二维超声联合SWE技术在孕产妇腹直肌评估中的应用价值.pdf
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1、昆明医科大学学报2 0 2 3,44(9):55 6 1Journal of Kunming Medical University二维超声联合SWE技术在孕产妇腹直肌评估中的应用价值D0I:10.12259/j.issn.2095-610X.S20230917CN 53-1221/R黄淼,徐飞,尹爱桃,陆永萍,尹娇,黎婷(云南大学附属医院超声科,云南昆明6 50 0 2 1)摘要】目的采用二维超声联合实时剪切波弹性成像技术(shear wave elastography,SWE)定量评估初产妇孕期、产后早期腹直肌间距(inter-rectus distance,IRD)及硬度,探讨初产妇孕产期
2、IRD与硬度相关性。方法选取2 0 2 1年10 月至2 0 2 2 年8 月于云南大学附属医院定期产检并足月分娩的初产妇2 50 例,孕期根据孕周分为早孕组、中孕组和晚孕组,产后根据分娩方式分为顺产组和剖宫产组,另选取健康未孕女性50 例为对照组。采用二维超声测量IRD,SWE 测量腹直肌弹性模量平均值(Emean);比较初产妇孕期及产后IRD及腹直肌硬度的差异,分析二者之间的相关性。结果孕期IRD和腹直肌硬度随孕周增加呈上升趋势,差异有统计学意义(P0.001);剖宫产组IRD高于顺产组,硬度低于顺产组;孕期BMI与IRD、腹直肌硬度呈正相关(r=0.515,0.6 41,0.56 4,0
3、.48 3,0.513,0.46 2,P 0.0 1),IRD 与腹直肌硬度呈正相关(r=0.559,0.58 0,0.42 5,P0.05),脐下3cm处IRD与硬度呈微弱负相关(r,=-0.227,P=0.0 2 3)。结论二维超声联合SWE技术评估孕产妇IRD及腹直肌硬度具有可行性,可以为产后腹直肌分离的诊断和治疗提供更加直观的临床依据。【关键词二维超声;腹直肌;剪切波弹性成像;孕期;产后中图分类号R445.1文献标志码A文章编号】2 0 9 5-6 10 X(2023)09-0055-07The Application Value of 2D Ultrasound Combined w
4、ith SWETechnique in the Evaluation of Rectus Abdominis inPregnant WomenHUANG Miao,XU Fei,YIN Aitao,LU Yongping,YIN Jiao,LI Ting(Dept.of Ultrasound,The Affiliated Hospital of Yunnan University,Kunming Yunnan 650021,China)Abstract Objective To evaluate the distance between rectus abdominis muscle(IRD)
5、and the hardness ofprimipara during the pregnancy and early postpartum by using two-dimensional ultrasound combined with shear waveelastography(SWE),and to explore the correlation between IRD and the hardness of primipara.Methods FromOctober 2021 to August 2022,a total of 250 primipara who received
6、the regular birth check-up in the AffiliatedHospital of Yunnan University and delivered at full term were selected.During the pregnancy,they were dividedinto the early pregnancy group,the middle pregnancy group and late pregnancy group based on the gestationalage.After the birth,they were then were
7、divided into the natural birth group and the cesarean section group based onthe delivery mode.Another 50 healthy non-pregnant women were selected as the control group.The mean elasticmodulus of rectus abdominis(Emean)was measured by two-dimensional ultrasound and SWE.The differences ofIRD and the re
