【摘要】：目的：探討經(jīng)陰道超聲（Transvaginal sonography，TVS）對不全流產(chǎn)和完全流產(chǎn)的診斷價值。 材料與方法：182例早孕流產(chǎn)患者，流產(chǎn)后第6～8天進(jìn)行首次常規(guī)TVS檢查，觀察早孕流產(chǎn)后宮腔內(nèi)膜清晰與否、是否有妊娠絨毛組織殘留、殘留物回聲情況等二維聲像圖，測量子宮內(nèi)膜厚度和/或子宮縱軸位宮腔前后徑（A-P值）及殘留物大小。采用彩色多普勒技術(shù)（Color Doppler flow imaging，CDFI）對宮腔內(nèi)殘留物進(jìn)行血流信號檢測；運用脈沖多普勒技術(shù)（Pulsed wave ultrasound，，PW）對血流信號作描記，獲得子宮動脈阻力指數(shù)（Resistivity index，RI）值和子宮螺旋動脈RI值。對于TVS檢查疑似不全流產(chǎn)患者均行清宮術(shù)取病理組織送活檢；而TVS檢查顯示無明顯不全流產(chǎn)證據(jù)的患者于流產(chǎn)后第13～15天復(fù)查TVS，再次記錄子宮內(nèi)膜厚度，并隨訪至流產(chǎn)后首次月經(jīng)來臨。如復(fù)查疑似有不全流產(chǎn)可能，則行清宮術(shù)進(jìn)行病理活檢。 采用獨立樣本t檢驗比較不全流產(chǎn)組和完全流產(chǎn)組雙側(cè)子宮動脈RI值和子宮螺旋動脈RI值；采用配對t檢驗比較完全流產(chǎn)后第6～8天和第13～15天的子宮內(nèi)膜厚度。以病理學(xué)結(jié)果為金標(biāo)準(zhǔn)，計算出二維超聲及CDFI對182例流產(chǎn)后患者的診斷效能；通過對子宮螺旋動脈RI值制作受試者特征曲線（Receiver operating characteristic，ROC），計算出其診斷不全流產(chǎn)和完全流產(chǎn)的最佳診斷界值，并分析其敏感性、特異性、準(zhǔn)確性、陽性預(yù)測值和陰性預(yù)測值。對同時完成二維超聲和CDFI和PW檢查的93例患者，采用2檢驗比較二者在不全流產(chǎn)的診斷效能。 結(jié)果：（1）不全流產(chǎn)組與完全流產(chǎn)組左側(cè)子宮動脈RI值分別為0.804±0.089、0.796±0.095，兩組之間的差異無統(tǒng)計學(xué)意義（t=0.367，P＞0.001）。不全流產(chǎn)組與完全流產(chǎn)組右側(cè)子宮動脈RI值分別為0.798±0.050、0.804±0.089，兩組之間的差異無統(tǒng)計學(xué)意義（t=0.295，P＞0.001）。 （2）不全流產(chǎn)組和完全流產(chǎn)組子宮螺旋動脈RI值分別為0.540±0.037、0.618±0.096，兩組之間的差異有統(tǒng)計學(xué)意義（t=3.558，P＜0.001）。 （3）完全流產(chǎn)組流產(chǎn)后第6～8天和第13～15天子宮內(nèi)膜厚度分別為0.470±0.175cm、0.664±0.305cm，兩者之間的差異有統(tǒng)計學(xué)意義（t=4.514，P＜0.001）。 （4）二維超聲及CDFI對182例流產(chǎn)后（以A-P值≥1.0cm為診斷不全流產(chǎn)的標(biāo)準(zhǔn)）患者的敏感性、特異性、準(zhǔn)確性、陽性預(yù)測值和陰性預(yù)測值分別為95.56%（43/45）、77.37%（106/137）、81.87%（132/182)、58.11%(43/74)和98.15%(106/108)。 （5）根據(jù)子宮螺旋動脈RI值制作ROC曲線，曲線下面積為0.883，子宮螺旋動脈RI值在診斷不全流產(chǎn)的最佳診斷界值為0.58，以RI≤0.58判斷為不全流產(chǎn)，＞0.58判斷為完全流產(chǎn)，其敏感性、特異性、準(zhǔn)確性、陽性預(yù)測值和陰性預(yù)測值分別為86.36%（39/45）、73.91%（35/48）、79.57%(74/93)、75.00%（39/52）和85.37%（35/41）。 （6）同時完成二維超聲和CDFI以及PW檢查的93例患者，兩者診斷不全流產(chǎn)的效能比較：PW檢查的敏感性低于二維超聲和CDFI（95.56%vs.86.36%），但二者差異無統(tǒng)計學(xué)意義（2=2.195，P=0.138）；PW檢查的特異性及準(zhǔn)確性均明顯高于二維超聲和CDFI（35.42%vs.72.92%；64.52%vs.79.57%），且二者之間的差異均有顯著統(tǒng)計學(xué)意義（2=13.594，P＜0.001；2=19.619，P＜0.001)。 結(jié)論：完全流產(chǎn)后第6～8天子宮內(nèi)膜厚度小于第13～15天子宮內(nèi)膜厚度。子宮動脈RI值判斷不全流產(chǎn)價值有限；PW檢查診斷不全流產(chǎn)的敏感性低于二維超聲和CDFI，特異性及準(zhǔn)確性均明顯高于二維超聲和CDFI，子宮螺旋動脈RI值能夠較好的鑒別不全流產(chǎn)和完全流產(chǎn)，有較高的臨床實用性。
[Abstract]:Objective: To evaluate the value of transvaginal sonography (TVS) in the diagnosis of incomplete and complete abortion.
