| Part?Feasibility study of utility of ultrasound for early prediction of placenta location in embryonic periodBackground and Objective:The placenta functions as an important bridge for blood, oxygen and nutrient exchange between fetus and mother. It has a fundamental role in fetal growth and development throughout pregnancy. Embryological studies have confirmed that the trophectoderm invading, embryo implantation and placenta vascularization mainly occur at the early stage of pregnancy. Ultrasound is considered to be a major and optimum way for the examination of placenta. The conventional theory is that ultrasound could be used in placenta examination after 10 weeks of gestation. However, for some diseases resulted from abnormal placenta location,such as cesarean scar pregnancy (CSP), early prediction of placenta location could directly impact the success of available treatment options.This study aims to investigate the feasibility of utility of ultrasound for prediction of the possible placenta location before 10 weeks of gestation in embryonic period, when the placenta still has not fully developed. Meanwhile, the contents and skills of the placental examination would be introduced in this study. The ultimate aim is to find the effective predictors for placenta location and then to provide information for the clinical management of diseases resulted from abnormal placenta location.Methods:207 normal pregnant women (gestation time?70 days) from January 2014 to December 2014 were enrolled in this study. Grey-scale and color Doppler ultrasound were performed.176 cases could show the gestational sac(GS) structures and characteristics clearly in the ultrasonography. The yolk sac location, germ location, location of the thickest GS wall, location of the rich blood flow around GS were observed and recorded. Among the 176 cases, there were 144 cases being continued pregnant. The actual placenta locations in middle and late pregnancy were followed up and recorded. Among the 176 cases, there were 17 cases being with incomplete abortion. The location of intrauterine residue and rich blood flow were observed and recorded. Among the 176 cases, there were 15 cases being with complete abortion. The GSs were collected and performed with histological and embryological examinations.31 cases were ranclomly selected and included in this study, the GS structures and characteristics couldn't be shown in the ultrasonogrophy as the gestation time is too short. Their gestation time was recorded.Spss 20.0 software was used for statistical analysis in this study. Kappa tests were used to analyze the consistence between the GS characteristics in embryonic period and the actual placenta location. A P value< 0.05 was considered statistically significant.Results:For 144 cases being continued pregnant, the gestation time was 53.68±8.57 days (37?70 days). Kappa tests showed there was moderate consistence between germ location and placenta location (kappa value =0.517, consistent rate=70.14%); there was moderate consistence between yolk sac location and placenta location (kappa value=0.564, consistent rate=72.92%); there was high consistence between location of the thickest GS wall and placenta location (kappa value=0.816, consistent rate=88.89%); there was high consistence between location of the rich blood flow and placenta location (kappa value=0.843, consistent rate=90.97%).For 17 cases being incomplete abortion, kappa tests showed:there was high consistence between GS characteristics and the location of intrauterine residue and rich blood flow (kappa value=0.900, consistent rate=94.12% for germ location; kappa value=1.000, consistent rate=100.00% for the others).For 161 cases being continued pregnant and incomplete abortion, there was high consistence between the GS characteristics in embryonic period and the actual placenta location. What's more, the location of thickest GS wall and rich blood flood around GS could be included in decision tree and were very good predictors for placenta location. The overall accuracy was 93.8%.For 31 cases, their GS characteristics could not be shown in ultrasonography. The gestation time was 33.82±2.88 days (29±41 days), when the gestation time is less than 33.81±2.88 days, prediction of placenta location by ultrasound in embryonic period could not be conducted.For 15 cases being complete abortion, the GS structures observed by naked eye and histological and embryological examinations were highly consistent with ultrasonography.Conclusions:Ultrasound could be used for early prediction for placenta location in embryonic period:The predictors in ultrasonography were yolk sac location, germ location, location of the thickest GS wall and location of the rich blood flow around GS. The last two predictors showed high consistence with the actual placenta location.If the gestation time is less than 33.81±2.88 days, the placenta location couldn't be predicted by ultrasonography. The prediction could be conducted after about 5 weeks of gestation.There is high consistence between GS structures observed by naked eyes and histological and embryological examinations and ultrasonography.Part ?Diagnostic value of prediction of placenta location in embryonic period in cesarean scar pregnancyBackground and Objective:As the global number of cesarean sections increasing, the complications resulted from this operation have attracted increasing attentions. Among the complications, cesarean section pregnancy (CSP) is the most important one. CSP has become a new kind but most common emergent and severe case in the clinical practice. As far