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中华妇幼临床医学杂志(电子版)

中华妇幼临床医学杂志(电子版) ›› 2020, Vol. 16 ›› Issue (02) : 161 -170. doi: 10.3877/cma.j.issn.1673-5250.2020.02.007

所属专题： 文献； 指南共识；

标准·方案·指南

《腹部放射学会和欧洲泌尿生殖放射学会关于胎盘植入性疾病MRI检查的联合共识声明》要点解读
王霞1, 赵福敏2, 李雅倩1, 宁刚2, 王晓东1,†()   
  1. 1. 四川大学华西第二医院妇产科、出生缺陷与相关妇儿疾病教育部重点实验室，成都　610041
    2. 四川大学华西第二医院放射科、出生缺陷与相关妇儿疾病教育部重点实验室，成都　610041
  • 收稿日期:2020-02-25 修回日期:2020-03-10 出版日期:2020-04-01
  • 通信作者: 王晓东

Interpretation of Society of Abdominal Radiology and European Society of Urogenital Radiology Joint Consensus Statement for MR Imaging of Placenta Accreta Spectrum Disorders

Xia Wang1, Fumin Zhao2, Yaqian Li1, Gang Ning2, Xiaodong Wang1,†()   

  1. 1. Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
    2. Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
  • Received:2020-02-25 Revised:2020-03-10 Published:2020-04-01
  • Corresponding author: Xiaodong Wang
  • About author:
    Corresponding author: Wang Xiaodong, Email:
  • Supported by:
    Key Research and Development Project of Science and Technology of Sichuan Province(2018SZ0265)
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引用本文：

王霞, 赵福敏, 李雅倩, 宁刚, 王晓东. 《腹部放射学会和欧洲泌尿生殖放射学会关于胎盘植入性疾病MRI检查的联合共识声明》要点解读[J]. 中华妇幼临床医学杂志(电子版), 2020, 16(02): 161-170.

Xia Wang, Fumin Zhao, Yaqian Li, Gang Ning, Xiaodong Wang. Interpretation of Society of Abdominal Radiology and European Society of Urogenital Radiology Joint Consensus Statement for MR Imaging of Placenta Accreta Spectrum Disorders[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2020, 16(02): 161-170.

2020年2月，由加州大学旧金山分校(UCSF)放射科医师牵头，联合欧洲放射学会(ESR)，在《欧洲放射学杂志》(European Radiology)在线刊出腹部放射学会(SAR)和欧洲泌尿生殖放射学会(ESUR)发布的《SAR和ESUR关于PAS的MRI检查的联合共识声明》(SAR and ESUR Joint Consensus Statement for MR Imaging of Placenta Accreta Spectrum Disorders)。该共识声明做出以下推荐，①使用规范化MRI技术方案，获取PAS影像学图像；②使用7项标准化专业术语判读PAS的MRI特点，并出具结构化诊断报告，包括胎盘内T2低信号带、胎盘/子宫膨出、胎盘后T2低信号线消失、子宫肌层变薄/中断、膀胱壁中断、胎盘局部外生团块和胎盘床异生血管。目前，我国孕妇的PAS发病率较高，三级医疗机构及绝大多数县级医疗机构，均配置MRI设备，但是对胎盘MRI影像学诊断的临床研究和应用迄今尚不规范，不能满足临床实践需求。笔者拟结合我国孕妇的PAS影像学诊断的临床实践，对《SAR和ESUR关于PAS的MRI检查的联合共识声明》要点进行解读，旨在为PAS的MRI临床诊断实践提供借鉴，便于达成多学科共识，规范PAS孕妇的围术期管理。产前根据胎盘侵犯的MRI诊断标准，相对准确鉴别诊断PAS类型，可为患者制定个体化的多学科诊治方案，避免术中意外事件发生，从而达到改善母儿结局的目的。

