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[摘要] 目的 探讨经阴道彩色多普勒超声诊断输卵管妊娠的临床价值。方法 分析经腹腔镜证实为异位妊娠患者54例的超声表现,并对其中44例附件包块的血流进行分析。结果 54例患者中有44例在一侧出现混合性包块,占81%,其中32例包块内及包块周围显示增多的血流信号,测得包块内的血流阻力指数(RI)=0.38±0.03,12例包块内少许星状血流信号,经腹腔证实其中10例已发生输卵管流产。结论 包块内RI<0.41可作为诊断宫外孕的依据,而包块内探不到血流信号,则可能发生输卵管流产,经阴道彩色多普勒可增加发现输卵管妊娠的敏感性.
[关键词] 经阴道彩色多普勒;输卵管;异位妊娠
[中图分类号] R714.221[文献标识码] A[文章编号] 1673-9701(2009)34-73-02
Value in Transvaginal Dupple Ultrasonography for Diagnosis of Tubal Pregnancy
WANG ChunhongYIN MingLI Qin
Department of Ultrasound,Taizhou Municipal People’s Hospital,Taizhou 225300,China
[Abstract] Objective To probe into the application value of transvaginal Dupple ultrasonography in the diagnosis of tubal pregnancy. Methods We analyzed the ultrasonographyin 54 cases of ectopic pregnancy confirmed by laparoscopy and the blood flow ofadnexal mass in 44 of 54 cases. Results The mixed mass occurred in the one side in 44 of 54 cases,accounting for 81%. In the 44 cases,32 cases showed increased blood flow within or around the mass, with the blood flow resistance index(RI)=0.38 -0.03, and 12 cases showed some stellate blood flow signals. Tubal abortion was conformed by laparoscopy in 10 cases. Conclusion RI<0.41 within the mass can be used as a basis for diagnosis of ectopic pregnancy. And if there is no blood signal in the mass,it may be diagnosed as tubal pregnancy. Therefore,the transvaginal Duppleultrasonography can increase the sensitivity of tubal pregnancy.
[Key words] Transvaginal Dupple ultrasonography;Tubal;Ectopic pregnancy
异位妊娠是妇产科常见的急腹症之一,异位妊娠发生在输卵管占异位妊娠的95%～98%[1]。如对异位妊娠适时的诊断和及时的治疗,可避免异位妊娠部位破裂、出血,减轻病人的痛苦,降低死亡率。我们回顾分析了腹腔镜证实为异位妊娠的患者54例的超声表现,探讨在诊断异位妊娠中的作用。
1资料与方法
1.1临床资料
54例患者经腹腔镜证实为输卵管妊娠,术中见50例子宫直肠窝内积液,44例患者在一侧附件见不规则的混合性包块,包块最小的3.5cm×2.8cm,最大的5.8cm×4.6cm。患者年龄20～38岁,平均年龄24岁,停经36～48d,血HCG阳性,下腹疼痛52例,占96%(52/54),不规则阴道出血48例,占86%(48/54)。使用仪器 GE公司 LOGIQ7阴道探头频率7～12MHz,探头扇扩角度180度。
1.2方法
患者排空膀胱,取膀胱截石位,将避孕套套入探头上送入阴道内观察子宫及附件情况,发现包块时冻结,测量其大小,观察有无妊娠结构,如有可确诊为宫外孕,如未发现则将彩色多普勒取样框位于包块上,获得血流图及血流频谱图,记录血流参数。
2结果
2.1异位妊娠经阴道超声声像图表现
54例异位妊娠,50例子宫增大,腔内无妊娠囊,内膜均增厚达0.8～1.4cm,16例可见宫腔内圆环状结构,似假孕囊声像。输卵管壁增厚,12例有输卵管环内有胚芽及心管搏动。44例患者附件一侧可见不规则的混合性包块(封三图2),包块最小的3.5cm×2.8cm,最大的5.8cm×4.6cm,34例子宫直肠窝有积液,2例未见异常包块。
2.2异位妊娠阴道彩色多普勒的临床表现
本组44例包块中有32例包块内及包块周围显示增多的彩色血流信号血流频谱为上升快、下降慢的高速低阻血流频谱RI=0.38±0.03(封三图1)。
3讨论
异位妊娠最常见的部位为输卵管,输卵管妊娠时,由于输卵管不能形成完整的蜕膜,孕卵植入后,其绒毛借蛋白水解酶的破坏作用,直接侵入管壁肌层,破坏肌层的微血管,引起输卵管充血、增粗、增厚、积血及包块形成[2]。本文54例患者中44例患者在一侧附件出现包块占81%,在超声上表现为子宫近卵巢处见混合性包快,边缘较为清晰,多呈混合性回声,呈圆形的细长结构,其内夹杂有不规则液性暗区,此种表现为超声诊断异位妊娠的直接征象[3]。
