流产手术后妊娠物残留疑似子宫动静脉瘘鉴别诊治分析

doi:10.12280/gjszjk.20210506

摘要/Abstract

摘要：

子宫动静脉瘘（uterine arteriovenous fistula,UAVF）属于子宫血管病变,是指子宫动脉分支与静脉分支之间绕过毛细血管网出现异常的直接交通。获得性UAVF常继发于子宫的创伤;由于流产手术后妊娠物残留与UAVF的B超表现存在一定的相似性,可能会干扰UAVF诊断的准确性。报道1例流产手术后B超提示子宫左后壁混合性块伴极丰富血流信号疑似UAVF病例,经过口服短效避孕药后行宫腔镜手术,最终确诊为妊娠物残留。结合文献复习,为流产手术后妊娠物残留与UAVF的鉴别诊治及预防提供经验。

关键词: 动静脉瘘, 子宫疾病, 胎盘, 滞留, 流产, 人工, 避孕, 妊娠物残留

Abstract:

Uterine arteriovenous fistula (UAVF) belongs to uterine vascular disease, which refers to the abnormal direct traffic between uterine artery branches and vein branches by passing the capillary network. The acquired UAVF is often secondary to uterine trauma. Due to the certain similarity in the B-ultrasound manifestations between pregnancy residue after abortion and UAVF, the accuracy of diagnosis may be interfered. A case of mixed mass of left posterior wall of uterus with extremely rich blood flow signals and suspected UAVF was reported. After oral short-acting contraceptive, hysteroscopic surgery was performed, and the pregnancy residue was diagnosed. Combined with literature review, this case report provided us more experience for the differential diagnosis, treatment and prevention of pregnancy residue after abortion and UAVF.

Key words: Arteriovenous fistula, Uterine diseases, Placenta, retained, Abortion, induced, Contraception, Pregnancy residue

王玉楣, 何晓英. 流产手术后妊娠物残留疑似子宫动静脉瘘鉴别诊治分析[J]. 国际生殖健康/计划生育, 2022, 41(2): 125-128.

WANG Yu-mei, HE Xiao-ying. Differential Diagnosis and Treatment of Suspected Uterine Arteriovenous Fistula or Pregnancy Residue after Abortion[J]. Journal of International Reproductive Health/Family Planning, 2022, 41(2): 125-128.

图/表 4

图1 2021年6月16日B超检查图像注：子宫左后壁见混合性回声,范围34 mm×34 mm×35 mm,边界不清晰,内达宫腔,外达浆膜层,内呈蜂窝状弱回声,较大者24 mm×7 mm×10 mm,彩色多普勒血流显像（color Doppler flow imaging,CDFI）见极丰富血流信号。

图2 2021年6月17日增强MRI图像注：A为MRI平扫图像,示宫底部肌层信号紊乱,约41 mm×36 mm×46 mm,局部宫腔黏膜显示不清,宫底肌层斑片状混杂信号影伴多发迂曲流空血管影。B为增强MRI图像,示宫底肌层显示不规则强化,与内膜边界不清。子宫后壁肌壁间见类圆形T1WI等、T2WI低信号,较大的直径约7 mm,增强后不均匀强化

图3 2021年6月21日复查B超图像注：子宫左后壁可见混合回声区,范围30 mm×16 mm×17 mm,内回声不均匀,可见不规则弱回声区,内见沸水征,其内及周边可见丰富血流信号,收缩期峰值速率（peak systolic velocity,PSV）为166.62 cm/s,阻力指数（resistance index,RI）为0.34,该混合回声区外缘距浆膜层约3.6 mm。

图4 2021年9月1日B超图像注：宫腔底部见混合性回声,大小14 mm×21 mm×21 mm,边界清晰,其混合回声下方见血流信号,来自于前壁肌层,RI为0.46。右前壁宫底部见低回声,大小20 mm×26 mm×24 mm,CDFI见血流信号。PSV为15.17 cm/s,RI为0.72。

