| Part1MRI findings and histologic basis of placentaObject:1.To analyse the clinic value of MRI findings and histologic basis of normal placenta.2.Analysis of fetal placental maturity of different grades of MRI, to explore the relationship between MRI classification and the gestational age in the second and third trimesterMaterial and Method:1.SubjectFrom April2009to April2012,50singleton pregnancies of after19gestational age have been collected by MRI,their mean age were30.2years old(rang20-36),the19-23gestational age(GA)for5cases,24～31GA for18cases,32～35GA for19cases,36-40GA for8cases,.2.Main instrument and equipment The Symphony1.5T superconducting magnetic resonance scanner of Siemens;phased-array coil with coronal, sagittal, and axial scanning, then were placenta vertical section, sagittal and transverse coronary scanning.Image postprocessing was done through the Functool software of Siemens company’s LEONARDO workstation.3.MR examination methodThe3D positioning using GRE sequence, MRI scanning sequences included: T1WI, T2WI (transverse, sagittal and coronal scan)The parameter of T2WI imaging with HASTE sequence were TR:1000ms, TE:74ms, slice thick6mm, layer spacing1.8mm, FOV:35cm, matrix164×256, NEX1, Incentive2times,with the fat suppression, and flow compensation technique. Some patients were Gd-DTPA enhancement.Ultrasonic examination methodGravida supine, patients examined before proper filling of bladder, using two-dimensional routine abdominal scan, when necessary, transvaginal ultrasonography, combined with color Doppler and three-dimensional ultrasound further examination. The main measurement of uterine size, size of the placenta, placenta after clearance (muscular layer of uterus, placenta low echo) the existence of internal and peripheral blood flow signal.4. Pathology examinationPlacenta fresh specimens fixed in10%formalin were obtained from normal full-term pregnancy abortion and postpartum,which were disposable paraffin-embedded、routine HE stainned and observed under Optical microscope.5. Statistical analysisData analyses were performed by SPSS14.0and the statistical differences were considered as statistically significant when P value was<0.05.Applying Kruskal-Wallis H statistic to compare between each gestational weeks placental mature grading by MRI.Result1.According to Grannum standard of ultrasonography of placental mature grading, MRI in placenta maturity grading is changes in the villous plate, the placental parenchyma and placental basal layer as the classification basis.2.According to the placental structure of T2WI,50cases of normal placenta MRI grading included grade o in4cases、grade Ⅰ in18cases、grade Ⅱ in23cases、 gradeⅢ in5cases.3.The enhanced MRI features of placenta:a:Immediately after Gd-DTPA enhancement shows lobular placental enhancement;b:then shows homogeneous enhancement of the placenta in the second pregnancy and enhanced obviously placental lobule in third trimester pregnancy. C:Delayed scanning placenta and uterine muscular layer homogeneous enhancement.4.Optical microscopy:Placental sections with clear background and villus structure within the normal visible small infarction, calcification.Conclusion:1. T2WI images of MRI can clearly show the structure of three layers of placenta:the villous plate、placental parenchyma and placental basal layer。2. Placental mature being a process of gradual change, the levels of maturity in the gestational age distribute in different extent and exist the mutual overlapping phenomenon. Part2MRI Evaluation of Placental Adhesive Disorders Treated by Interventional TherapyObjective:l.To research MRI data of interventional therapy for patients with clinically suspected PADs and correlation between the evaluation of MRI diagnosis of PADs and operation and/or clinical diagnostic criteria.2.To explore MRI signs before and after treatment intervention in postpartum PADs.Material and Method1. SubjectFrom2009April to2012April,30patients of interruption of pregnancy or postpartum have been collected, aged21to36years, averaged (30±4) years old, whose placenta were not complete or not delivery,having irregular vaginal bleeding.All patients underwent percutaneous bilateral uterine arterial chemoembolization interventional therapy and MRI examination within a week. In30patients, the first delivery of20cases, second deliveries of5cases,5cases of pregnancy abortion; history of induced abortion in21cases, history of cesarean section in10cases, history of operation of uterine leiomyoma in3cases,8cases complicated with placenta previa.2. Main instrument and MR examination method The Symphony1.5T superconducting magnetic resonance scanner of Siemens;phased-array coil with coronal, sagittal, and axial scanning, then were placenta vertical section, sagittal and transverse coronary scanning.The parameter of T2WI imaging with HASTE sequence were TR:1000ms, TE:74ms, slice thick6mm, layer spacing1.8mm, FOV:35cm, matrix240x320, NEX1, Incentive2times,with the fat suppression, and flow compensation technique.All patients were Gd-DTPA enhancement and scan range