应用超声评分法、生化指标及MRI对胎儿肾积水等泌尿系统疾病的研究
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摘要
研究背景与目的
越来越多的资料表明,在所有先天性畸形中胎儿泌尿系统异常的发病率已上升为第一位,其中肾积水为最常见的超声表现,发病率为0.9%-2.5%。现阶段,超声仍是诊断胎儿畸形首选的、不可替代的检查方法。胎儿肾积水的超声诊断并不难,国际上已有两种定义和分类的常用方法：即肾盂前后径(pelvic anterior posterior diameter:PAPD)和胎儿泌尿协会(the Society for Fetal Urology:SFU)分级。但对评估胎儿肾积水的预后来说,这两种方法均欠准确。肾盂前后径过于简单,准确性差,国内外大量文献报道了定义胎儿肾积水的不同界值,如4mm、5mm、7mm、8mm、9mm、10mm、12mm、15mm等,但无论哪一界值,总有部分胎儿肾积水会于生后消失,即为生理性肾积水；也总有部分会于生后加重而需要手术,即属于病理性肾积水,没有哪一个PAPD界值能有效鉴别这两种情况。SFU分级则过于笼统烦杂,缺乏定量分析,例如肾盂扩张、肾盏可见、肾盏扩张、肾盂肾盏严重扩张等,只能凭检查者的主观判断而缺乏客观量化标准。
总之,无论用哪种方法来定义胎儿肾积水,无论怎样调整孕周以及PAPD界值,总有大量的交叉病例。如果不能有效地鉴别这些交叉病例,部分正常胎儿就会因过度诊断而误诊为肾积水,导致盲目引产；部分胎儿会因诊断不足造成漏诊,引致医疗纠纷。临床中岂待准确评估胎儿肾积水预后的新方法。我国现阶段医患关系紧张,而计划生育和优生优育政策又对超声医师提出了更高的要求,不容许有大的漏诊误诊。我们医院设有全省最大的产前诊断中心,担负着全省胎儿畸形的会诊任务……这几方面的原因促使我们研究了这个课题,目的是有效鉴别诊断胎儿生理性与病理性肾积水,以指导产前干预和产后处理,为孕妇及其家庭提供更准确的信息。
胎儿病理性肾积水的产生原因已较明确,但胎儿生理性肾积水的原因还只是几种假说,缺乏临床对照研究。其中输尿管功能性收缩和一过性解剖性狭窄属理论推断,很难实验证实；但孕妇体内孕酮的影响、母体水和作用均可通过研究证实,但尚无报道。
磁共振对胎儿中枢神经系统异常的诊断价值已得到肯定,但超声与磁共振诊断胎儿泌尿系统畸形的对照研究的报道尚少,对胎儿肾积水的磁共振诊断价值尚缺乏专题研究。
第一部分超声评分法鉴别诊断胎儿生理性与病理性肾积水的价值
目的：通过对胎儿肾积水的大样本临床资料的分析,研究超声评分法鉴别诊断胎儿生理性与病理性肾积水的价值。
方法：对158例晚孕期肾积水(PAPD≥10mm)胎儿进行超声检查、超声评分和追踪随访。超声评分参数包括PAPD、肾实质厚度和肾盂肾盏形态；肾盂肾盏的形态学分级参考SFU分级系统,并对其进行半定量化改良。根据肾积水的严重程度不同,将3项参数分别进行超声评分(0-3分),并累计每只肾脏的超声总评分。根据随访结果(包括产后超声及其他检查、手术病理及引产解剖病理),将胎儿肾积水分为生理性和病理性肾积水,并绘制3项超声参数与超声评分法鉴别诊断两种胎儿肾积水的操作者特征(ROC)曲线,经Z-检验对4条ROC曲线下面积进行配对比较,找出最佳曲线及诊断胎儿病理性肾积水的最佳截断值和相应的灵敏度、特异度等。所有数据均采用SPSS 16.0统计软件包进行录入和处理。
结果：158例胎儿,共198只肾积水,其中139只(70.20%)为生理性肾积水,59只(29.80%)为病理性肾积水。超声评分≤3分,均为生理性肾积水；评分≥8,均为病理性肾积水。评分为4、5、6、7分,病理性肾积水的比例分别为10.53%(2/19)、26.67%(4/15)、45.45%(5/11)、83.33%(10/12)。超声评分越高,病理性肾积水的比例越大。超声评分诊断胎儿病理性肾积水的曲线下面积最大(0.982),与PAPD (0.897)、肾实质厚度(0.957)、肾盂肾盏形态(0.944)的曲线下面积比较有明显的统计学差异(P<0.05),即超声评分为鉴别诊断胎儿生理性与病理性肾积水的最好方法。曲线的最左上方点超声评分5分为诊断的最佳截断值,其灵敏度、特异度、阳性预测值、阴性预测值、粗一致率及約登指数分别为89.83%,94.24%,86.89%,95.62%,92.93%和0.8407。
结论：超声评分法将与胎儿肾积水程度密切相关的三个因素进行量化并综合分析,能有效地鉴别诊断胎儿生理性与病理性肾积水。它简单实用,准确性高,是一种评估胎儿肾积水预后的的新方法,值得临床推广应用。
第二部分孕母血清孕酮水平与胎儿生理性肾积水原因的相关性分析
目的：研究胎儿生理性肾积水是否与孕母血清孕酮水平升高有关,探讨胎儿生理性肾积水的原因。
方法：37例在我院行超声检查、并经产后证实胎儿为生理性肾积水的孕妇为研究组,30例正常妊娠(胎儿肾集合系统无分离)的孕妇为对照组,孕周尽量与研究组一致,孕妇妊娠前查体均无肾积水。抽取两组孕妇的空腹静脉血2ml,离心后检测孕妇血清孕酮水平并记录。同时超声检查并记录两组孕妇的双肾情况：肾盂无分离或肾盂分离<10mm者视为正常,肾盂分离≥1Omm为肾积水。于分娩后1-2个月对母婴二人进行超声复查,证实孕期为胎儿生理性肾积水者录入资料,否则除外。以孕周作为协变量(消除孕周的影响),对两组孕妇血清孕酮值进行Logistic回归检验；经卡方检验对两组孕妇分娩前后双肾情况进行比较,双尾,P<0.05为有统计学意义。
结果：两组孕妇血清孕酮值均随孕周的增加持续升高。胎儿生理性肾积水组：37例,孕妇血清孕酮值159ng/ml～230.9ng/ml,平均189.06±18.76ng/ml；孕妇11只肾积水。对照组：30例,孕妇血清孕酮值157ng/ml～235ng/ml,平均190.9±20.16ng/ml；孕妇8只肾积水。经Logistic回归检验,两组的孕酮值无统计学意义(X2=0.0171,P=0.8950)；经卡方检验,两组孕妇的肾积水情况亦无统计学差异(P>0.05)。
