Clinical Application Of Ultrasound In Preoperative Diagnosis, Risk Assessment And Long - Term Follow - Up Of Cesarean Section Scar Pregnancy

Objective:To explore the role of two-dimensional and three-dimensional transvaginal ultrasound in the differential diagnosis of cesarean scar pregnancy and other pregnancies implanted in the lower part of the uterus.Methods:Ninety-three patients with a history of one or more cesarean sections whose gestational sac was in the lower part of the uterus in the early pregnancy were prospectively collected. The gestational sac implantation location, the relationship between the gestational sac and cesarean scar, the source of trophoblastic blood flow and the residual muscular thickness were evaluated by two-dimensional and three-dimensional transvaginal ultrasound. The cases were divided into two groups:cesarean scar pregnancy and other pregnancies implanted in the lower part of uterus according to the subsequent treatment outcome. The chorionic villus within the scar in the laparotomy or laparoscope was considered as the gold standard for diagnosis. The alternative diagnostic criteria was that the blood loss was greater than 100ml during dilation and curettage. If a case didn’t meet the above standard, it was regarded as the other pregnancy implanted into the lower part of the uterus, which included two situations: firstly, the gestational sac was implanted in the anterior lower part of the uterus near the cesarean scar; Secondly, the gestational sac was implanted in the posterior lower part of the uterus. The difference of the gestational sac implantation location, the relationship between the gestational sac, the source of the trophblastic blood flow and the residual muscular thickness was compared between the cesarean scar pregnancy group and the group of other pregnancies implanted in the lower part of the uterus. The reliability of two-dimensional and three-dimensional ultrasonic indicators was calculated. The sensitivity, specificity, positive predicative value and negative predicative value of ultrasonic indicators were calculated. The diagnostic model was established by the logistic regression analysis and the diagnostic efficiency of the model was evaluated by the receiver operating characteristic curve.Results:Sixty-six cesarean scar pregnancies and twenty-seven other pregnancies implanted in the lower part of the uterus were enrolled in the study. In the cesarean scar pregnancy group,15/66 was located in the anterior lower part,7/66 was located in the posterior lower part and 44/66 was uncertain about the implantation location evaluated by the two-dimensional ultrasound; in the group of other pregnancies implanted in the lower part of the uterus,3/27 was located in the anterior lower part,5/27 was located in the posterior lower part and 19/27 was uncertain about the implantation location evaluated by the two-dimensional ultrasound. There is no significant statistical difference between the two groups(P>0.05). In the cesarean scar pregnancy group,4/66 was close to or crossing the scar,62/66 was implanted in the scar; in the group of other pregnancies implanted in the lower part of the uterus,11/27 was close to or crossing the scar,16/27 was implanted in the scar. There were significant differences between the two groups(P <0.05). In the cesarean scar group,58/66 trophblastic blood flow was from the anterior lower part,3/66 was from the posterior lower part and 5/66 was uncertain; in the group of other pregnancies implanted in the lower part of the uterus,11/27 trophblastic blood flow was from the anterior lower part,12/27 was from the posterior lower part and 4/27 was uncertain. There were significant differences between the two groups (P<0.05). The residual muscular thickness was significant different between the cesarean scar group and the group of other pregnancies implanted in the lower part of the uterus(1.6±1.0mm vs 3.4±1.8mm, P<0.05). The relationship between the gestational sac and the scar, the source of trophblastic blood flow and the residual muscular thickness were selected as the diagnostic indicators by Logistic regression model. The area under the receiver operating characteristic curve of Logistic regression model is 0.863, higher than that of the residual muscular thickness as an independent indicator. When P=0.680 as the cutoff value, the diagnostic accuracy was 86%; the sensitivity, specificity, positive predictive value, and negative predictive value was 90.9%,74.1%,89.6%,76.9%, higher than that of each independent indicator. The Kappa of the relationship between the gestational sac and cesarean scar and the source of trophblastic flow blood was 0.774,0.736. The ICC of the residual muscular thickness was 0.997. The above diagnostic indicator of the two-dimensional and three-dimensional ultrasound had a good consistency.Conclusion:The combined use of ultrasonic indicators such as the relationship between the gestational sac and cesarean scar, the source of the trophblastic blood flow and the residual muscular thickness better contributed to the differential diagnosis in cesarean scar and other pregnancies implanted in the lower part of the uterus.Objective:To investigate the clinical value of ultrasonography in the massive haemorrhage of cesarean scar pregnancy.Material and Methods:Clinical and ultrasonograhic data of 119 cesarean scar pregnancy patients were retrospective analysed. According to whether the amount of bleeding during operation was more than 400ml or not, these patients were divided into two groups:massive hemorrhage group and non-massive hemorrhage group. Analysis the risk factors related to massive hemorrhage with Logistic Regression and evaluate the model by receiver operating characteristic curve.Results:There were significant differences between the massive hemorrhage group and non-massive hemorrhage group in the lesion size(49.0±5.9cm vs 25.9±16.7cm), the lesion type(the endogenous type 3/34、the exogenous type 11/34、the mass type 20/34 vs the endogenous type 25/85、the exogenous type 35/85、the mass type 25/85), the residual muscular thickness(0.9±0.8cm vs 3.0±2.0cm), and the flow grade(Ⅰ grade 0/34、 Ⅱ grade 9/34、 Ⅲgrade 25/34 vs Ⅰ grade 25/85、Ⅱ grade 37/85、Ⅲ grade 24/85)(P< 0.05). There were no significant differences between the massive hemorrhage group and non-massive hemorrhage group in β-HCG(48423±76288 vs 23356±31003) and treatment(curettage 12/34、surgery 22/34 vs curettage 48/85、surgery 37/85)(P>0.05). The size, type of lesions, flow grade and residual muscular thickness were screened as risk factors by Logistic Regression model. If apply P=0.3 as cutoff, the diagnostic accuracy, the sensitivity, specificity, positive predictive value, and negative predictive value was 90.75%,88.23%,91.76%,81.08%,95.12%.Conclusion:Ultrasonography can accurately predict the risk of massive hemorrhage during the operation of cesarean scar pregnancy.Objective:To explore whether scar repair while treating cesarean scar pregnancy could contribute to scar healing.Material and Methods:Forty patients who had finished cesarean scar pregnancy treatment for more than half a year were prospectively included in this study. According to the prior therapeutic method, these patients were divided into surgery group (n=19) and curettage group (n=21). The differences of scar shape and residual myometrium between two groups were evaluated by saline infusion sonohysterography. Based on the ratio between the thickness of the remaining myometrium over the scar and the sickness of the myometrium adjacent to the scar, A scar can be classified as large(the ratio<50%);small(the ratio> 50%); intact(no thinning myometrium).Results:Between the two groups, the scar length, width, depth, volume, the residual myometrial thickness and the ratio between the thickness of the remaining myometrium over the scar and the thickness of the myometrium adjacent to the scar were not statistically different (all P>0.05), In the surgery group, there are eight big defect scars and eleven small defect scars or intact scars, In the curettage group, there are six big defect scars and fifteen small defect scars or intact scars, and there were no significant differences in the scar types(x2=0.80, P=0.37).Conclusion:Scar repair not contribute to improve the scar healing in treating cesarean scar pregnancy.