附件区出现孕囊、胚芽和胎心波动可以确诊为异位妊娠,但毕竟是少数,当附件区缺乏特异性时,彩色多普勒显像有助于提高诊断的敏感性和特异性[4],因为滋养层结构改变和新生血管存在很强的相关性,彩色多普勒显像可监测滋养层细胞的生物活性(封三图2、图3)。Bernardimi等[5]观察异位妊娠包块内为低阻高速血流,滋养血流阻力(0.36±0.02),我们所测得的结果为RI<0.41血流可作为诊断异位妊娠依据。包块内见少许血流信号或探不见血流信号,HCG<1000IU,认为发生输卵管流产。
超声在输卵管妊娠中发挥重要作用,尤其是经阴道超声,因探头频率高、分辨率强,可测量直径1.0cm以上的肿块,贴近盆腔脏器,无需膀胱充盈、准确、方便,对早期未破裂的异位妊娠加上彩色多普勒血流图显像,以其特有的滋养层血流及高速低阻的血流频谱,可明显地增加发现异位妊娠的敏感性。
[参考文献]
[1] 贾译清,王炼,姜玉新,等. 临床超声鉴别诊断学[M]. 第2版. 南京:江苏科学技术出版社,2007:849.
[2] Hanchate V, Garg A, Sheth R, et al. Transvaginal sonographic diagnosis of live monochorionic twin ectopic pregrancy[J]. J Chin Ultrasound,2002,31(1):52.
[3] Michael B. Color doppler in the diagnosis of ectopic pregrancy in the emergency dcpartment:is there anvthing beyond a mass and fluid?[J]. J Emerg Med,2002,22(4):379.
[4] Craven CM,Chedwich LR,Ward K,et al. Placental basal plate formation is associated with fibrin deposition in decidual veins at sites of trophoblast cell invasion[J]. Am J Obstet Gynecol,2002,186(2):291.
[5] Bernandini I,Valenzano M,Foglia G. Spontaneous interatitial pregnancy on a tubal stump after unilateral abenectong followed by trans vaginal colour Doppler ultrasound[J]. Hum Reprod,1998,13(6):723.
(收稿日期:2009-09-30)
[关键词] 经阴道彩色多普勒;输卵管;异位妊娠
[中图分类号] R714.221[文献标识码] A[文章编号] 1673-9701(2009)34-73-02
Value in Transvaginal Dupple Ultrasonography for Diagnosis of Tubal Pregnancy
WANG ChunhongYIN MingLI Qin
Department of Ultrasound,Taizhou Municipal People’s Hospital,Taizhou 225300,China
[Abstract] Objective To probe into the application value of transvaginal Dupple ultrasonography in the diagnosis of tubal pregnancy. Methods We analyzed the ultrasonographyin 54 cases of ectopic pregnancy confirmed by laparoscopy and the blood flow ofadnexal mass in 44 of 54 cases. Results The mixed mass occurred in the one side in 44 of 54 cases,accounting for 81%. In the 44 cases,32 cases showed increased blood flow within or around the mass, with the blood flow resistance index(RI)=0.38 -0.03, and 12 cases showed some stellate blood flow signals. Tubal abortion was conformed by laparoscopy in 10 cases. Conclusion RI<0.41 within the mass can be used as a basis for diagnosis of ectopic pregnancy. And if there is no blood signal in the mass,it may be diagnosed as tubal pregnancy. Therefore,the transvaginal Duppleultrasonography can increase the sensitivity of tubal pregnancy.
