Page 70 - 2022-06-中国全科医学

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【Abstract】 Background China is seeing an increase in the ratio of parturients of advanced maternal age，a
population at high risk of stress urinary incontinence （SUI）. Objective To quantitatively assess pelvic floor structure and
function changes and SUI，and to determine the ultrasonic diagnostic indices and threshold values for SUI in the early postpartum
period in parturients of advanced maternal age using 2D and 3D ultrasound and real-time shear wave elastography （SWE） of the
pelvic floor. Methods Participants were 194 puerperants who received ambulatory services in the early postpartum period（within
the first 6-8 weeks after childbirth） from North China University of Science and Technology Affiliated Hospital from August 2016
to February 2021，including 105 of advanced maternal age（≥ 35 years old） and 89 of proper maternal age（<35 years old）.
SUI was determined by medical history，physical examination，urination diary and urodynamic test results and clinical diagnosis.
Intergroup comparisons were conducted in terms of the detection rate of SUI，and parameters of 2D and 3D ultrasound and real-
time SWE of the pelvic floor〔bladder neck position at rest（h 1BL ） and tension （h 2BL ），degree of mobility of bladder neck
（Δh BL ），urethral inclination angle at rest（UIA 1 ） and tension（UIA 2 ），and urethral rotation angle（URA），posterior
vesicourethral angle at rest（PVUA 1 ） and tension（PVUA 2 ），levator ani hiatus area at rest（LHA 1 ） and tension（LHA 2 ），
elastic modulus of puborectal muscle in resting（E 1 ） and anal constriction state（E 2 ），and the difference between E 1 and E 2
（ΔE）〕. The above-mentioned multimodal ultrasound parameters were also compared between those with SUI （n=51） and
without （n=54） in the advanced maternal age group. The performance of multimodal ultrasound parameters in predicting early
postpartum SUI was analyzed using the analysis of the area under the receiver operating characteristic curve（AUC），and was
estimated with the accuracy of clinical diagnosis as the gold standard. Results Compared to parturients of proper maternal age，
those of advanced maternal age had higher h 1BL ，h 2BL ，Δh BL ，PVUA 1 ，and LHA 2 ，and lower bilateral E 1 ，E 2 ，and ΔE （P<0.05）.
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Moreover，they had higher detection rate of SUI〔48.6%（51/105）vs 32.6%（29/89）〕（χ =5.081，P=0.028）. Parturients
of advanced maternal age with SUI had greater h 1BL ，h 2BL ，Δh BL ，UIA 2 ，URA，PVUA 1 ，PVUA 2 ，LHA 1 ，LHA 2 ，and less
bilateral E 1 ，E 2 ，and ΔE than those without（P<0.05）. For parturients of advanced maternal age，the analysis of the receiver
operating characteristic curve of multimodal ultrasound parameters predicting early postpartum SUI revealed that the AUC for
h 1BL ，h 2BL ，Δh BL ，PVUA 1 ，PVUA 2 ，LHA 1 ，LHA 2 ，bilateral E 2 ，or bilateral ΔE was greater than 0.700. In particular，the
AUC was greater than 0.850 for h 1BL （-2.28 cm optimal cutoff，82.4% sensitivity，90.2% specificity），h 2BL （-0.50 cm optimal
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cutoff，83.3% sensitivity，85.2% specificity），LHA 1 （16.79 cm optimal cutoff，94.1% sensitivity，90.2% specificity），
or bilateral ΔE（16.85 kPa optimal cutoff，88.9% sensitivity，87.0% specificity）. Binary Logistic regression analysis of
PRESUI=-3.691×h 2BL -0.952×LHA 1 +0.675×bilateral ΔE，an algorithm with three ultrasound parameters incorporated for
predicting SUI in parturients of advanced maternal age，indicated that the AUC of h 2BL in combination with LHA 1 and bilateral ΔE
was 0.992〔95%CI（0.982，0.999）〕，with 0.571 optimal cutoff，96.1% sensitivity and 96.3% specificity. Conclusion
The early postpartum pelvic floor structure of parturients of advanced maternal age，especially those with SUI，was more relaxed
than that of those of proper maternal age. Multimodal ultrasound can quantitatively evaluate the changes of early postpartum pelvic
floor structure and function in parturients of advanced maternal age. h 1BL ，h 2BL ，LHA 1 ，bilateral ΔE or the combination of h 2BL ，
LHA 1 and bilateral ΔE could be used as an ultrasonic predictor of early postpartum SUI in this group，and the latter has higher
diagnostic value.
【Key words】 Urinary incontinence，stress；Pelvic floor；Postpartum period；Ultrasonography，doppler；Elasticity
imaging techniques；Maternal health；Diagnostic techniques and procedures

随着社会生活节奏的加快、生活压力的增加、原发 1 资料与方法
不孕人群的增多及辅助生殖技术水平的提高和应用，我 1.1 一般资料 选取 2016 年 8 月至 2021 年 2 月于华
国高龄产妇在产妇中的所占比例呈上升趋势 ［1］ 。研究 北理工大学附属医院门诊就诊的产后早期（6~8 周）高
表明，高龄产妇是女性压力性尿失禁（SUI）的高危人群， 龄产妇（年龄≥ 35 岁）105 例为高龄组，并依据病史、
而产后早期的盆底康复锻炼可以在一定程度上使患者盆 体格检查结果、排尿日记、尿动力学检查结果等临床综
底肌群功能恢复 ［2-3］ ，因此及时发现高龄产妇产后早期 合指标及临床诊断分为SUI亚组（51例）与非SUI亚组（54
盆底结构及功能的变化显得尤为重要。本研究旨在应用 例）；选取同期来本院门诊就诊的产后早期适龄产妇
盆底二维、三维超声及实时剪切波弹性成像（SWE）定 （<35 岁）89 例为适龄组。高龄产妇的判定标准参考文
量分析高龄产妇产后早期盆底结构及功能的变化，并确 献［4］，SUI 的判定标准参考文献［5］。
立高龄产妇产后早期 SUI 的超声诊断指标及界值，为临 纳入标准：妊娠前无盆底功能障碍性疾病、足月分
床及时干预以防止及延缓 SUI 的发生、发展提供依据。 娩、单胎妊娠、新生儿体质量≤ 4 kg、产后未行盆底肌