8、ctus abdominis hardness during the pregnancy and postpartum were compared,and the correlationbetween them was analyzed.Results IRD and the hardness increased with the gestational age and the difference收稿日期 2 0 2 3-0 5-0 8基金项目云南省万人计划-名医专项基金资助项目(YNWR-MY-2018-004);云南省“十四五”省级医学影像科临床重点专科基金资助项目(2 0 2 2)作者
9、简介黄淼(19 9 8),女,云南曲靖人,在读硕士研究生,主要从事超声临床研究工作。通信作者徐飞,E-mail:x f 6 6 3159 9 12 6.c o m56was statistically significant(P 0.01).IRD of the cesarean section group was higher than that of the vaginal deliverygroup,and the hardness was lower than that of the vaginal delivery group.BMI during the pregnancy IRD
10、 waspositively correlated with IRD and the hardness of rectus abdominis muscle(r,=0.515,0.641,0.564,0.483,0.513,0.462,P 0.01)and IRD was positively correlated with the hardness of rectus abdominis muscle(r,=0.559,0.580,0.425,P 0.05),and IRD was negatively correlated withthe hardness at 3cm below the
11、 umbilical cord(r,=-0.227,P=0.023).Conclusion It is feasible to evaluate IRDand the rectus abdominis hardness by 2D ultrasound combined with SWE,which can provide more intuitive clinicalbasis for the diagnosis and treatment of postpartum rectus abdominis separation.Key words Two-dimensional ultrasou
12、nd;Rectus abdominis;Shear wave elastography;Pregnancy;昆明医科大学学报Postpartum第44卷腹部左右两侧的腹直肌由腹白线连接,白线距离增加超过生理上两侧腹直肌内侧缘间距(inter-rectus distance,I RD)称为腹直肌分离(diastasisrecti abdominis,D RA)1。妊娠期为适应不断扩张的腹壁肌肉,作用于腹白线的腹内压持续增加,腹白线极致拉伸,两侧腹直肌变薄、距离增宽 2 。DRA破坏腹壁肌肉的完整性,影响腹部肌肉力量的传导,出现腹肌收缩力下降、盆底组织松弛、盆腔脏器脱垂及骨盆稳定性下降等症状,此外
13、,DRA导致产妇腹壁变形、腹部膨隆,影响形体美观,增加产妇心理负担,影响产后生活质量 3。研究表明 4-5,中国育龄期妇女产后DRA的发生率为45.14%,晚孕期DRA发生率为10 0%,产后1a,32.6%的女性仍然存在DRA。目前,国际上推荐DRA的诊断金标准是超声,具有分辨率高、有效评估肌肉形态变化的优势 6 。实时剪切波弹性成像技术(shearwaveelastography,SWE)作为超声衍生出的新技术之一,能简单便捷、安全无创、实时动态评估肌肉的硬度及功能状态 7 。本研究采用二维超声联合SWE技术评估孕产妇IRD及腹直肌硬度,探讨IRD与腹直肌硬度的相关性,为产后早期DRA的诊
14、断及治疗提供依据。1资料与方法1.1一般资料选取2 0 2 1年10 月至2 0 2 2 年8 月于云南大学附属医院进行常规产前超声检查的孕妇150 例,选取同一时期分娩后42 45d进行常规超声检查的初产妇10 0 例,孕期根据孕周分为早孕组、中孕组和晚孕组各50 例,产后根据分娩方式分为顺产组和剖宫产组各50 例;另选取健康未孕的育龄期女性50 人为对照组。本研究经云南大学附属医院伦理委员会批准(伦理审批号:2 0 2 116 4),以上所有参与研究者均知情同意。纳人标准 8 :首次怀孕的孕妇;单胎妊娠;足月分娩的初产妇;剖宫产切口为横切口。排除标准:合并糖尿病、高血压;既往腹部手术史;先