结论：胎儿生理性肾积水的原因并非孕妇体内孕酮水平升高,而可能与胎儿泌尿系统发育过程中细微解剖结构(起搏细胞)与功能的不完善、不协调有关。
第三部分超声与磁共振对胎儿肾积水等泌尿系统疾病的对比研究
目的：对照研究超声与磁共振检查对胎儿肾积水等泌尿系统疾病的诊断价值,探讨磁共振对胎儿泌尿系统的哪些疾病具有辅助诊断意义。
方法：对46例在我院经超声诊断为泌尿系统畸形的胎儿,48小时内行MRI检查。比较超声与磁共振诊断的异同,并与出生后的临床诊断与处理结果进行比较。
结果：胎儿病理性肾积水20例(27只),泌尿系统其他畸形26例。超声对肾积水、肾盂输尿管接合处、扩张的输尿管及输尿管膀胱接合处的诊断或显示率分别是100%(27/27)、50%(6/12)、83.33(10/12)、0；磁共振对四者的诊断或显示率分别为100% (27/27)、41.67%(5/12)、66.67%(8/12)、25%(3/12)。26例胎儿泌尿系统其他畸形中,16例超声与磁共振诊断皆正确,4例超声正确而磁共振不正确,6例超声不正确而磁共振正确。经配对卡方检验,两者比较无统计学差异(X2=0.1,P=0.7518)。
结论：正常情况下,胎儿泌尿系统畸形的诊断依赖于超声检查,但在羊水过少、孕妇腹壁肥厚、胎儿体位影响或骨骼声影遮挡等致超声显像不清时,胎儿泌尿系统畸形的磁共振检查是必要的。
创新点
1、本研究立足于临床的需要,首次提出应用超声评分法鉴别诊断胎儿生理性与病理性肾积水。超声评分法将与胎儿肾积水程度密切相关的3个因素进行综合分析,极大地提高了诊断的灵敏度(90%)与特异度(94%),希望能在临床上推广应用。
2、首次对胎儿生理性肾积水与孕母血清孕酮水平进行了相关研究,认为胎儿生理性肾积水的原因并非孕妇体内孕酮水平升高,并对胎儿生理性肾积水的产生原因作了深入地探讨,提出了自己的看法。
Background and purpose
More and more literatures showed that morbility of fetal urinary system abnormity had been the first in all the congenital abnormalities, which the most common ultrasonic appearance was hydronephrosis. The morbility of fetal hydronephrosis is 0.9%～2.5%. Now, ultrasound (US) is still the first and irreplaceable imageology method to diagnose fetal abnormality. Although it is easy to diagnose fetal hydronephrosis and there are two methods to define and classified it, I.e. pelvic anterior posterior diameter (PAPD) and the Society for Fetal Urology (SFU) grade. The two methods are not accurate to evaluate the fetal hydronephrosis prognosis. There are different cutoff value, such as 4mm、5mm、7mm、8mm、9mm、10mm、12mm、15mm, but PAPD is too simple and insufficient. After birth, there are always some fetal hydronephrosis to vanish which was called physiological hydronephrosis, and also some fetal hydronephrosis to aggravate which was called pathological hydronephrosis. No PAPD cutoff value can identify the two conditions. SFU grade is indiscriminate and insufficient of quantitive analysis, as pelviectasis、visible of renal calyces、calycectasis ad. only depending on the subjective judgment of inspector.
In short, there are always a great deal of overlap cases no matter how to gauge the cutoff and pregnancy weeks with each method. If we can not identify efficiently the overlap cases, the outcome was:high false positive rate owing to misdiagnosis will cause unnecessary anxiety or blind termination of pregnancy for the pregnant women, whereas low sensitivity may cause missed diagnosis and possible lawsuit for the doctors. It is important to find a new method which can evaluate the prognosis