子宫肌壁间妊娠超声诊断分析

目的总结子宫肌壁间妊娠超声图像特征及鉴别诊断要点。方法对2008年1月至2013年12月南方医科大学附属深圳市妇幼保健院收治的4例子宫肌壁间妊娠患者临床、超声分型表现及手术病理检查、临床诊治结果进行总结分析。结果 4例患者中1例早期超声诊断正确,3例超声误诊,手术及病理检查证实为子宫肌壁间妊娠后重新对超声图像予以分型。4例子宫肌壁间妊娠患者超声分型表现及临床诊治结果：（1）妊娠囊型2例,1例入院前超声显示子宫底后壁肌层内妊娠囊回声,与子宫腔不相通,与子宫内膜不相连接,妊娠囊四周肌层包绕,周边肌层内血管扩张、血流丰富,超声诊断为子宫底后壁肌壁间妊娠,经甲氨蝶呤保守治疗成功。另一例术前超声显示左侧子宫腔内妊娠囊回声,胚胎存活,误诊为子宫左侧宫内妊娠,清宫手术失败后再次超声检查显示子宫下段左侧后壁肌层内妊娠囊,胚胎存活,妊娠囊内缘与子宫内膜不相连接,四周肌层包绕;剖腹探查术后病理诊断为子宫下段左侧后壁肌壁间妊娠。（2）包块型1例,入院前超声显示子宫右侧宫角处混合回声包块,包块内缘紧贴子宫内膜,周边可见菲薄肌层包绕,包块内部及周边肌层血管扩张、血流丰富,超声误诊为子宫右侧宫角妊娠,宫腔镜及腹腔镜手术后病理诊断为子宫右侧宫角前壁肌壁间妊娠。（3）破裂型1例,入院前超声显示子宫后方偏右侧混合回声包块,包块紧贴子宫右后壁,与子宫肌层关系密切,盆腔内透声差的无回声区,超声误诊为右侧输卵管异位妊娠破裂,腹腔镜手术后病理诊断为子宫右侧后壁肌壁间妊娠。3例患者明确诊断后均经临床治愈。结论子宫肌壁间妊娠罕见,超声显示妊娠囊（或包块）位于子宫肌层内,与子宫腔不相通,与子宫内膜不相连接,四周由子宫肌层包绕,肌层内血管扩张、血流丰富者可提示为子宫肌?     

经阴道超声与经腹部超声诊断异位妊娠的比较

目的比较经阴道超声(TVS)与经腹超声(TAS)在异位妊娠诊断中的价值。方法对109例异位妊娠患者以双盲法分别进行经腹部和经阴道超声检查。结果子宫清晰显示率、子宫内膜测定率、盆腔肿块显示率、盆腔肿块清晰显示率、肿块内检出孕囊样结构及原始心管搏动率,以及肿块内彩色血流信号检出率,TVS均明显高于TAS。结论TVS比TAS诊断异位妊娠更准确。临床诊断疑为异位妊娠的患者,应首选进行TAS或TVS检查,有条件的医院应常规进行TVS检查。     

经阴道超声对未破裂型宫外孕的诊断应用

目的 探讨经阴道超声(TVS)及时准确诊断未破裂型宫外孕的检查方法.方法 回顾性分析我院2004年1月-2005年1月确诊的64例未破裂型宫外孕患者的超声检查资料.具体方法是先行常规超声检查显示子宫及卵巢后注意追踪显示输卵管;后行TVS扫查子宫以上部位,并与肠管回声鉴别;用探头反复轻推,根据可疑病灶与卵巢是否同步运动以辨别其与卵巢的关系. 结果 64例均显示附件区妊娠囊样环状回声.根据声像图显示中妊娠囊样环状回声与输卵管及卵巢的关系分为3型:Ⅰ型:输卵管可显示型(29例):较清楚显示输卵管,管内可见妊娠囊样环状回声;其中5例于初检漏诊后注意追踪显示输卵管而提示宫外孕诊断;Ⅱ型:与卵巢分界清型(27例):6例于初检漏诊后注意扫查子宫底以上部位、并与肠管回声鉴别而提示宫外孕诊断;Ⅲ型:与卵巢分界不清型(8例):7例在反复轻推探头后辨别与卵巢是否同步运动而提示宫外孕诊断.结论 TVS在检查方法上的完善有助于更及时、准确地诊断未破裂型宫外孕.     