15、天性腹壁结构异常;BMI35kg/m。资料收集:收集所有孕产妇的身高、体重、BMI、腹直肌间距、腹直肌硬度及初产妇分娩方式、宫产术式等。1.2仪器设备采用法国SuperSonicAixplorer超声诊断仪,配备高频线阵探头SL15-4,频率为4 15MHz,具备ShearWaveTM实时剪切波超声工作站。1.3研究方法二维超声成像:检查前嘱受检者排空膀胱,取平卧位,充分暴露腹部剑突至耻骨联合之间的区域。采用高频超声探头平行于肌纤维走行方向纵向及横向常规扫查整个腹部,两侧腹直肌无法于同一切面显示者采用宽景成像。分别于脐上3cm、脐水平和脐下3cm处以腹直肌内侧缘的强回声为标志点测量IRD,见图
16、1,以IRD+3、IRD o和IRD-3表示,测量3次取其平均值。SWE成像:清晰显示双侧或一侧腹直肌后启动SWE模式,采用矩形取样框铺满一侧腹直肌,将测量弹性值的感兴趣区域(region of interest,ROI),设置为直径5mm的圆形,用彩色编码的弹性图表示弹性模量,观察3 5s图像稳定后冻结图像,于脐上3cm、脐水平、脐下3cm近腹直肌内侧缘12 cm处分别测量3次,取平均值为腹直肌弹性模量平均值(meanof elasticmodulus,Emean),见图2。以上检查均由同一医师完成,时间控制在3 5min内。第9 期黄淼,等二维超声联合SWE技术在孕产妇腹直肌评估中的应用价
17、值571Dist 3.57cm图1腹直肌间距测量Fig.1Rectus abdominis distance measurement(IRD:3.57 cm)100 kPaDB/LOVms80604020+O-Box-RatioRatio(kPa)MeanMinMaxSDDiamDepthMeanMinMaxSDDiamDeoth9.9kPa9.5kPa10.6kPa0.3kPa2.00mm1.4cm-kPa-kPa-kPa-kPammcm图2 腹直肌硬度测量Fig.2 Rectus abdominis hardness measurement(SWE:Emean 9.9kPa Emax 10
18、.6kPa Emin9.5kPa)1.4统计学处理采用统计学分析软件SPSS26.0对所有数据进行统计学分析,数据分布采用S-W检验,方差齐且服从正态分布用均数标准差表示,采用单因素方差分析,组间比较采用LSD检验;非正态分布的计量资料用M(P25,Pr s)表示,多组间比较采用Kruskal-WallisH检验,组间两两间比较采用Mann-Whitney U检验。BMI与IRD及IRD与硬度相关性采用Spearman相关性分析,BMI与硬度相关性采用Pearson相关性分析。以P0.05为差异有统计学意义。2结果2.1孕产妇人口统计学资料比较对所有纳人研究者进行人口统计学特征分析,见表1。各
19、分组间身高、体重、体重指数(BMI)差异有统计学意义(P0.05),产后时间差异无统计58组别早孕组中孕组晚孕组对照组顺产组宫产组FP*P0.05),各分组间年龄差异无统计学意义(P0.05)。2.2女妊娠期与对照组IRD及弹性值比较采用非参数检验及方差分析对妊娠期IRD及硬度进行分析,结果显示早、中、晚孕组3个位点处IRD及弹性值随孕周增加均呈逐渐上升趋势;不同位点IRD及硬度比较,均有 IRDIRD+3IRD-3、E me a n g E me a n+3 E me a n-3,两两比较差异均有统计学意义(P0.01);晚孕期脐水平处IRD及弹性值达最大值:2 1.0(13.7,2 6.5
20、),(2 3.6 7 4.33);早孕组与对照组比较IRD,差异无统计学表2 不同妊娠期与对照组不同位点IRD及腹直肌弹性值比较(xs)/M(P25,P7 5)Tab.2 Comparison of IRD and elastic value of rectus abdominalis muscle at different sites between different pregnancyperiod and control group(x s)/M(P25,P75)组别IRD+3早孕组6.0(0.0,12.0)中孕组16.0(11.8,23.4)晚孕组28.3(22.1,41.4)对照组0
21、.0(0.0,0.0)FIZ136.894P0.001*P0.05。表3初产妇产后与对照组不同位点IRD及腹直肌弹性值比较(xs)/M(P25,P7 5)Tab.3Comparison of IRD and elastic values of rectus abdominalis at different points between primipara and control group(x s)/M(P25,P75)组别IRD+3顺产组18.5(14.8,27.0)剖宫产24.0(18.0,30.0)对照组0.0(0.0,0.0)FIZ95.469P0.001*P0.05),早孕组与对照组
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