关键词: 胎盘植入性疾病, 磁共振成像, 围术期管理, 共识, 孕妇

In February 2020, Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) Joint Consensus Statement for MR Imaging of Placenta Accreta Spectrum Disorders (PAS) which was led by radiologists at the University of California, San Francisco (UCSF), and in conjunction with the European Society of Radiology (ESR) was published online in journal of European Radiology. The consensus statement recommends use of standardized MRI technology to obtain PAS images; meanwhile, it is recommended to use 7 pieces of standardized technical terms to interpret MRI characteristics of PAS and issue a structured diagnostic report, including intraplacental dark T2 bands, placental/uterine bulge, loss of low T2 retroplacental line, myometrial thinning/disruption, bladder wall interruption, focal exophytic placental mass and abnormal vascularization of placental bed. At present, the incidence of PAS is high in China. The tertiary medical institutions and the vast majority of county-level medical institutions are equipped with MRI equipment. However, the clinical research and application of placental imaging diagnosis have not been standardized so far and cannot meet needs of clinical practice in China. The authors intend to interpret the main points of the SAR and ESUR joint consensus statement on MRI of PAS, in conjunction with the clinical practice of imaging diagnosis of PAS in China, and aim to provide a reference for MRI practice of PAS, so as to reach a multidisciplinary consensus and regulate perioperative management of PAS, relatively accurate identification of PAS types before birth by MRI criteria for placental invasion, formulate individualized multidisciplinary diagnosis and treatment plan for patients, try to avoid intraoperative accidents, and improve maternal and fetal outcomes.