参考文献 19

[1]	Chen LK, Yang BL, Chen KC, et al. Successful Transarterial Embolization of Uterine Arteriovenous Malformation: Report of Three Cases[J]. Iran J Radiol, 2016, 13(1):e15358. doi: 10.5812/iranjradiol.15358. doi: 10.5812/iranjradiol.15358
[2]	Wang Z, Chen J, Shi H, et al. Efficacy and safety of embolization in iatrogenic traumatic uterine vascular malformations[J]. Clin Radiol, 2012, 67(6):541-545. doi: 10.1016/j.crad.2011.11.002. doi: 10.1016/j.crad.2011.11.002 pmid: 22261390
[3]	Callen PW. Ultrasonography in obstetrics and gynecology[M]. 4th ed. Philadelphia:WB Saunders, 2000.
[4]	Corusic A, Barisic D, Lovric H, et al. Successful laparoscopic bipolar coagulation of a large arteriovenous malformation due to invasive trophoblastic disease: a case report[J]. J Minim Invasive Gynecol, 2009, 16(3):368-371. doi: 10.1016/j.jmig.2009.01.012. doi: 10.1016/j.jmig.2009.01.012 URL
[5]	来芳, 谢亚羽, 曹亚芳, 等. 超声检查诊断宫腔内妊娠物残留临床价值分析[J]. 医学影像学杂志, 2012, 22(12):2131-2132. doi: 10.3969/j.issn.1006-9011.2012.12.061. doi: 10.3969/j.issn.1006-9011.2012.12.061
[6]	Chapman DR, Lutz MH. Report of a successful delivery after nonsurgical management of a choriocarcinoma-related pelvic arteriovenous fistula[J]. Am J Obstet Gynecol, 1985, 153(2):155-157. doi: 10.1016/0002-9378(85)90102-4. doi: 10.1016/0002-9378(85)90102-4 pmid: 4037010
[7]	Orhan K, Icen M, Aksoy S, et al. Large arteriovenous malformation of the oromaxillofacial region with multiple phleboliths[J]. Oral Surg Oral Med Oral Pathol Oral Radiol, 2012, 114(4):e147-e158. doi: 10.1016/j.oooo.2012.05.007. doi: 10.1016/j.oooo.2012.05.007 URL
[8]	Baughman WC, Corteville JE, Shah RR. Placenta accreta: spectrum of US and MR imaging findings[J]. Radiographics, 2008, 28(7):1905-1916. doi: 10.1148/rg.287085060. doi: 10.1148/rg.287085060 URL
[9]	Lalitha N, Seetha P, Shanmugasundaram R, et al. Uterine Arteriovenous Malformation: Case Series and Literature Review[J]. J Obstet Gynaecol India, 2016, 66(4):282-286. doi: 10.1007/s13224-015-0680-2. doi: 10.1007/s13224-015-0680-2 URL
[10]	殷亚东, 刘岚. 子宫动静脉瘘引起晚期产后出血的诊疗进展[J]. 国际妇产科学杂志, 2021, 48(1):84-88. doi: 10.12280/gjfckx.20200541. doi: 10.12280/gjfckx.20200541
[11]	Touhami O, Gregoire J, Noel P, et al. Uterine arteriovenous malformations following gestational trophoblastic neoplasia: a systematic review[J]. Eur J Obstet Gynecol Reprod Biol, 2014, 181:54-59. doi: 10.1016/j.ejogrb.2014.07.023. doi: 10.1016/j.ejogrb.2014.07.023 pmid: 25126982
[12]	张敏鸽, 严亚娃. 子宫动静脉瘘诊治进展[J]. 中国妇产科临床杂志, 2013, 14(6):563-565. doi: 10.3969/j.issn.1672-1861.2013. 06.030. doi: 10.3969/j.issn.1672-1861.2013. 06.030
[13]	Russo JA, Gil L, DePiñeres T. Controversies in family planning: arteriovenous malformation[J]. Contraception, 2013, 88(3):326-329. doi: 10.1016/j.contraception.2012.03.011. doi: 10.1016/j.contraception.2012.03.011 URL
[14]	叶君, 盛红梅, 张金辉. 孕三烯酮联合短效避孕药治疗功能失调性子宫出血28例分析[J]. 中国妇幼保健, 2011, 26(19):2918-2919.
[15]	Scioscia M, Zantedeschi B, Trivella G, et al. A suggestive diagnosis of uterine arteriovenous fistula based on ultrasonography and hysteroscopy[J]. Eur J Obstet Gynecol Reprod Biol, 2012, 160(1):116-117. doi: 10.1016/j.ejogrb.2011.09.019. doi: 10.1016/j.ejogrb.2011.09.019 pmid: 22104476
[16]	高翠娴. 宫腔镜电切术对剖宫产术后子宫瘢痕妊娠的临床治疗效果评估[J]. 当代医学, 2021, 27(18):173-174. doi: 10.3969/j.issn.1009-4393.2021.18.072. doi: 10.3969/j.issn.1009-4393.2021.18.072
[17]	班艳丽, 崔保霞. 妊娠组织物残留的宫腔镜手术[J]. 实用妇产科杂志, 2019, 35(11):807-810.
[18]	朱晓明. 807例高危人工流产高危因素分析[J]. 中国妇幼保健, 2011, 26(8):1189-1190.
[19]	王玉楣, 车映. 81例皮下埋植剂依托孕烯使用后临床分析[J]. 国际生殖健康/计划生育杂志, 2019, 38(5):378-381. doi: 10.3969/j.issn.1674-1889.2019.05.006. doi: 10.3969/j.issn.1674-1889.2019.05.006