[Key words] Transvaginal Dupple ultrasonography;Tubal;Ectopic pregnancy
异位妊娠是妇产科常见的急腹症之一,异位妊娠发生在输卵管占异位妊娠的95%～98%[1]。如对异位妊娠适时的诊断和及时的治疗,可避免异位妊娠部位破裂、出血,减轻病人的痛苦,降低死亡率。我们回顾分析了腹腔镜证实为异位妊娠的患者54例的超声表现,探讨在诊断异位妊娠中的作用。
1资料与方法
1.1临床资料
54例患者经腹腔镜证实为输卵管妊娠,术中见50例子宫直肠窝内积液,44例患者在一侧附件见不规则的混合性包块,包块最小的3.5cm×2.8cm,最大的5.8cm×4.6cm。患者年龄20～38岁,平均年龄24岁,停经36～48d,血HCG阳性,下腹疼痛52例,占96%(52/54),不规则阴道出血48例,占86%(48/54)。使用仪器 GE公司 LOGIQ7阴道探头频率7～12MHz,探头扇扩角度180度。
1.2方法
患者排空膀胱,取膀胱截石位,将避孕套套入探头上送入阴道内观察子宫及附件情况,发现包块时冻结,测量其大小,观察有无妊娠结构,如有可确诊为宫外孕,如未发现则将彩色多普勒取样框位于包块上,获得血流图及血流频谱图,记录血流参数。
2结果
2.1异位妊娠经阴道超声声像图表现
54例异位妊娠,50例子宫增大,腔内无妊娠囊,内膜均增厚达0.8～1.4cm,16例可见宫腔内圆环状结构,似假孕囊声像。输卵管壁增厚,12例有输卵管环内有胚芽及心管搏动。44例患者附件一侧可见不规则的混合性包块(封三图2),包块最小的3.5cm×2.8cm,最大的5.8cm×4.6cm,34例子宫直肠窝有积液,2例未见异常包块。
2.2异位妊娠阴道彩色多普勒的临床表现
本组44例包块中有32例包块内及包块周围显示增多的彩色血流信号血流频谱为上升快、下降慢的高速低阻血流频谱RI=0.38±0.03(封三图1)。
3讨论
异位妊娠最常见的部位为输卵管,输卵管妊娠时,由于输卵管不能形成完整的蜕膜,孕卵植入后,其绒毛借蛋白水解酶的破坏作用,直接侵入管壁肌层,破坏肌层的微血管,引起输卵管充血、增粗、增厚、积血及包块形成[2]。本文54例患者中44例患者在一侧附件出现包块占81%,在超声上表现为子宫近卵巢处见混合性包快,边缘较为清晰,多呈混合性回声,呈圆形的细长结构,其内夹杂有不规则液性暗区,此种表现为超声诊断异位妊娠的直接征象[3]。
附件区出现孕囊、胚芽和胎心波动可以确诊为异位妊娠,但毕竟是少数,当附件区缺乏特异性时,彩色多普勒显像有助于提高诊断的敏感性和特异性[4],因为滋养层结构改变和新生血管存在很强的相关性,彩色多普勒显像可监测滋养层细胞的生物活性(封三图2、图3)。Bernardimi等[5]观察异位妊娠包块内为低阻高速血流,滋养血流阻力(0.36±0.02),我们所测得的结果为RI<0.41血流可作为诊断异位妊娠依据。包块内见少许血流信号或探不见血流信号,HCG<1000IU,认为发生输卵管流产。
超声在输卵管妊娠中发挥重要作用,尤其是经阴道超声,因探头频率高、分辨率强,可测量直径1.0cm以上的肿块,贴近盆腔脏器,无需膀胱充盈、准确、方便,对早期未破裂的异位妊娠加上彩色多普勒血流图显像,以其特有的滋养层血流及高速低阻的血流频谱,可明显地增加发现异位妊娠的敏感性。
[参考文献]
[1] 贾译清,王炼,姜玉新,等. 临床超声鉴别诊断学[M]. 第2版. 南京:江苏科学技术出版社,2007:849.
[2] Hanchate V, Garg A, Sheth R, et al. Transvaginal sonographic diagnosis of live monochorionic twin ectopic pregrancy[J]. J Chin Ultrasound,2002,31(1):52.
[3] Michael B. Color doppler in the diagnosis of ectopic pregrancy in the emergency dcpartment:is there anvthing beyond a mass and fluid?[J]. J Emerg Med,2002,22(4):379.
[4] Craven CM,Chedwich LR,Ward K,et al. Placental basal plate formation is associated with fibrin deposition in decidual veins at sites of trophoblast cell invasion[J]. Am J Obstet Gynecol,2002,186(2):291.
[5] Bernandini I,Valenzano M,Foglia G. Spontaneous interatitial pregnancy on a tubal stump after unilateral abenectong followed by trans vaginal colour Doppler ultrasound[J]. Hum Reprod,1998,13(6):723.
(收稿日期:2009-09-30)