Key words: Placenta accrete spectrum disorders, Magnetic resonance imaging, Perioperative management, Consensus, Pregnant women
表1 胎盘MRI检查条件和技术关键推荐概要
临床项目 推荐概要
硬件 采用外表面线圈为1.5 T或3.0 T的MRI硬件系统
患者准备 对PAS孕妇进行MRI检查的理想时间是孕龄为28～32孕周。检查时，孕妇取仰卧位、膀胱适度充盈，无需使用静脉钆基造影剂
成像序列及平面 经子宫矢状位、冠状位、轴位2维T2W HASTE/SSFSE序列多平面成像，对评估PAS是必不可少的。轴向斜平面T2W序列应垂直于胎盘-子宫肌层界面，推荐扫描层厚≤4 mm，不推荐使用T2W脂肪抑制序列
表2 对PAS孕妇的胎盘侵袭形态，采取1.5 T MRI检查的推荐方案
参数 稳态序列 T2半傅立叶序列 T1 3D序列脂肪饱和技术 DWI
轴位 冠状位/矢状位 轴位 冠状位/矢状位 矢状位 轴位 轴位/矢状位
重复时间/回波时间(ms) 3.31/1.36 3.51/1.41 800/85 800/87 4.27/1.56 4.35/1.61 3 200/75
翻转角度(°) 60 60 120 120 10 10 10
视野(mm) 320～400 320～400 320～400 430 320～400 320～400 320～400
矩阵 256×192 320×270 320×216 384×256 256×256 256×192 256×192
并行采集因子 2 2 2 2 3 2 2
层厚(mm) 4 4 4 4 3 3 5
层间距(mm) 0.9～1.0 0 0.9～1.0 0 0 0 0
每个成像叠块层数(层) 35 20～24 35 20～24 40 72 －
每个叠块扫描时间(s) 20～15 18～10 20～15 16 21～18 17 180
成像叠块数(块) 2～3 1 2～3 1 1 2 1
表3 对PAS孕妇的胎盘侵袭形态，采取3.0 T MRI检查的推荐方案
参数 SSFSE(轴位/冠状位/矢状位) LAVA-Flex或Dixon双回波(胎盘中心轴位) SSFSE[非螺旋桨技术，胎盘上方冠状位/高分辨率成像(视野缩小)] DWI(可选择，胎盘中心轴位和矢状位) T2 FSE(非螺旋桨技术，可选择，胎盘中心轴位和矢状位)
重复时间/回波时间(ms) 2 000/100 4.2/1.2 2 000/100 5 000/30.5 4 000/120(轴位)、11 000/74(矢状位)
翻转角度(°) － 15 － － 120(轴位)
激发次数(次) － 1 － 2 2
层厚/层间距(mm) 4/0 3/0 4/0 6/0 4/0
矩阵 384×256 260×256 384×256 80×80 320×256
视野(mm) 360 340 260～280 340 240
相位 右至左 前至后 右至左 － 右至左
过度采样 PE FOV 1.0 PE FOV 1.1 PE FOV 1.0 PE FOV 1 无相位卷褶
表4 文献复习总结辅助诊断PAS的MRI特点及其判读的标准化术语
MRI特点 定义 准确率(基于专家意见)
T2W胎盘内低信号带 T2WI可见胎盘内≥1个低信号区，一般呈线性结构，常连接胎盘母体面 90%(95%CI：65%～93%)
胎盘/子宫膨出 胎盘组织向邻近器官，通常为膀胱和宫旁组织膨出，导致子宫浆膜偏离正常位置。子宫浆膜可能完整，但是其轮廓、形态异常 100%(95%CI：92%～100%)
T2W低信号线消失 T2WI可看到胎盘床后面的一条低信号细线消失 90%(95%CI：84%～96%)
子宫肌层变薄 胎盘附着部位子宫肌层变薄，可仅为<1 mm，甚至不可见 90%(95%CI：87%～95%)
膀胱壁中断 正常的低信号膀胱壁不规则或中断，可伴随膀胱腔内积血形成 100%(95%CI：97%～100%)
局部外生团块 可见胎盘组织突出于子宫壁，并进一步延伸超过子宫壁。最常见胎盘组织部分或全部充满膀胱腔，或向侧面突向宫旁组织 95%(95%CI：95%～100%)
胎盘床异生血管 胎盘床血管增多，伴随子宫胎盘界面中断。胎盘床异生血管可能以不同程度延伸至附着部位子宫肌层，甚至到达子宫浆膜，并可能伴有膀胱、子宫和阴道周围的新生血管形成 100%(95%CI：96%～100%)
胎盘内信号不均 在T1W和T2W序列上，可见胎盘内信号不均匀分布 70%(95%CI：58%～81%)
胎盘不对称增厚/形状 与其他位置胎盘组织相比，PAS孕妇的胎盘，通常是覆盖子宫内口的部位(在前置胎盘情况下)，发生不对称增厚/形状 50%(95%CI：39%～61%)
胎盘缺血性梗死 在胎盘缺血性梗死急性期，出现T2W高信号区和TIW低信号区；在胎盘缺血性梗死非急性期，可见胎盘慢性梗死部位，出现缺血不对称变薄 60%(95%CI：49%～70%)
胎盘内异常血管 在T2WI上，可见胎盘内部深处弯曲、扩大的血管流空的胎盘内异常血管 70%(95%CI：65%～79%)
图1 正常胎盘和子宫肌层MRI特点示意图
