The Diagnosis Of Cesarean Scar Pregnancy By Using MRI And Risk Factors Analysis Of Cesarean Scar Pregnancy

Object1、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 equipment24patients 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 method28cases 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 analysisAt 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 MRI1) 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 bladderAmong23cystic 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 treatmentPART TWOA comparative study of the Value of MRI in the diagnosis of Cesarean sac pregnancy and transvaginal ultrasoundObject: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 equipment24patients 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 method28cases 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 procedure21of28cases 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.Results1、MRI findings of gestation sacAmong28cases, 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 sacAmong28cases, 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 scarsIn27of28cases, 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 cavity3、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 pregnancyObject: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 methods1、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 abruption4、used two sets of information for independent samples t test and observed if there is significant difference in terms of risk between the two groups5、analyzed the CSP-related risk factors by using Logist regression1、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.