Departments of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
Departments of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
Am J Obstet Gynecol. 2021 Sep;225(3):292.e1-292.e17. doi: 10.1016/j.ajog.2021.03.018. Epub 2021 Mar 17.
Ultrasound has demonstrated a high accuracy in the prenatal diagnosis of placenta accreta spectrum. However, it is not known whether ultrasound findings can pinpoint the depths of villous invasion, recommend surgical strategies, and predict clinical outcomes.
We described an ultrasound descriptor for the placenta accreta spectrum and investigated whether it can predict the severity of villous invasion and clinical outcomes.
The patients with placenta accreta spectrum in this retrospective cross-sectional study were diagnosed and managed in our hospital from 2002 to 2017. The placenta, with overlying myometrium and bladder, was mapped with color Doppler sonography while the patient's bladder was full. A "rail sign" was defined as 2 parallel neovascularizations depicted by color Doppler sonography over the uterovesical junction and bladder mucosa, with interconnecting bridging vessels perpendicular to both. The patients received serial ultrasound examinations and surgery at our hospital. An unpaired t test and Pearson chi-square test compared the pathology subtypes, surgical strategies, and clinical outcomes in patients with or without a rail sign.
We enrolled 133 consecutive cases of placenta accreta spectrum confirmed either by surgical inspection or pathology examination. Patients with a rail sign had a significantly higher risk of an abnormally invasive placenta (placenta increta or placenta percreta) than those patients without a rail sign (83.3% [60 of 72] vs 27.9% [17 of 61]; odds ratio, 12.94; P<.001). In addition, patients with a rail sign had a higher probability of perioperative approaches, including preoperative vascular control (58.3% [42 of 72] vs 21.3% [13 of 61]; odds ratio, 5.17; P<.001) and uterine artery embolization (34.7% [25 of 72] vs 11.5% [7 of 61]; odds ratio, 4.1; P=.0002]. Furthermore, patients with a rail sign carried a higher risk of adverse clinical outcomes than patients without a rail sign, such as blood transfusion (80.6% [58 of 72] vs 36.1% [22 of 61]; odds ratio, 7.34; P<.001], admission to the intensive care unit (33.3% [24 of 72] vs 16.4% [10 of 61]; odds ratio, 2.55; P=.026), hysterectomy (75% [54 of 72] vs 24.6% [15 of 61]; odds ratio, 9.2; P<.001), and bladder invasion (16.7% [12 of 72] vs 4.9% [3 of 61]; odds ratio, 3.86; P=.033). Notably, the negative predictive value of bladder invasion was 95.1%, indicating a high confidence to reject bladder invasion while the rail sign was negative. When the rail sign was used as a screening test, the positive likelihood ratio of predicting deep villous invasion was 3.64 and correlated with an increased probability of 20% to 25%. Patients with a rail sign also had a greater blood loss (2944±2748 mL vs 1530±1895 mL; P<.001) and a longer hospital stay (11.9±10.9 days vs 8.6±7.1 days; P=.036) than patients without a rail sign.
A "rail sign" depicted by color Doppler sonography correlates with deeper villous invasion, additional perioperative approaches, and more adverse outcomes.
超声在胎盘植入谱系疾病的产前诊断中具有较高的准确性。然而，目前尚不清楚超声检查结果是否可以确定绒毛侵入的深度、推荐手术策略并预测临床结局。
我们描述了胎盘植入谱系疾病的一种超声描述符，并探讨了其是否可以预测绒毛侵犯的严重程度和临床结局。
本回顾性横断面研究纳入了 2002 年至 2017 年在我院诊断和治疗的胎盘植入谱系疾病患者。患者膀胱充盈时，使用彩色多普勒超声对胎盘（包括附着于其上的子宫肌层和膀胱）进行映射。“轨道征”定义为在膀胱黏膜上和子宫膀胱交界处，由彩色多普勒超声显示的 2 条平行的新生血管，其间有垂直于两者的连接桥血管。患者在我院接受了连续的超声检查和手术。采用独立样本 t 检验和 Pearson 卡方检验比较了有和无轨道征患者的病理亚型、手术策略和临床结局。
我们共纳入了 133 例经手术检查或病理检查证实的胎盘植入谱系疾病连续病例。有轨道征的患者异常性胎盘植入（胎盘植入或胎盘穿透）的风险明显高于无轨道征的患者（83.3%[60/72]比 27.9%[17/61]；比值比，12.94；P<.001）。此外，有轨道征的患者更有可能采用围手术期方法，包括术前血管控制（58.3%[42/72]比 21.3%[13/61]；比值比，5.17；P<.001）和子宫动脉栓塞术（34.7%[25/72]比 11.5%[7/61]；比值比，4.1；P=.0002）。此外，有轨道征的患者与无轨道征的患者相比，有更高的发生不良临床结局的风险，如输血（80.6%[58/72]比 36.1%[22/61]；比值比，7.34；P<.001）、入住重症监护病房（33.3%[24/72]比 16.4%[10/61]；比值比，2.55；P=.026）、子宫切除术（75%[54/72]比 24.6%[15/61]；比值比，9.2；P<.001）和膀胱侵犯（16.7%[12/72]比 4.9%[3/61]；比值比，3.86；P=.033）。值得注意的是，膀胱侵犯的阴性预测值为 95.1%，这表明当轨道征为阴性时，对膀胱侵犯有很高的置信度可以排除。当轨道征作为筛选试验时，预测深层绒毛侵犯的阳性似然比为 3.64，与增加 20%至 25%的可能性相关。有轨道征的患者还具有更大的出血量（2944±2748 mL 比 1530±1895 mL；P<.001）和更长的住院时间（11.9±10.9 天比 8.6±7.1 天；P=.036）。
彩色多普勒超声显示的“轨道征”与更深的绒毛侵犯、更多的围手术期方法和更差的临床结局相关。