经腹彩超和经阴道超声诊断异位妊娠的临床应用价值及有效性

目的比较经腹彩超(TAS)与经阴道超声(TVS)诊断异位妊娠的临床应用价值及有效性。方法选取我院2018年1月至2018年12月收治的120例异位妊娠患者作为研究对象,均行TAS扫查与TVS扫查。以病理诊断结果为检验金标准,比较两种超声扫查方法的诊断准确率。结果TAS扫查诊断准确率为74.17%,显著低于TVS扫查的90.83%(P<0.05)。TVS扫查对宫外混合性团块、宫外孕囊影、孕囊影中胚芽检出率高于TAS扫查,差异具有统计学意义(P<0.05);两种超声扫查方法对胎心检出率比较,差异无统计学意义(P>0.05)。结论相较于TAS扫查,TVS扫查可更有效地诊断早期异位妊娠,同时,TAS扫查仍是异位妊娠诊断中的一个重要的辅助检查方法。     

经阴道超声诊断异位妊娠的价值

目的探讨(早期)异位妊娠(EP)的经阴道超声(TVS)诊断应用价值.方法对146例不规则少量阴道流血(或)下腹痛的育龄妇女或停经后经腹B超(TAS)提示宫腔内未见孕囊者疑EP的均行TVS检查,观察宫内是否有孕囊,仔细寻找识别卵巢及肿块结构并分清其关系,必要时结合彩色多普勒,观察肿块血流成像,分晰其血流频谱.结果 TVS能很好地显示子宫、卵巢、未破孕囊及含血(块)肿块的声像结构.识别出完整的卵巢,是输卵管异位妊娠确诊的关键;彩色多普勒血流成像(CDFI)所记录的滋养层血流频谱或怪异频谱是二维TVS的补充,二者结合诊断EP的准确性高达97%.结论 TVS诊断EP简单、无创、准确性高,是诊断早期异位妊娠的首选方法.     

Intrauterine pseudogestational sac in ectopic pregnancy.

Ultrasonic diagnosis of ectopic pregnancy has been thought to depend on exclusion of intrauterine pregnancy on the basis of absence of an intrauterine gestational sac. Two cases illustrating intrauterine echoes suggesting a gestational sac associated with ectopic pregnancy and a plausible explanation for this phenomenon are presented. Because of this and the rare possibility of coexisting intrauterine and extrauterine pregnancies, the ultrasonographer must be wary of dismissing the possibility of an ectopic pregnancy because of an intrauterine gestational sac, whether real or apparent.     

Intramural pregnancy presenting in a patient with tuberous sclerosis

Intramural pregnancies are a rare form of ectopic pregnancy located within the myometrium separate from the endometrial cavity. In an effort to prevent potential complications, diagnosis should be made early when more conservative approaches can be performed to preserve reproductive potential. The diagnosis of ectopic pregnancies can be successfully accomplished through sonography; however, intramural pregnancies may be difficult to diagnose as they can appear similar to other etiologies. We present a unique case of a ruptured intramural pregnancy diagnosed with sonography and pelvic MRI in a patient with tuberous sclerosis. Surgical enucleation of the intramural pregnancy was successfully performed with postoperative resolution of beta hCG levels. © 2010 Wiley Periodicals, Inc. J Clin Ultrasound 38:393‐396, 2010     

Low-resistance endometrial arterial flow in the exclusion of ectopic pregnancy revisited.

The objective of this study was to evaluate the efficacy of endometrial arterial flow in the exclusion of ectopic pregnancy. From October 1997 to June 1999, 66 women with elevated beta-human chorionic gonadotropin titers and clinical indications of ectopic pregnancy were evaluated by endovaginal sonography. Women with a gestational sac containing an embryo, a yolk sac, or both were excluded from the study. Doppler ultrasonography was performed in the remaining cases when a definite intrauterine pregnancy could not be visualized. In all cases the thermal index was kept to less than 1.0, consistent with as-low-as-reasonably-achievable principles. Trophoblastic flow was defined as a resistive index of less than 0.6 within the endometrium. Statistical analysis was performed using a 2-tailed t test. Twenty women had ectopic pregnancies; 33 had spontaneous pregnancy losses; and 13 had normal intrauterine pregnancies. A total of 29 women had endometrial trophoblastic flow: 11 of 13 with intrauterine pregnancies, 1 of 20 with ectopic pregnancies, and 17 of 33 with spontaneous pregnancy losses. The negative predictive value for the presence of endometrial low-resistance flow for excluding ectopic pregnancy was 97%. The presence of low-resistance arterial endometrial flow can be a useful sign in diagnosing an early intrauterine pregnancy and decreasing the probability that an ectopic pregnancy is present, particularly in patients with otherwise normal ultrasonographic findings.     