图2 PAS孕妇胎盘MRI检查可见T2W胎盘内低信号带[图2A：PAS孕妇胎盘MRI检查的T2W胎盘内低信号带示意图。PAS孕妇胎盘边缘不规则的低信号条带，通常与胎盘母体面相连。图2B：胎盘轴位MRI特点，可见多个T2W胎盘内低信号带(箭头所示)，并且与胎盘胎儿面相连。图2C：宫颈矢状位MRI特点，可见前置胎盘]
图3 PAS孕妇胎盘MRI检查可见胎盘/子宫膨出[图3A：PAS孕妇胎盘MRI检查的胎盘/子宫膨出示意图。PAS胎盘组织异常膨出，引起子宫浆膜偏离正常位置，通常伴有膨出区域的子宫肌层变薄。图3B：PAS孕妇胎盘矢状位MRI特点，可见胎盘组织异常膨出(箭头所示)，使子宫浆膜偏离正常位置，轮廓形状变形，胎盘内还可见信号不均匀的T2W暗带和异常血管]
图4 PAS孕妇胎盘MRI检查可见胎盘后低信号线消失[图4A：PAS孕妇胎盘MRI检查的胎盘后低信号线消失示意图。PAS胎盘、子宫界面内层连续，线性T2低信号蜕膜层消失。图4B：PAS孕妇胎盘矢状位MRI特点，可见胎盘床后T2低信号线消失(白色箭头所示)，正常胎盘、子宫肌层界面T2低信号线(黑色箭头所示)]
图5 PAS孕妇胎盘MRI检查可见子宫肌层变薄[图5A：PAS孕妇胎盘MRI检查的子宫肌层变薄示意图。PAS胎盘附着部位子宫肌层变薄至厚度<1 mm，甚至不可见(变薄程度可不相同)。图5B：PAS孕妇轴位MRI检查，可见子宫肌层外层/子宫浆膜T2W低信号线(白色箭头所示)，但是胎盘子宫界面内层低信号线消失，可见正常胎盘子宫肌层"三明治"分层表现(黑色箭头所示)，子宫肌层内可见多个低信号流空血管影]
图6 PAS孕妇胎盘MRI检查可见低信号膀胱壁不规则或中断[图6A：PAS孕妇胎盘MRI检查的低信号膀胱壁不规则或中断示意图。PAS胎盘组织侵入膀胱顶，导致膀胱壁中断。图6B、6C：PAS孕妇胎盘矢状位MRI特点，可见胎盘侵入膀胱顶，引起低信号膀胱壁中断(黑色箭头所示)；可见弯曲的低信号流空血管影(短白色箭头所示)，以及膀胱"帐篷征"(长白色箭头所示)]
图7 PAS孕妇胎盘MRI检查可见局灶外生团块[图7A：PAS孕妇胎盘MRI检查的局灶外生团块示意图。PAS胎盘组织穿透子宫壁向外突出，呈局部外生团块。图7B：PAS孕妇胎盘轴位MRI特点，可见胎盘向宫旁组织突出，并呈团块状外观(箭头所示)]
图8 PAS孕妇胎盘MRI检查可见胎盘床异生血管[图8A：PAS孕妇胎盘MRI检查的胎盘床异生血管示意图。PAS孕妇胎盘床明显增多的血管，伴胎盘子宫界面内层信号线中断。图8B：PAS孕妇胎盘矢状位MRI特点，可见胎盘床明显增多的血管影(长箭头所示)，伴胎盘子宫界面中断，还可见向子宫肌层延伸至子宫浆膜的血管影(短箭头所示)。图8C：PAS孕妇胎盘轴位MRI特点，可见胎盘床明显增多的血管影(箭头所示)]
图9 PAS孕妇胎盘MRI检查可见胎盘内信号不均[图9A：PAS孕妇胎盘MRI检查的胎盘内信号不均示意图。PAS胎盘内除T2W低信号带及异常血管以外的信号不均匀改变。图9B：PAS孕妇胎盘冠状位MRI特点，可见胎盘呈信号不均匀表现，可见T2W低信号带(箭头所示)及异常血管影]
图10 PAS孕妇胎盘MRI检查可见胎盘不对称增厚/形状[图10A：PAS孕妇胎盘MRI检查的胎盘不对称增厚/形状示意图。PAS胎盘不对称增厚/形状，可伴其他特征表现，如T2W低信号带。图10B：PAS孕妇胎盘矢状位MRI特点，可见与正常部位胎盘(黑色箭头所示)相比，植入部位胎盘出现不均匀增厚(白色箭头所示)]
图11 PAS孕妇胎盘MRI检查可见胎盘缺血性梗死[图11A：PAS孕妇胎盘MRI检查的胎盘缺血性梗死示意图。PAS胎盘因梗死区域胎盘组织局部丢失而异常变薄。图11B：PAS孕妇胎盘矢状位MRI特点，可见慢性梗死部位胎盘呈不对称变薄(箭头指示)，小部分变薄的胎盘组织仍存在可排除副胎盘可能性]
图12 PAS孕妇胎盘MRI检查可见胎盘内血管异常[图12A：PAS孕妇胎盘MRI检查的胎盘内血管异常示意图。正常胎盘内无大的流空血管影，PAS胎盘深处出现弯曲、扩大的流空血管影，胎盘深处的血管极度不正常，尤其在远离脐带插入部位。图12B：PAS孕妇胎盘冠状位MRI特点，可见胎盘深处异常血管和弯曲、扩大的流空血管影(箭头指示)]
图13 MRI检查可见将子宫划分为S1和S2区域[矢状位MRI特点，垂直于膀胱后壁中央的直线，将子宫划分为直线上方的S1区域和直线下方的S2区域。在S2区域可见子宫肌层信号中断(白色箭头所示)]
表5 PAS孕妇胎盘MRI检查结果的结构化报告
结构化报告项目 结构化报告项目
临床诊断报告项目a 胎盘侵袭检测b
? 年龄 ? 胎盘内T2低信号带
? 孕龄 ? 胎盘/子宫膨出
? 剖宫产术分娩史、次数 ? 胎盘后T2低信号线消失
? 相关超声检查结果报告(如果有) ? 子宫肌层变薄
MRI检查报告项目 ? 膀胱壁中断
? 是否存在前置胎盘 ? 局部外生团块
? 胎盘侵袭位置 ? 胎盘床异生血管
MRI：胎盘侵袭深度 ? 胎盘内信号不均
? PA或PI ? 胎盘不对称增厚/形状
? PP ? 胎盘缺血性梗死
胎盘侵袭至子宫外MRI特点 ? 胎盘内异常血管
? 膀胱受累：累及部位及结构 MRI：胎盘侵袭部位c
? 宫旁受累：累及部位及结构 ? ?
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