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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) ›› 2022, Vol. 18 ›› Issue (05) : 606 -614. doi: 10.3877/cma.j.issn.1673-5250.2022.05.016

论著

三维盆底超声预测产妇发生盆腔脏器脱垂的价值及影响因素
赵春桃1,†(), 梁峰雪1, 杨瑞敏1, 陈云璇1, 陈曦1, 焦桂清2   
  1. 1河北北方学院附属第一医院超声医学科，张家口　075000
    2河北北方学院附属第一医院妇产科，张家口　075000
  • 收稿日期:2022-04-27 修回日期:2022-09-12 出版日期:2022-10-01
  • 通信作者: 赵春桃

Value of three-dimensional pelvic floor ultrasound in predicting the occurrence of pelvic organ prolapse in parturients and its influencing factors

Chuntao Zhao1,†(), Fengxue Liang1, Ruimin Yang1, Yunxuan Chen1, Xi Chen1, Guiqing Jiao2   

  1. 1Department of Ultrasound Medicine, The First Affiliated Hospital of Hebei North University, Zhangjiakou 075000, Hebei Province, China
    2Department of Obstetrics and Gynecology, The First Affiliated Hospital of Hebei North University, Zhangjiakou 075000, Hebei Province, China
  • Received:2022-04-27 Revised:2022-09-12 Published:2022-10-01
  • Corresponding author: Chuntao Zhao
  • Supported by:
    Scientific Research Fund of Hebei Provincial Health Department(20150473)
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引用本文：

赵春桃, 梁峰雪, 杨瑞敏, 陈云璇, 陈曦, 焦桂清. 三维盆底超声预测产妇发生盆腔脏器脱垂的价值及影响因素[J]. 中华妇幼临床医学杂志(电子版), 2022, 18(05): 606-614.

Chuntao Zhao, Fengxue Liang, Ruimin Yang, Yunxuan Chen, Xi Chen, Guiqing Jiao. Value of three-dimensional pelvic floor ultrasound in predicting the occurrence of pelvic organ prolapse in parturients and its influencing factors[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2022, 18(05): 606-614.

目的

探讨三维盆底超声结果对产妇发生盆腔脏器脱垂(POP)的预测价值及影响因素。

方法

采用随机数字表法，随机选择2019年4月至2022年2月，于河北北方学院附属第一医院收治的40例POP产妇为研究对象，纳入研究组。采用相同方法随机选择同期于本院进行产后复查的盆底功能正常产妇40例纳入对照组。对2组受试者均于产后6个月时，进行三维盆底超声检查。对其相关临床资料与三维盆底超声检测结果，采用成组t检验、χ2检验进行统计学比较。采用受试者工作特征(ROC)曲线及其曲线下面积(AUC)，评价三维盆底超声结果单独及联合应用，对产妇发生POP的预测价值。采用多因素logistic回归分析产妇发生POP的影响因素，并采用ROC曲线、C指数及校准曲线评估该多因素logistic回归模型对产妇发生POP的预测准确性。2组受试者年龄等一般临床资料比较，差异均无统计学意义(P>0.05)。本研究遵循的程序符合2013年新修订的《世界医学协会赫尔辛基宣言》要求。