Transvaginal sonographic diagnosis of live monochorionic twin ectopic pregnancy.

Ectopic pregnancy is a leading cause of pregnancy-related deaths; its incidence has progressively increased in recent years. Spontaneous twin ectopic pregnancy, however, is extremely rare. Among more than 100 reported cases of twin tubal pregnancies, only 5 cases in which fetal cardiac motion has been visualized in both embryos have been reported. We describe an additional case of a live monochorionic twin ectopic pregnancy in a patient with no predisposing factor. With transabdominal sonography, we initially diagnosed a single ectopic pregnancy, visualized as an ill-defined mass in the left adnexa. However, with transvaginal sonography, we determined the left adnexal mass to contain a single monochorionic gestational sac with 2 embryos, each with cardiac motion. These findings were confirmed with color Doppler sonography and at laparotomy. The introduction of high-resolution transvaginal sonography has resulted in the earlier diagnosis of ectopic pregnancy and has contributed to a recent decrease in the maternal mortality and morbidity associated with this condition.     

Ectopic uterine scar pregnancy: A case report

IntroductionImplantation of a gestational sac in a previous Caesarean section scar of the lower uterine segment is a rare form of ectopic pregnancy.Case reportWe report a case of Caesarean scar ectopic pregnancy in a 25-year-old female, diagnosed by ultrasonography and confirmed by magnetic resonance imaging. We present the clinical details, imaging findings, and management of the patient.DiscussionImaging plays an important role in the diagnosis of ectopic pregnancy and ultrasonography is the modality of choice. Ultrasonography features of scar ectopic pregnancy include empty uterus and cervix with normal endometrium and endocervical canal, gestational sac (with embryo and/or yolk sac) in the anterior part of the lower uterine segment in the region of the Caesarean scar with a thin myometrial layer between the bladder wall and gestational sac. Magnetic resonance imaging may be used as an adjunct imaging modality in cases with inconclusive or equivocal sonographic findings. Termination of pregnancy in the first trimester should be considered and treatment options should be individualized as there is no universal agreement on the best or most preferred treatment modality.ConclusionAwareness of specific ultrasound features of scar ectopic pregnancy is crucial for early recognition, correct diagnosis, and initiating prompt management to prevent complications.     

Ectopic pregnancy: transvaginal sonographic findings of 152 cases.

In a retrospective study performed on 152 cases of verified ectopic pregnancy, the features at transvaginal sonography were evaluated. A total of 146 (96%) of the patients had at least one abnormal sonographic feature and pelvic/cul-de-sac fluid was the most common finding, detected in all of the 146 patients. Pelvic/cul-de-sac fluid was particulate in 103 patients and simple in 43. Pelvic/cul-de-sac fluid together with extrauterine findings were found to be present in 93.8% (137/146) of the patients, suggesting the fact that if pelvic/cul-de-sac fluid was detected, every effort should be made to image the tube. The extrauterine transvaginal sonographic features included 102 (63.0%) patients with a mass, 60 (41.1%) with a gestational sac (with or without yolk sac or embryo), and eight (5.3%) with a living embryo. Comparison of the sonographic findings according to the status of the ectopic pregnancy revealed that particulate fluid (98.9%), and an extra-uterine mass (88.2%) were the features that aided in the diagnosis of ruptured and aborted ectopic pregnancies, whereas an extrauterine gestational sac (72.9%), and a living embryo (11.9%) were associated with intact ectopic pregnancies. Our findings support the practice of using transvaginal sonography, and ss-human chorionic gonadotropin measurements in the diagnosis and prediction of the status of ectopic pregnancy.     