as we know, there has been no classification, diagnostic and therapeutic standard for CSP. Through the first part of the study found that ultrasound can be used to observe the characteristics of the embryo of the gestational sac placental formation location prediction.This study aims to classify CSP by the possible placenta location in embryonic period, also known as the actual embryo implanting location. Meanwhile, the value of CSP classification in the diagnosis of CSP will be investigated in this study. This study provides useful information for the medical management of CSP in the clinical practice.Methods:89 patients with suspected CSP at the early stage of pregnancy in embryonic period underwent treatment from January 2015 to July 2016 were enrolled in this study. The morphology of the GSs was integrated. All the GSs of the patients were located nearly into the cesarean scar. Both transabdominal and transvaginal ultrasound were performed on the patients.According to the results of the first part of the study, the location of the placenta may be divided into three types according to the observation of the characteristics of the gestational sac:First, the echocardiographic features of the CSP were analyzed.CSP was classified into three types in this study:Type ?, the placenta is located in the anterior wall of the lower uterus segment (In other words, the thickest GS wall is next to the lower uterus segment and there shows rich blood flow, what's more, the GS would implant into the scar in varying degree); Type ?,the placenta is located both in the anterior and posterior wall of the uterus, and covers the internal cervical os. The thickest GS wall is located the anterior and the posterior wall of the lower uterus segment. There shows rich blood flow. Type?, the placenta is located in the posterior wall of the lower uterus segment. Under this consideration, most part of the placenta is located in the posterior wall of the lower uterus segment. While a small part of the placenta is next to the scar. The thickest GS wall is located in the in the posterior wall of the lower uterus segment and there shows rich blood flow.The data of 89 patients with CSP were collected, including the age of pregnant women, the number of pregnancies, the number of cesarean sections and the interval between last cesarean section.the 89 cases of suspected CSP were followed up. The information about diagnosis (including the muscle thickness of the scar, the blood flow of the scar), treatment (including hospitalization days, treatment ways and bleeding volume) and prognosis (results of the first ultrasound examination after-treatment) was recorded.2. spss 20.0 software was used for statistical analysis in this study, ?2tests and AVONA tests were used for comparisons. A P value<0.05 was considered statistically significant. Results:According to the ultrasonograhic features in embryonic period,89 cases was divided into three classifications. Type ? was 46 cases (51.7%), type ? was 28 cases (31.5%) and type ? was 15 cases (16.9%).There was no significant difference in patients'ages, gestation time, cesarean section times and interval time among the three types.Diagnosis:The mean muscle thickness of the scar was (0.28+0.14) cm. There was significant difference in the muscle thickness of the scar among the three types. [(0.24±0.12) cm, (0.31±0.15) cm and (0.36±0.16) cm, respectively. (F=5.304, P=0.007). type? was thinnest, trailed by type ? and type?, there was significant difference in the blood flow of the scar (?2=25.528,p=0.000). Type ? and type ? were mostly with moderate blood signals. Some of type? cases were even with abundant blood signals. White type? was mostly with sparse blood signals.Treatment:The mean hospitalization days were (12.33+10.98) days, there was significant differences in the hospitalization days among the three types. [(15.09±13.24) days, (9.32±6.37) days and (9.47±8.04) days, respectively. (F=3.157, P=0.048)]. type I was the longest. There was significant difference in the treatment ways (?2=16.796, p=0.002). The mean blood volume was (72.70±137.12)mL, there was no significant difference in blood volume among the three groups [(84.57± 169.44)mL, (76.71±108.63)mL and (29.00±24.80)mL, respectively. (F=0.944, P=0.390)]Prognosis:According to the first ultrasound examinations after treatment, the prognosis could be divided into three kinds:mass, minimal residue and cure. For type I,34.78% were mass cases,13.04% were minimal residue cases and 52.17% were cure cases. For type ?,21.43% were mass cases,21.43% were minimal residue cases and 57.14% were cure cases. For type?,6.67% were mass cases, 13.33% were minimal residue cases and 80.00% were cure cases. There were significant differences in prognosis among the three types (x2=9.72, p<0.05). The prognosis of type I was the worst, white the prognosis of type ? was the best.Conclusions:Ultrasound could be used to classify CSP. According to the feasibility for early prediction of placenta location in embryonic period. The classifications were type I (placenta located in the anterior wall), type II (placenta located in the anterior and posterior wall).There were significant differences in the muscle thickness of the scar, the blood flow of the scar, hospitalization time, treatment ways, and prognosis among the three types. This study indicated that the classification in this study has high value in the assessment of the diagnosis, treatment and prognosis of CSP. This new classification could be used in the clinical management of CSP. |
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