结果

①研究组患者顺产、有会阴侧切/裂伤史及未进行Kegel训练者占比，均显著高于对照组，并且差异均有统计学意义(χ2＝10.03、8.57、6.47，P＝0.002、0.003、0.039)。②研究组患者的膀胱颈旋转角(BNRA)、膀胱尿道后角(PUA)、膀胱颈倾斜角(BNIA)、膀胱颈活动度(BND)、最大缩肛状态下肛提肌裂孔面积(AC-LHA)、静息状态下肛提肌裂孔面积(R-LHA)、最大Valsalva动作下肛提肌裂孔面积(V-LHA)，均显著大于对照组，并且差异均有统计学意义(t＝13.82、15.36、10.35、6.86、5.41、3.38、6.98，P<0.001)。③三维盆底超声7项(BNRA、PUA、BNIA、BND、AC-LHA、R-LHA、V-LHA)检测结果对预测产妇发生POP的ROC曲线分析显示，上述7项超声结果分别单独及联合预测产妇发生POP的AUC分别为0.745(95%CI：0.611~0.879，P<0.001)，0.796(95%CI：0.692~0.906，P<0.001)，0.720(95%CI：0.593~0.847，P＝0.001)，0.701(95%CI：0.561~0.840，P＝0.002)，0.679(95%CI：0.545~0.813，P＝0.005)，0.653(95%CI：0.520~0.786，P＝0.008)，0.712(95%CI：0.577~0.845，P＝0.001)及0.851(95%CI：0.743~0.959，P<0.001)。④以POP产妇为因变量，以分娩方式、会阴侧切/裂伤、Kegel训练、上述7项超声结果为自变量进行多因素非条件logistic回归分析结果显示，顺产、有会阴侧切/裂伤史、BNRA>30°、PUA>135°、BNIA>54°、BND>18 mm、AC-LHA≥13 cm2、R-LHA≥17 cm2、V-LHA≥18 cm2，均是产妇发生POP的独立危险因素(OR＝3.800、2.238、5.689、5.992、5.199、4.288、3.301、2.723、4.732，95%CI：2.814~6.596、2.110~4.176、3.556~9.631、3.707~10.087、3.362~8.846、3.009~7.376、2.592~5.819、2.291~4.964、3.179~8.095，P<0.05)；Kegel训练对产后盆底有保护作用(OR＝0.596，95%CI：0.518~0.674，P＝0.008)；该模型对预测产妇发生POP的AUC为0.822(95%CI：0.759~0.885)，敏感度为94.2%，特异度为60.1%；该模型的C指数为0.809(95%CI：0.744~0.874)，对产妇发生POP的区分度较好，该模型的Hosmer-Lemeshow检验P值为0.870，校准度较高。对该模型的内部数据验证结果显示，校正C指数为0.814(95%CI：0.750~0.878)，Hosmer-Lemeshow检验P值为0.894；对该模型的校准度进行验证显示，预测产妇发生POP的校准图中，理想曲线与实际曲线吻合较好，偏倚校正曲线偏移较小，表明其对产妇发生POP预测与实际的一致性良好。

结论

三维盆底超声各项检测联合应用，对产妇发生POP预测准确度较高。顺产、有会阴侧切/裂伤及BNRA>30°、PUA>135°、BNIA>54°、BND>18 mm、AC-LHA≥13 cm2、R-LHA≥17 cm2、V-LHA≥18 cm2，均是产妇发生POP的独立危险因素，而Kegel训练则对产后盆底有保护作用。

关键词: 盆腔器官脱垂, 产后期, 三维盆底超声检查, 预测价值, 影响因素分析, 女(雌)性
Objective

To explore the value of three-dimensional pelvic floor ultrasound results in predicting the occurrence of pelvic organ prolapse (POP) in parturients and its influencing factors.

Methods

By random number table method, a total of 40 patients with postpartum POP admitted to the First Affiliated Hospital of Hebei North University from April 2019 to February 2022 were randomly selected for the study and included into study group. And 40 cases of parturients with normal pelvic floor function who underwent postpartum reexamination in the same hospital during the same period were selected as controls by random number table method and were included into control group. Subjects in two groups all received three-dimensional pelvic floor ultrasound 6 months after delivery. Relevant clinical data and three-dimensional pelvic floor ultrasound results of two groups were compared by independent-samples t test and chi-square test. The receiver operating characteristic (ROC) curve and its area under the curve (AUC) were used to evaluate the predictive value of three-dimensional pelvic floor ultrasound results alone and in combination for the occurrence of POP in parturients. Multivariate logistic regression analysis was used to analyze the influencing factors of POP in parturients, and the ROC curve, C-index and calibration curve were used to evaluate the predictive accuracy and discriminating ability of this multivariate logistic regression model for the occurrence of POP in parturients. There was no significant difference in general clinical data between two groups, such as age (P>0.05). The study met the requirements of Helsinki Declaration of World Medical Association newly revised 2013.