剖宫产切口疤痕妊娠与宫颈妊娠的超声监测

目的:分析剖宫产切口疤痕妊娠与宫颈妊娠的超声声像变化特征,评价经阴道彩色多普勒超声在子宫下部异位妊娠诊治中的监测价值。方法:总结1995~2005年6月本院住院诊治的子宫下段剖宫产切口疤痕妊娠和宫颈妊娠病例,分析其彩色多普勒超声声像特征,追踪其临床转归及手术、病理结果。结果:剖宫产切口疤痕妊娠9例,宫颈妊娠5例,均由临床手术病理证实,根据经阴道彩色多普勒超声声像学特征分为4型:I型为胚胎存活型(5例),II型为胚胎停育有孕囊型(2例),III型为类滋养细胞疾病型(4例),IV型为绒毛退变型(3例)。I型全宫切除3例,保守治疗2例,II型2例均行全宫切除;III型全宫切除1例,经腹宫颈切开取绒毛术1例,余2例保守治疗;IV型均为保守治疗。结论:经阴道彩色多普勒超声对子宫下部异位妊娠能够提供较准确的定位定性诊断,正确的超声分型有助于临床选择合适的治疗方案,估计病程及转归。     

Conservative treatment of ectopic pregnancies using a single echo-guided injection of methotrexate into the gestational sac.

The authors describe the possibility of the conservative treatment of five early ectopic pregnancies. A single injection of methotrexate into the tubal gestational sac was performed under vaginal ultrasound guidance. In all five cases, a clear ectopic gestational sac could be visualized. The pregnancies dated from the 5th to the 7th week of amenorrhea. Strict ultrasound follow-up following injection showed a gradual reduction in the size of the tubal gestational sac. At the same time, plasma beta-hCG gradually decreased to zero after a maximum time period of 25 days. Subsequent hysterosalpingography performed on all of the women demonstrated bilateral normal patent tubes.It is concluded that, in selected patients, transvaginal injection provides an alternative relatively non-invasive approach to the management of ectopic pregnancy. It is proposed that the adoption of a policy of earlier diagnosis and treatment may lead to a reduction in the incidence of some tubal causes of infertility.     

经阴道超声诊断卵巢妊娠价值的初步探讨

目的评价经阴道超声对卵巢妊娠的诊断价值。方法回顾性分析21例卵巢妊娠的超声图像特征，并与手术及病理结果进行对照分析。结果所有病例经阴道超声检查均诊断为宫外孕，9例未破裂型卵巢妊娠中，经阴道超声检查进一步提示部位在卵巢者3例，在卵巢表面者3例，部位不清者1例，误诊为输卵管妊娠2例，定位符合率66．7％；12例破裂型卵巢妊娠中，经阴道超声检查均未进一步提示病灶部位。其声像图特征为：子宫正常或略大，宫腔内未见胚囊；卵巢内部或表面见完整的胚囊结构或不均质强回声；或附件区见杂乱不均质回声，其内可测及或未测及完整的胚囊结构，盆腹腔常见多量游离液体。结论经阴道超声对未破裂型卵巢妊娠的术前诊断有一定价值。     

经阴道超声诊断胚胎移植术后宫内外复合妊娠:60例分析

目的 评估经阴道超声诊断胚胎移植后宫内外复合妊娠的价值。方法 回顾性分析60例经手术证实的宫内外复合妊娠患者的经阴道超声资料,观察声像图特点,分析延迟诊断的原因,对比宫内胚芽及宫外胚芽长度。结果 经阴道超声诊断宫内外复合妊娠准确率为100%（60/60）。延迟诊断4例（4/60,6.67%）,其中3例存在卵巢过度刺激综合征,1例为漏诊。宫外异位妊娠表现为混合回声包块25例（25/60,41.67%）,不均质稍高回声包块17例（17/60,28.33%）,不均质中等回声包块1例（1/60,1.67%）,孕囊样回声17例（17/60,28.33%）。宫内妊娠表现为类孕囊1例（1/60,1.67%）,孕囊仅见卵黄囊10例（10/60,16.67%）,孕囊见卵黄囊及胚芽49例（49/60,81.67%）。宫内胚芽长（0.42±0.39）cm,宫外胚芽长（0.31±0.26）cm,差异有统计学意义（t=2.35,P=0.03）。结论 经阴道超声在诊断胚胎移植术后宫内外复合妊娠中具有重要意义。     

