性分析120例胎盘植入患者的临床资料, 其中孕早期18例，孕中晚期102例。所有孕妇均行产前超声检查，比较产前超声对不同孕期胎盘植入的诊断效能，分析超声特点。随访产妇预后并分析胎盘植入产妇预后的相关影响因素。结果 与孕中晚期胎盘植入相比，孕早期胎盘植入的超声检出率更低。孕早期胎盘植入的超声特征以妊娠囊位置低为主，其次为前壁肌层变薄，然后是胎盘内低回声区或透声区(类陷窝)、蜕膜-子宫/胎盘-子宫界面不规则。孕中晚期胎盘植入的超声特征以胎盘内漩涡形成为主，其次为胎盘与子宫肌层、宫颈组织界限不清且周围的血流信号丰富，胎盘后间隙消失，胎盘异常增厚。多因素分析显示，剖宫产史、产后出血、前置胎盘均是胎盘植入孕妇预后不良的危险因素，而前壁胎盘、诊断者有经验则是保护性因素。结论 孕早期和孕中晚期胎盘植入的产前超声特征有较大差异，剖宫产史、胎盘附着位置、产后出血、前置胎盘及诊断者经验是影响胎盘植入孕妇预后的主要因素。Abstract:Objective To compare the prenatal ultrasonographic features and prognostic factors of placenta accreta between first-trimester pregnancy and second-, third-trimester pregnancy.Methods The clinical materials of 120 patients with placenta accreta were analyzed retrospectively, including 18 cases in first-trimester pregnancy and 102 cases in second-, third-trimester pregnancy. All the pregnant women were conducted with prenatal ultrasound examination, the efficacy of prenatal ultrasound in diagnosing placenta accreta during different periods of pregnancy was compared, and the ultrasonic characteristics were analyzed. The prognosis of pregnant women was followed up and the related factors of prognosis in pregnant women with placenta accreta were analyzed.Results Compared with pregnant women with placenta accreta in second- and third-trimester pregnancy, the ultrasonic detection rate of placental accreta in the first-trimester pregnancy was lower. The ultrasonic features of placental accreta in the first-trimester pregnancy were mainly the low position of gestational sac, followed by the thinning of anterior wall muscle layer, the low echo area or sound transmission area (lacunae like) in the placenta, and the irregular decidua uterus or placenta uterus interface. The ultrasonic features of placental accreta in the second- and third-trimester pregnancy were mainly the formation of intraplacental vortex, followed by unclear boundary between placenta and uterine myometrium and cervical tissue, rich peripheral blood flow signals, disappearance of retroplacental space and abnormal thickening of placenta. Multivariate analysis showed that the history of cesarean section, postpartum hemorrhage and placenta previa were the risk factors for poor prognosis of pregnant women with placenta accreta, while the anterior wall placenta and the experience of the diagnostician were the protective factors.Conclusion There are great differences in prenatal ultrasonic characteristics of placental accreta between the first-trimester pregnancy and second-, third-trimester pregnancy. The history of cesarean section, placental attachment, postpartum hemorrhage, placenta previa and the experience of the diagnostician are the main factors affecting the prognosis of pregnant women with placental accreta.
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表 1 孕早期与孕中晚期胎盘植入的超声诊断情况比较[n(%)]
孕期 检出 未检出 孕早期(n=18) 12(66.67) 6(33.33) 孕中晚期(n=102) 98(96.08)* 4(3.92)* 与孕早期比较, *P < 0.05。 
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表 2 孕早期与孕中晚期胎盘植入的超声特征比较[n(%)]
孕期 超声图像特征 检出结果 孕早期 妊娠囊位置低 10(55.56) (n=18) 前壁肌层变薄 4(22.22) 胎盘内低回声区或透声区(类陷窝) 3(16.67) 蜕膜-子宫/胎盘-子宫界面不规则 3(16.67) 孕中晚期 胎盘内漩涡形成 61(59.80) (n=102) 胎盘与子宫肌层、宫颈组织界限不清，且周围的血流信号丰富 40(39.22) 胎盘后间隙消失 36(35.29) 胎盘异常增厚 16(15.69)
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表 3 影响胎盘植入孕妇预后的单因素分析[n(%)]
因素 n 预后不良组(n=13) 预后良好组(n=107) 产后出血 有 28 10(76.92) 18(16.82)* 无 92 3(23.08) 89(83.18)* 分娩史 有 46 6(46.15) 40(37.38) 无 74 7(53.85) 67(62.62) 剖宫产史 有 31 8(61.54) 23(21.50)* 无 89 5(38.46) 84(78.50)* 前置胎盘 是 50 9(69.23) 41(38.32)* 否 70 4(30.77) 66(61.68)* 前壁胎盘 是 44 3(23.08) 41(38.32)* 否 76 10(76.92) 66(61.78)* 诊断者经验 有 41 1(7.69) 40(37.38)* 无 79 12(92.31) 67(62.62)* 与预后不良组比较, *P < 0.05。
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表 4 胎盘植入预后不良的多因分析结果
变量 β S. E. Wald P OR 95%CI 产后出血 3.514 0.558 11.286 < 0.001 33.582 30.024~38.925 剖宫产史 2.711 0.412 15.605 < 0.001 10.908 8.547~15.998 前置胎盘 2.658 0.305 28.573 < 0.001 14.278 11.589~19.501 前壁胎盘 -1.905 0.214 41.598 < 0.001 6.719 4.362~9.224 诊断者经验 -2.032 0.427 11.145 < 0.001 7.629 5.017~10.804
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