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中华医学超声杂志(电子版) ›› 2018, Vol. 15 ›› Issue (08) : 569 -578. doi: 10.3877/cma.j.issn.1672-6448.2018.08.002

所属专题: 妇产科超声影像学 产前超声 文献 妇产科超声

综述

胎盘植入的产前超声新进展
梁美玲1, 李胜利1,()   
  1. 1. 518028 南方医科大学附属深圳市妇幼保健院超声科
  • 收稿日期:2017-10-24 出版日期:2018-08-01
  • 通信作者: 李胜利
  • 基金资助:
    国家自然科学基金(81571758); 深圳市科技计划项目(JSGG20160428154812749); 深圳市卫生计生系统科研项目(201506059)

Recent advances of the prenatal ultrasonographic in the placenta accrete

Meiling Liang1, Shengli Li1()   

  • Received:2017-10-24 Published:2018-08-01
  • Corresponding author: Shengli Li
引用本文:

梁美玲, 李胜利. 胎盘植入的产前超声新进展[J]. 中华医学超声杂志(电子版), 2018, 15(08): 569-578.

Meiling Liang, Shengli Li. Recent advances of the prenatal ultrasonographic in the placenta accrete[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2018, 15(08): 569-578.

图1 前置胎盘植入子宫瘢痕处分级示意图。1级为胎盘粘连(PC),绒毛粘连至肌层;2级为胎盘植入(PI),绒毛侵入子宫肌层;3级为胎盘穿透(PP),绒毛穿透子宫肌壁全层并穿透子宫浆膜层
图2 不同类型胎盘植入示意图,显示前置胎盘合并异常粘连和侵袭
图3~5 子宫切除标本显微镜观察胎盘床。图3子宫切除标本可见薄的蜕膜层在胎盘绒毛(PV)和肌层(M)之间(HE ×2.5);图4,5子宫切除标本蜕膜层变薄(HE ×2.5),部分区域蜕膜缺失(HE ×10),蜕膜层厚度0.5 mm(图4),蜕膜层厚度0.1 mm(图5)
图6 孕34周胎盘前置伴胎盘植入病例,子宫切除标本显微镜观察胎盘床,可见薄薄的子宫肌层(M),蜕膜层(D)被胎盘绒毛(PV) "侵蚀"中断(HE×4)
图7 妊娠期子宫血管解剖示意图
图8,9 异常粘连和侵入性胎盘示意图。图8为正常胎盘子叶;图9为胎盘植入(PI)到深肌层循环。正常子叶变形,失去胎盘隔,形成陷窝(L);在异常粘连和侵入性的胎盘中,螺旋动脉的不完全重构仅限于植入区域,而不影响整个胎盘功能;除在植入区域内的弓形子宫血管扩张外,瘢痕周围有新生血管形成的现象
表1 2016年欧洲工作组对异常侵入性胎盘的标准化描述
图11 正常胎盘后间隙可显示
图15 患者有3次剖宫产史,经腹部超声长轴切面观察孕34周胎盘床,探头加压前后图像显示胎盘后低回声区(箭头所示)
图18,19 经阴道超声观察孕20周前置胎盘伴胎盘植入。图18胎盘内形成大量大小不等和形状不同的腔隙(箭头所示) "虫蚀"表现;图19彩色多普勒显示腔隙内有高速湍流的血流流动
图20,21 患者无手术史,经腹部超声长轴切面观察孕33周胎盘,无胎盘植入;图20箭头示胎盘湖,伴轻度(左图)探头压力,增加探头压力(右图);图21声像图中多个"虫蚀"表现似胎盘植入
图22~24 经腹部超声长轴切面观察胎盘。图22孕20周前置胎盘伴胎盘植入病例,其供应血管来自弓形循环胎盘和膀胱之间进入陷窝;图23孕28周声像图示胎盘湖(箭头所示),无伴发产科并发症,注意子宫肌层;图24为胎盘湖内相应螺旋动脉的血流监测图
图27 箭头示膀胱壁光滑、规则
图30 孕34周手术发现胎盘植入区扩张的新生血管和膨胀的子宫肌层
图31~33 胎盘植入时子宫肌层变薄或消失(图31,32);图33箭头示正常子宫肌层
图34,35 胎盘植入病例,晚孕期子宫肌层继发性变薄超声声像图及手术所见。图34经腹部超声长轴切面观察孕36周胎盘床,膀胱下肌层缺陷(箭头所示);图35外科处理时可见子宫窗口(箭头所示)
图37 手术标本显示胎盘植入区可见新生血管和肌层肿胀
图39 声像图示正常胎盘床
图41 彩色多普勒示正常胎盘床下血流稀少
图43 胎盘陷窝供应血管
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