Results

①The proportions of patients with spontaneous labor, history of lateral episiotomy/laceration and without Kegel training in study group were significantly higher than those in control group, and the differences were statistically significant (χ2=10.03, 8.57, 6.47; P=0.002, 0.003, 0.039). ②The bladder neck rotation angle (BNRA), posterior urethrovesical angle (PUA), bladder neck inclination angle (BNIA), bladder neck distance (BND), anal constriction-levator hiatus area (AC-LHA), rest-levator hiatus area (R-LHA), Valsalva-levator hiatus area (V-LHA) in study group were significantly higher than those in control group, and the differences were statistically significant (t=13.82, 15.36, 10.35, 6.86, 5.41, 3.38, 6.98; all P<0.001). ③The ROC curve analysis results of 7 parameters of three-dimensional pelvic floor ultrasound (BNRA, PUA, BNIA, BND, AC-LHA, R-LHA, V-LHA) for predicting the occurrence of POP in parturients showed that the AUC of these 7 parameters alone and the combination of these 7 parameters for predicting the occurrence of POP in parturients were 0.745 (95%CI: 0.611-0.879, P<0.001), 0.796 (95%CI: 0.692-0.906, P<0.001), 0.720 (95%CI: 0.593-0.847, P=0.001), 0.701 (95%CI: 0.561-0.840, P=0.002), 0.679 (95%CI: 0.545-0.813, P=0.005), 0.653 (95%CI: 0.520-0.786, P=0.008), 0.712 (95%CI: 0.577-0.845, P=0.001) and 0.851 (95%CI: 0.743-0.959, P<0.001), respectively. ④Multivariate unconditional logistic regression analysis with whether the subjects were postpartum POP as dependent variable, and mode of delivery, lateral episiotomy/laceration, Kegel training, the above 7 ultrasound parameters as the independent variables showed that spontaneous labor, history of lateral episiotomy/laceration, BNRA>30°, PUA>135°, BNIA>54°, BND>18 mm, AC-LHA≥13 cm2, R-LHA≥17 cm2, and V-LHA≥18 cm2 all were independent risk factors for the occurrence of POP in parturients (OR=3.800, 2.238, 5.689, 5.992, 5.199, 4.288, 3.301, 2.723, 4.732; 95%CI: 2.814-6.596, 2.110-4.176, 3.556-9.631, 3.707-10.087, 3.362-8.846, 3.009-7.376, 2.592-5.819, 2.291-4.964, 3.179-8.095; all P<0.05); Kegel training had a protective effect on postpartum pelvic floor (OR=0.596, 95%CI: 0.518-0.674, P=0.008). AUC of the multivariate unconditional logistic regression model for predicting the occurrence of POP in parturients was 0.822 (95%CI: 0.759-0.885), with a sensitivity of 94.2% and specificity of 60.1%. The C-index of this model was 0.809 (95%CI: 0.744-0.874), indicating that the model was well differentiated, and P-value of Hosmer-Lemeshow test for this model was 0.870, indicating that the model was well calibrated. Internal data validation of the model showed that the corrected C-index was 0.814 (95%CI: 0.750-0.878) and P-value of the Hosmer-Lemeshow test was 0.894; meanwhile, the validation of calibration of the prediction model showed that the ideal curve in calibration plot for predicting postpartum POP matched good with the actual curve, and the bias calibration curve had a small bias, indicating good agreement between its prediction and actual of POP occurrence in parturients.

Conclusions

The accuracy of combined application of all three-dimensional pelvic floor ultrasound parameters to predict the occurrence of POP in parturients is high. Spontaneous delivery, history of lateral episiotomy/laceration and BNRA>30°, PUA>135°, BNIA>54°, BND>18 mm, AC-LHA≥13 cm2, R-LHA≥17 cm2, and V-LHA≥18 cm2 are independent risk factors for the occurrence of POP in parturients, while Kegel training has a protective effect on the postpartum pelvic floor.