from uterine bottom to symphysis pubis.3.Signal intensity description and Image processingAll tissues of MRI signal intensity with the myometrium as control. Before diagnosis, diagnosis by two over and above high radiologists were not aware of operation and pathology, diagnosis of signal intensity, MRI placental location, morphology, site of implantation and uterine muscle wall and the adjacent organs may be affected. In order to clinical diagnosis and operation pathology results as the standard, to assess the diagnostic value of MRI.4. Statistical analysisData analyses were performed by SPSS14.0and the statistical differences were considered as statistically significant when P value was<0.05.Applying Kappa statistic to compare pathology and clinical diagnosis standard and MRI diagnosis.Result:1.There were statistical differences in the correlation between the evaluation of MRI diagnosis of PADs and operation and/or clinical diagnosis,and Kappa=0.733, P=0.000.2.Placenta accrete:MRI shown the myometrium signal integrity and the endometrial cavitysignal with irregular, fuzzy or discontinuous. 3.Placenta increte:MRI shown the myometrium signal irregular, the endometrial cavitysignal with discontinuous and the vessels through the myometrium.4.Placenta percrete:MRI shown the myometrium local signal disappeared、the tissue of placenta beyond the myometrium and the adjacent bladder or bowel infiltrated.5.On Gadolinium-enhanced T1WI,the placental tissue invaded the myometrium in the shape of "garland"or "nodul".6.After interventional treatment the residual part of placenta implantation was the clear boundary and hypointense signal by comparing normal myometrial signal.Conclusion1. MRI features of before interventional therapy of PADs:with no rules, fuzzy or interrupt with the uterus (placenta accrete); uterine myometrium signal irregular or invasion, thin myometrium (placenta increte); normal myometrial local signal disappears completely, sometimes can display the bladder or bowel invasion (placenta percrete).2MRI features of after interventional therapy of PADs:placenta implants and palace wall fusion, implantation and penetration of the myometrium remains visible mixed high signal, enhanced scan shows more clear, placenta implantation residue than normal myometrium enhanced signal is reduced, the boundary is clear3. MRI can show the placental implantation site and myometrial invasion degree.There were statistical differences in the correlation between the evaluation of MRI diagnosis of PADs and operation and/or clinical diagnosis.MRI has an important reference value and can accurately evaluate curative effect before and after interventional therapy to placental adhesive disorders. Part3Clinical study of transcatheter uterine artrey chemoembolization for postpartum placental adhesive disordersObjective:1. To explore treatment principle and operation skills by transcatheter uterine artrey chemoembolization for postpartum placental adhesive disorders.2.To investigate clinical curative effect, complications and prognosis by transcatheter uterine artrey chemoembolization for postpartum placental adhesive disorders.3. To explore the change of human chorionic gonadotropin-beta(β-hCG) before and after treatment by transcatheter uterine artrey chemoembolization for postpartum placental adhesive disorders.Material and Method1. SubjectFrom2009April to2012April,23patientsof placental adhesive disorders with postpartum hemorrhage have been collected, aged29to45years, averaged (34±3) years old, whose placenta were not complete delivery,having irregular vaginal bleeding.All patients underwent percutaneous uterine arterial chemoembolization interventional therapy。The mean gestational age(GA) was29±3.6weeks(range25-38).The patients were divided into the emergency group(7cases) and selective group(16cases). Criteria for the diagnosis of PADs1) the clinical manifestations, cesarean section postpartum placental or part and muscular wall adhesion, placenta forcibly stripping or clamp there is still residual, peeling, rough surface hemorrhage.2) B ultrasound or MRI confirmed the diagnosis of uterine cavity residual placenta, invasive imaging changes of uterus muscle layer, and the unclear boundaries.3) pathology, postpartum discharge tissue confirmed necrotic or old placental villus tissue.Evaluation Criteria of curative effect of PADs1) novalid:irregular menstruation, vaginal bleeding volume was not reduced, repeated ultrasound uterus shape is irregular, muscle layers thick, uterine artery embolization for the treatment of β-HCG level in the serum decreased significantly;2) valid:follow-up for half a year, the basic rules of the menstruation, amount of bleeding in vagina reduction, repeated ultrasound uterine morphology, the myometrium close to normal; β-HCG levels in serum decreased significantly2weeks after uterine artery embolization in the treatment of4weeks later, close to the normal results;3) effective:followed-up for half a year, return to normal menstrual cycle, the amount of vaginal bleeding was significantly