Ectopic pregnancy

Ectopic pregnancy occurs at a rate of 19.7 cases per 1,000 pregnancies in North America and is a leading cause of maternal mortality in the first trimester. Greater awareness of risk factors and improved technology (biochemical markers and ultrasonography) allow ectopic pregnancy to be identified before the development of life-threatening events. The evaluation may include a combination of determination of urine and serum human chorionic gonadotropin (hCG) levels, serum progesterone levels, ultrasonography, culdocentesis and laparoscopy. Key to the diagnosis is determination of the presence or absence of an intrauterine gestational sac correlated with quantitative serum beta-subunit hCG (beta-hCG) levels. An ectopic pregnancy should be suspected if transvaginal ultrasonography shows no intrauterine gestational sac when the beta-hCG level is higher than 1,500 mlU per mL (1,500 IU per L). If the beta-hCG level plateaus or fails to double in 48 hours and the ultrasound examination fails to identify an intrauterine gestational sac, uterine curettage may determine the presence or absence of chorionic villi. Although past treatment consisted of an open laparotomy and salpingectomy, current laparoscopic techniques for unruptured ectopic pregnancy emphasize tubal preservation. Other treatment options include the use of methotrexate therapy for small, unruptured ectopic pregnancies in hemodynamically stable patients. Expectant management may have a role when beta-hCG levels are low and declining.     

Spontaneous unilateral dizygotic twin tubal pregnancy

Spontaneous dizygotic unilateral twin tubal pregnancy is an extremely rare occurrence with a high risk for pregnancy-related mortality, and a diagnostic challenge for obstetricians. We present a case of a 27-year-old woman with spontaneous twin tubal pregnancy. Transvaginal color Doppler sonography revealed 2 separate gestational sacs within the right adnexa, each containing an embryo. Cytogenetic examination of the trophoblastic tissues confirmed the diagnosis of dizygotic twin ectopic pregnancy. Clinical signs and symptoms together with imaging studies help in the diagnosis of this rare variant of ectopic pregnancies.     

Ectopic pregnancy. Diagnosis by sonography correlated with quantitative HCG levels

Pelvic sonograms were correlated with simultaneous human chorionic gonadotropin (HCG) determinations in 150 women with early intrauterine pregnancy (N = 76) and ectopic pregnancy (N = 74). Of the 76 patients with intrauterine pregnancy (IUP), 55 had HCG levels exceeding 1,800 mIU/ml (Second International Standard), and in each case a gestational sac was identified. In comparison, 35 of 74 (47%) patients with ectopic pregnancy had HCG levels of 1,800 mIU/ml or more, and no case demonstrated a gestational sac. Although six patients (8%) with ectopic pregnancy demonstrated a "pseudogestational sac," no case was confused with a true gestational sac. We conclude that, when the HCG level exceeds 1,800 mIU/ml, an intrauterine gestational sac is normally detected and its absence is evidence for an ectopic pregnancy.     

Accuracy of transvaginal ultrasound and serum hCG in the diagnosis of ectopic pregnancy.

Transvaginal ultrasound was performed upon admission of 127 patients with a clinical suspicion of ectopic pregnancy in association with human chorionic gonadotropin (hCG) determination. Failure to visualize with sonography an intrauterine gestational sac with an hCG level superior to 1000 mIU/ml identified 25/42 tubal pregnancies with a positive predictive value of 86% and a specificity of 93%. Abnormal adnexal findings occurred in 95% of the ectopic pregnancies. Extrauterine gestational sacs with or without embryos could be confidently detected in 19 ectopic pregnancies (45%). A complex adnexal mass was seen in 19 cases and yielded a positive predictive value of 90% (19/21). Adnexal gestational sacs and complex masses were seen more frequently in those ectopic pregnancies with an hCG level above 1000 mIU/ml but the difference was not significant (100% versus 78%). Simple adnexal cysts were found more frequently in intrauterine pregnancies, and fluid in the cul-de-sac was also not indicative of ectopic pregnancy (positive predictive value, 29%). Transvaginal ultrasound has a primary role in the diagnosis of ectopic pregnancy. The combined use of uterine and adnexal sonography associated with elevated hCG levels allows a definitive diagnosis in the vast majority of cases at a very early stage, when the chances for a successful conservative treatment are greater.     

Three-dimensional transvaginal sonography of interstitial pregnancy

We describe the case of a 33-year-old pregnant woman, gravida 1 para 0, who was referred to us with a presumptive diagnosis of an interstitial pregnancy. The patient had had amenorrhea for 7 weeks and had previously undergone myomectomy. Two-dimensional sonographic examination revealed a gestational sac located outside the uterine cavity but could not define its exact anatomic position. Using transvaginal 3-dimensional sonography, we were able to correctly depict the sac, which was located where the fallopian tube crossed the uterine horn. We performed a cornual resection, during which the diagnosis of interstitial pregnancy was confirmed. The use of 3-dimensional sonography in this patient's case thus led to appropriate early treatment and avoidance of possible subsequent morbidity.