目的:为了评估超声检查,流行病学,妊娠早期终止妊娠(TOP)或无存活妊娠处理后子宫肌层血管分布增强(EMV)的临床和进化特征.
方法:这项前瞻性研究包括在2021年3月至2022年3月期间在热那亚圣马蒂诺大学医院综合诊所进行早期妊娠前5-6周或早期妊娠无活力妊娠处理后接受随访超声检查的妇女。使用二维和三维超声和虚拟器官计算机辅助分析来表征EMV。超声诊断EMV时异常,曲折的子宫肌层血管结构,高速血流,观察到向子宫内膜突出,而一个异常的交界区,子宫内膜中线缺失和子宫内膜异质性支持诊断。EMV患者接受期待治疗,每2周进行一次计划的超声检查随访,直至消退。
结果:在研究期间,305名女性接受了TOP,其中132人在5-6周后参加了最初的随访,其中52例被诊断为EMV。96名妇女因无法怀孕而接受管理,其中32人提出随访,其中6人被诊断为EMV。因此,总的来说,401名女性中的164名被纳入研究,其中58名(35%)被确定为EMV。因此,TOP后5-6周的EMV患病率在52/305(17%)和52/132(39%)之间,并且在处理无活性妊娠后的发生率在6/96(6%)和6/32(19%)之间。一半(29/58)的EMV妇女出现出血/盆腔疼痛,在第一次随访检查中,血清人绒毛膜促性腺激素检测到29%(17/58)。在超声评估中,所有EMV病例均表现出丰富的曲折肌层血管,从子宫肌层向子宫内膜高速流动,在97%的病例中,子宫内膜不均匀,通常(其中67%)包含囊性区域,98%的病例中没有子宫内膜中线,97%的病例中没有异常的交界区(64%中断,33%不规则)。大多数(67%)患有EMV的妇女都是产妇,其中90%经历了TOP而不是无法怀孕的管理。与没有EMV的女性相比,对TOP或非可行妊娠的医疗管理更为频繁(93%vs77%,P=0.023)。多元回归分析显示,在TOP与非存活妊娠后,EMV的风险增加(比值比(OR),3.67(95%CI,1.16-11.56),P=0.026)和与未分娩妇女相比(OR,2.95(95%CI,1.45-6.01),P=0.002)。所有患有EMV的女性都接受了期待管理。11名妇女没有返回接受随后的随访检查,也没有出现在我们的门诊或急诊设施,所以失去了进一步的后续行动。其余病例中有96%(45/47)在手术后7-16周内观察到病变的自发消退。两名妇女因骨盆不适而选择接受手术,组织学显示,新生血管与绒毛膜绒毛混合。
结论:EMV是在孕早期TOP或无活性妊娠管理后5-6周的短暂且常见的发现。TOP和冒充是EMV的危险因素。EMV的预期管理是合适的,因为,在几乎所有情况下,这自发地解决,无并发症,在2-4个月内。©2023国际妇产科超声学会。
OBJECTIVE: To assess the ultrasonographic, epidemiological, clinical and evolutive characteristics of enhanced myometrial vascularity (EMV) following a first-trimester termination of pregnancy (TOP) or management of non-viable pregnancy.
METHODS: This prospective
study included women who underwent follow-up ultrasound examination 5-6 weeks after a first-trimester TOP or after management of a first-trimester non-viable pregnancy at the University Hospital Polyclinic San Martino of Genoa between March 2021 and March 2022. EMV was characterized using two- and three-dimensional ultrasound and Virtual Organ Computer-aided Analysis. Ultrasonographic diagnosis of EMV was made when an unusual, tortuous myometrial vessel structure, with high-velocity blood flow, protruding towards the endometrium was observed, while an abnormal junctional zone, absent endometrial midline and heterogeneous endometrium supported the diagnosis. Patients with EMV underwent expectant management with planned ultrasonographic follow-up every 2 weeks until resolution.
RESULTS: During the
study period, 305 women underwent TOP, of whom 132 attended the initial follow-up 5-6 weeks later, at which 52 were diagnosed with EMV. Ninety-six women were managed for a non-viable pregnancy, of whom 32 presented for follow-up, at which six had a diagnosis of EMV. Thus, overall, 164 of 401 women were included in the
study and EMV was identified in 58 (35%) of these. The prevalence of EMV 5-6 weeks after a TOP was therefore between 52/305 (17%) and 52/132 (39%), and that after management of a non-viable pregnancy was between 6/96 (6%) and 6/32 (19%). Bleeding/pelvic pain was present in half (29/58) of the women with EMV, and serum human chorionic gonadotropin was detectable in 29% (17/58) at the first follow-up examination. At ultrasound assessment, all cases with EMV presented abundant tortuous myometrial vessels with high-velocity flow projecting from the
myometrium towards the endometrium, along with non-uniform heterogeneous endometrium in 97% of cases, which often (67% of these) contained cystic areas, absence of the endometrial midline in 98% of cases and an abnormal junctional zone in 97% of cases (64% interrupted, 33% irregular). Most (67%) women with EMV were parous and 90% of them had undergone TOP rather than management for a non-viable pregnancy. Medical management of the TOP or non-viable pregnancy was more frequent in women with than those without EMV (93% vs 77%, P = 0.023). Multiple regression analysis showed the risk of EMV to be increased following TOP vs non-viable pregnancy (odds ratio (OR), 3.67 (95% CI, 1.16-11.56), P = 0.026) and in parous compared with nulliparous women (OR, 2.95 (95% CI, 1.45-6.01), P = 0.002). All women with EMV underwent expectant management. Eleven women did not return for subsequent follow-up examinations and did not present to our outpatient or emergency facilities, so were lost to further follow-up. Spontaneous resolution of the lesion was observed within 7-16 weeks after the procedure in 96% (45/47) of the remaining cases. Two women chose to undergo surgery for pelvic discomfort, and histology showed the presence of neovessels mixed with retained chorionic villi.
CONCLUSIONS: EMV is a transient and common finding 5-6 weeks following first-trimester TOP or management of non-viable pregnancy. TOP and being parous are risk factors for EMV. Expectant management of EMV is appropriate, because, in almost all cases, this resolves spontaneously, without complications, within 2-4 months. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.