Materials and Methods: 182 cases of early pregnancy abortion were examined by TVS for the first time from 6 to 8 days after abortion. The endometrial thickness, A-P value and residual size were measured by two-dimensional ultrasonography. Color Doppler flow imaging (CDFI) was used to detect the blood flow signals of intrauterine residues. Pulsed wave ultrasound (PW) was used to record the blood signals to obtain the value of resistance index (RI) of uterine artery and RI of uterine spiral artery. The uterine biopsy was performed in all the pregnant women, and the TVS examination showed that the patients without evident incomplete abortion were reexamined on the 13th to 15th day after abortion. The endometrial thickness was recorded again and followed up until the onset of the first menstruation after abortion.
The RI values of bilateral uterine arteries and uterine spiral arteries in incomplete abortion group and complete abortion group were compared by independent sample t test, and the endometrial thickness of 6-8 days and 13-15 days after complete abortion was compared by paired t test. The diagnosis of 182 cases of post-abortion patients by two-dimensional ultrasound and CDFI was calculated according to the golden standard of pathological results. Efficiency: The best diagnostic thresholds for incomplete abortion and complete abortion were calculated by making the receiver operating characteristic (ROC) of the uterine spiral artery RI, and the sensitivity, specificity, accuracy, positive predictive value and negative predictive value were analyzed. In 93 patients, 2 tests were used to compare the diagnostic efficiency of two patients in incomplete abortion.
Results: (1) The RI values of the left uterine artery in incomplete abortion group and complete abortion group were 0.804 (+ 0.089) and 0.796 (+ 0.095), respectively. There was no significant difference between the two groups (t = 0.367, P > 0.001). The RI values of the right uterine artery in incomplete abortion group and complete abortion group were 0.798 (+ 0.050) and 0.804 (+ 0.089), respectively. There was no significant difference between the two groups (t = 0.29). 5, P > 0.001).
(2) The RI values of uterine spiral artery in incomplete abortion group and complete abortion group were 0.540 (+ 0.037) and 0.618 (+ 0.096) respectively. The difference between the two groups was statistically significant (t = 3.558, P < 0.001).
(3) The endometrial thickness of the complete abortion group was 0.470 (+ 0.175 cm) and 0.664 (+ 0.305 cm) on the 6th to 8th and 13th to 15th days after abortion, respectively. The difference between the two groups was statistically significant (t = 4.514, P < 0.001).
(4) The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of two-dimensional ultrasound and CDFI were 95.56% (43/45), 77.37% (106/137), 81.87% (132/182), 58.11% (43/74) and 98.15% (106/108) respectively.
(5) ROC curve was made according to RI value of uterine spiral artery. The area under the curve was 0.883. The best diagnostic threshold of RI value of uterine spiral artery was 0.58. The best diagnostic threshold of incomplete abortion was RI < 0.58. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value were 86.36% (39/45), 73.58 and 0.58 respectively. .91% (35/48), 79.57% (74/93), 75% (39/52) and 85.37% (35/41).
(6) Ninety-three patients with incomplete abortion underwent two-dimensional ultrasound, CDFI and PW simultaneously. The sensitivity of PW was lower than that of two-dimensional ultrasound and CDFI (95.56% vs. 86.36%), but there was no significant difference between them (2 = 2.195, P = 0.138); the specificity and accuracy of PW were significantly higher than that of two-dimensional ultrasound and CDFI (35.42% vs. 72). 92%; 64.52% vs. 79.57%, and the difference between them was statistically significant (2 = 13.594, P < 0.001; 2 = 19.619, P < 0.001).
Conclusion:The thickness of endometrium on the 6th to 8th day after complete abortion is less than that on the 13th to 15th day.The value of RI in judging incomplete abortion is limited.The sensitivity of PW in diagnosing incomplete abortion is lower than that of two-dimensional ultrasound and CDFI.The specificity and accuracy of PW in diagnosing incomplete abortion are obviously higher than that of two-dimensional ultrasound and CDFI. Identification of incomplete abortion and complete abortion is of high clinical utility.
【學(xué)位授予單位】：蘇州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R445.1;R169.42

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