Key words: Pelvic organ prolapse, Postpartum period, Three-dimensional pelvic floor ultrasound, Predictive value, Root cause analysis, Female
表1 2组受试者相关临床资料比较
组别 例数 年龄(岁，±s) BMI(kg/m2，±s) 孕次(次，±s) 产次(次，±s) 分娩时孕龄(周，±s) 分娩间隔时间(月，±s) GDM[例数(%)] HDCP[例数(%)]
研究组 40 34.5±2.3 26.3±3.3 1.5±1.1 1.2±0.6 39.0±1.3 31.5±5.5 6(15.0) 10(25.0)
对照组 40 34.1±2.2 25.0±3.05 1.1±1.0 1.0±0.5 39.1±1.3 32.0±5.7 8(20.0) 15(37.5)
统计量   t＝0.81 t＝1.86 t＝1.70 t＝1.80 t＝0.10 t＝0.38 χ2＝0.35 χ2＝1.45
P值   0.418 0.067 0.093 0.076 0.917 0.708 0.556 0.228
组别 例数 妊娠期心脏病[例数(%)] 新生儿出生体重[例数(%)] 分娩方式[例数(%)] 难产史[例数(%)] 妇科手术史[例数(%)]a
<3 kg 3~4 kg >4 kg 顺产 剖宫产术
研究组 40 5(12.5) 7(17.5) 25(62.5) 8(20.0) 30(75.0) 10(25.0) 5(12.5) 15(37.5)
对照组 40 3(7.5) 5(12.5) 20(50.0) 15(37.5) 17(42.5) 23(57.5) 2(5.0) 12(30.0)
统计量   χ2＝0.56 χ2＝3.02 χ2＝10.03 χ2＝1.41 χ2＝0.50
P值   0.456 0.221 0.002 0.235 0.478
组别 例数 会阴侧切/裂伤史[例数(%)] Kegel训练[例数(%)] 产后开始工作时间[例数(%)]
0 >0~2次/周 >2次/周 ≤3个月 >3~6个月 >6~12个月 >12个月
研究组 40 18(45.0) 27(67.5) 9(22.5) 4(10.0) 8(20.0) 22(55.0) 6(15.0) 4(10.0)
对照组 40 6(15.0) 16(40.0) 14(35.0) 10(25.0) 9(22.5) 20(50.0) 6(15.0) 5(12.5)
统计量   χ2＝8.57 χ2＝6.47 χ2＝0.26
P值   0.003 0.039 0.966
表2 2组受试者三维盆底超声结果比较(±s)
组别 例数 BNRA(°) PUA(°) BNIA(°) BND(mm) AC-LHA(cm2) R-LHA(cm2) V-LHA(cm2)
研究组 40 40.7±9.4 153.4±10.2 64.5±12.5 21.3±4.9 15.0±2.9 18.6±3.1 21.9±5.0
对照组 40 19.3±2.6 118.1±10.3 43.4±3.1 15.3±2.3 10.7±4.1 16.2±3.2 15.0±3.7
t值   13.82 15.36 10.35 6.86 5.41 3.38 6.98
P值   <0.001 <0.001 <0.001 <0.001 <0.001 0.001 <0.001
图1 研究组1例患者(25岁)静息状态和最大Valsalva动作下盆底及肛提肌裂孔超声图(图1A、1B：分别为静息状态与最大Valsalva动作下盆底矢状面超声图，可见尿道内口呈漏斗样改变；图1C、1D：分别为静息状态及最大Valsalva动作下肛提肌裂孔冠状面超声图，可见直肠膨出；图1E：静息状态下肛提肌裂孔横断面超声图；图1F：最大Valsalva动作下肛提肌裂孔三维超声重建图)
表3 三维盆底超声结果预测产妇发生POP的ROC曲线分析
三维盆底超声结果 AUC AUC 95%CI P值 最佳临界值 敏感度(%) 特异度(%) 约登指数
BNRA(°) 0.745 0.611~0.879 <0.001 30 70.8 61.5 0.313
PUA(°) 0.796 0.692~0.906 <0.001 135 77.7 82.6 0.603
BNIA(°) 0.720 0.593~0.847 0.001 54 66.7 64.5 0.312
BND(mm) 0.701 0.561~0.840 0.002 18 64.4 58.0 0.224
AC-LHA(cm2) 0.679 0.545~0.813 0.005 13 63.0 54.5 0.175
R-LHA(cm2) 0.653 0.520~0.786 0.008 17 60.2 51.9 0.121
V-LHA(cm2) 0.712 0.577~0.845 0.001 18 65.7 61.5 0.272
上述7项结果联合 0.851 0.743~0.959 <0.001 — 90.1 81.2 0.713
图2 三维盆底超声结果预测产妇发生POP的ROC曲线注：POP为盆腔脏器脱垂。ROC曲线为受试者工作特征曲线。BNRA为膀胱颈旋转角，PUA为膀胱尿道后角，BNIA为膀胱颈倾斜角，BND为膀胱颈活动度，AC-LHA为最大缩肛状态下肛提肌裂孔面积，R-LHA为静息状态下肛提肌裂孔面积，V-LHA为最大Valsalva动作下肛提肌裂孔面积
表4 影响产妇发生POP因素的多因素非条件logistic回归分析
影响因素 B SE Wald值 P OR值 OR值95%CI
顺产 1.335 0.318 17.624 0.008 3.800 2.814~6.596
有会阴侧切/裂伤史 0.806 0.277 8.464 0.019 2.238 2.110~4.176
有Kegel训练 -0.518 0.242 4.581 0.046 0.596 0.518~0.674
BNRA>30° 1.739 0.315 30.474 <0.001 5.689 3.556~9.631
PUA>135° 1.790 0.309 33.552 <0.001 5.992 3.707~10.087
BNIA>54° 1.648 0.325 25.709 0.003 5.199 3.362~8.846
BND>18 mm 1.456 0.322 20.443 0.005 4.288 3.009~7.376
AC-LHA≥13 cm2 1.194 0.305 15.322 0.009 3.301 2.592~5.819
R-LHA≥17 cm2 1.002 0.293 12.166 0.012 2.723 2.291~4.964
V-LHA≥18 cm2 1.554 0.324 23.003 0.004 4.732 3.179~8.095
图5 影响产妇发生POP因素的多因素非条件logistic回归模型的内部验证校准图
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