超声作为低至中等风险胎盘植入谱系围手术期出血的主要预测指标：与MRI在前置胎盘女性中的前瞻性比较

摘要(中文译文)

胎盘植入谱系疾病（PAS）是前置胎盘女性中日益常见且可能危及生命的并发症。尽管产前超声与MRI在临床广泛应用，但两者之间的一致性及其对围手术期出血的预测价值比较仍缺乏充分研究，尤其是在胎盘植入占主导地位的低至中危人群中。本研究旨在比较标准化超声与MRI印象之间的一致性，并评估各模态对围手术期出血的预测价值。本前瞻性队列研究纳入47例前置胎盘女性，于妊娠28+0至32+6周前瞻性接受标准化超声和MRI检查，并在剖宫产时收集围手术期结局。两种模态均基于标准化结构、血管及侵袭性标志物复合指标，采用三级印象系统（无/疑似/可能）进行分类。主要结局为模态间一致性（线性加权Cohen's κ）；次要结局为各模态印象与产后出血（PPH；估计失血量≥1000 mL）及估计失血量（EBL）的关联。47例女性中18例（38.3%）确诊PAS，以胎盘植入为主（83.3%）。模态间一致性为一般（加权κ=0.263），结构一致性为中等（κ=0.539），而血管一致性几乎不存在（κ=0.085）。超声印象与PPH发生率呈剂量依赖性关联（无、疑似、可能三级分别为38.5%、52.9%和82.4%；=0.048）及EBL（分别为800、1000和1800 mL；=0.003），逻辑回归证实每升高一级PPH风险增加2.70倍（=0.018；AUC 0.657）。MRI印象与PPH（=1.000）、EBL（=0.743）或PAS状态（=0.741；AUC 0.543）均无关联。PPH女性血清AFP显著升高（=0.005）。在这一以植入为主、低至中危的队列中，超声而非MRI显示出与围手术期出血显著的剂量依赖性关联。这些发现不应被解读为MRI普遍不足的证据，而是反映了特定影像学背景，即MRI在深部侵袭特征描述方面的优势在临床上较少具有决定性。这些结果支持超声作为该人群出血风险分层的主要工具。

Abstract

Placenta accreta spectrum (PAS) is an increasingly prevalent and potentially life-threatening complication in women with placenta previa. Despite widespread clinical use, the inter-modality agreement between prenatal ultrasound and MRI and their comparative value for predicting perioperative hemorrhage remain poorly characterized, particularly in low-to-moderate risk populations where placenta accreta predominates. We aimed to compare inter-modality agreement between standardized ultrasound and MRI impressions and to evaluate each modality's predictive value for perioperative hemorrhage. This prospective cohort study enrolled 47 women with placenta previa who underwent both standardized ultrasound and MRI prospectively between 28 + 0 and 32 + 6 weeks of gestation, with perioperative outcomes collected at the time of cesarean delivery. Both modalities were classified using a three-tier impression system (None/Suspected/Likely) based on standardized structural, vascular, and invasive marker composites. The primary outcome was inter-modality agreement (linearly weighted Cohen's κ); secondary outcomes were the association of each modality's impression with postpartum hemorrhage (PPH; estimated blood loss ≥ 1000 mL) and estimated blood loss (EBL). PAS was confirmed in 18 of 47 women (38.3%), predominantly placenta accreta (83.3%). Inter-modality agreement was fair (weighted κ = 0.263), structural concordance was moderate (κ = 0.539), while vascular agreement was near-absent (κ = 0.085). Ultrasound impression demonstrated a dose-dependent association with PPH rates (38.5%, 52.9%, and 82.4% across None, Suspected, and Likely tiers; = 0.048) and EBL (800, 1000, and 1800 mL; = 0.003), with logistic regression confirming a 2.70-fold increase in PPH odds per tier ( = 0.018; AUC 0.657). MRI impression was not associated with PPH ( = 1.000), EBL ( = 0.743), or PAS status ( = 0.741; AUC 0.543). Serum AFP was significantly elevated in women with PPH ( = 0.005). In this accreta-predominant, low-to-moderate risk cohort, ultrasound-but not MRI-demonstrated a significant dose-dependent association with perioperative hemorrhage. These findings should not be interpreted as evidence of general MRI inadequacy but rather as reflecting the specific imaging context in which MRI's strengths in deep invasion characterization are less clinically determinative. These results support ultrasound as the primary tool for hemorrhage risk stratification in this population.

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