reduced, repeated ultrasound uterine morphology, the myometrium returned to normal; β-HCG levels in2weeks in serum decreased rapidly after uterine artery embolization therapy,4weeks after seroconversion.2. Methods of TreatmentThe two groups were firstly treated with bilateral uterine artery angiography and then super selective perfusion of MTX with gelatin sponge embolization of uterine artery.After operation,all patients were observed with body temperature changes、 postoperative vaginal bleeding、menstruation、placenta, hospitalization time.Routine preoperative establish intravenous access, indwelling catheter, sterilization shop towel, through the right femoral artery puncture, puncture and intubation of the Seldinger technology, using5.0F Cobra tube or uterine artery angiography tube were performed bilateral iliac artery angiography, display uterine artery after a microcatheter into the uterine artery, PADs showed irregular blood sinus or vascular lake, contrast agent concentration, venous phase staining persists, clear placental lesions after perfusion of30-50ML methotrexate (MTX) plus50ml physiological saline, with gelatin sponge embolization of uterine artery, DSA angiography was performed to peripheral arterial branches disappeared, hemorrhage and shock before blood transfusion patients fully, maintain the stability of blood pressure, emergency embolization. Embolism after a week in B ultrasound guided curettage3.Treatment after OperationAfter operation,all patients were given active support for symptomatic treatment, treated with analgesics and intravenous antibiotics,recorded with blood pressure, breath, pulse, body temperature, lower extremity arterial pulsation observed within24hours after operation,monitored with intrauterine change by ultrasound,recorded after3days,7days,2week,4weeks the serumβ-HCG value.4Statistical analysisSPSS14statistical software for data processing, P<0.05was statistically significant(1) the emergency embolization group and selective embolization group: measurement data using T test, count data using Fisher’s exact test.(2) serumβ-hCG changes of patients before and after interventional therapy of PADs:at different time points within groups the use of Kruskal-Wallis H test, and further using Dunnett, s T3test for multiple comparisons.Result1.This group of23patients with interventional therapy were successful operation without hysterectomy.The mean operation time was60±5.8minutes(range50-80). We can find intraoperative angiography of uterine artery distal occlusion, vaginal bleeding after operation disappeared, hemorrhagic shock patients postoperatively back to normal、21cases recovered to normal after curettage of uterus.There were no bleeding of vagina by follow-up of2months.The emergency embolization group and selective embolization group in blood transfusion (P=0.004), the amount of bleeding (P=0.00) and time of hospitalization (P=0.00) had significant difference, the average age of (P=0.95), the number of cesarean section (P=0.83), curettage times (P=1), there is no prefix the placenta (P=1) has no statistical significance.2.The serum β-hCG change of research group at each time point had significant difference (K=52.576, P=0.00) before and after treatment in23cases; the study group before treatment and after treatment of3days, there were no significant differences in HCG (P=0.000), before treatment and after treatment7days difference (P=0.000), and after treatment2there are differences (P=0.000),3days after treatment and7days after treatment were (P=0.00), and after2weeks of therapy were (P=0.000),7days after treatment and2weeks after treatment also has difference (P=0.00),.3.After Ultrasound or MRI scan,23cases of uterine cavity were no placental tissue residue, but there were5cases of myometrium is still visible residue of placenta and serump-HCG value returned to normal levels within5-6weeks after the delivery of the placenta. The20patients were followed up in5cases of pregnancy and birth of a healthy child.4.Postoperative side effects:nausea, vomiting, fever and pain were common, gaven support for symptomatic treatment. The main complications associated with catheterization technique was hematoma.Conclusion1.Combining MTX perfusion with chemoembolization could be completely temporary occlusion of placental blood implantation,which could cause residual placental tissue the degeneration and necrosis or even fall-off.2.Through uterine artery chemoembolization with high success rate,the patients could retain the uterus and fertility ability again, fewer complications, faster postoperative recovery, and can prevent PADs cause bleeding or uterine rupture risk; this group of patients is the emergency embolization and selective embolization in the amount of bleeding and hospitalization time have significant difference.3.Monitoring chorionic gonadotropin numerical(β-hCG) could be used as one of indexes to judge clinical effect of PADs by chemoembolization therapy before and after operation because human chorionic gonadotropin (β-hCG) decreased significantly. |
PDF Full Text Request