of fetal hydronephrosis. The doctor-patient relationship is strained at the present stage, the policy of family planning and prenatal and postnatal care require US doctors to do better. The biggest prenatal diagnosis and consultation center of province is in our hospital......All was the reasons to carry out the study. The purpose of differential diagnosis of fetal physiological and pathological hydronephrosis is to guide prenatal intervention and postnatal management and provide the more accurate informations for pregnant woman
The reason of fetal pathological hydronephrosis is identified, but that of fetal physiological hydronephrosis is still hypothesis and lack of clinical control study. The theory deduction of ureter functional retract and temporary stricture can not be confirmed by experiment. It can be confirmed by experiment for progestin and hydration of pregnant woman, but no report.
The diagnostic value for magnetic resonance imaging (MRI) to diagnose fetal central nervous system was confirmed, but there were little control study to compare the value of diagnosis fetal hydronephrosis with US and MRI, and no apecial study to report the diagnostic value for MRI to diagnose fetal hydronephrosis.
PartⅠ:Differential Diagnosis of Fetal Physiological and Pathological Hydronephrosis Using Ultrasound Score
Objective:to research the differential diagnosis value of fetal physiological and pathological hydronephrosis using US score through the analysis of fetal large sample clinical data.
Methods:158 fetuses (198 kidneys) with hydronephrosis (PAPD≥10mm) after 28 weeks' gestation were diagnosed by prenatal US in our hospital, then give the cases US score and follow-up. The parameters included PAPD, renal parenchyma thickness (RPT), pelvicaliceal morphology (PM). PM was graded according to our improved and semi-quantitative SFU grading system. The three parameters were graded from 0 to 3 score according to the severity of hydronephrosis and the total US score of each kidney was obtained by adding the scores of three parameters. All the cases were allocated to two groups (physiological and pathological hydronephrosis) based on the postnatal US and other clinical examinations. The data of prenatal PAPD, RPT, PM, US score and postnatal outcome were added up and four receiver operating characteristic (ROC) curves were obtained. Then we made pairwise comparison of ROC curves via Z test and revealed the best ROC curves and cutoff value, sensitivity, specificity, et.al. All data analyses were conducted with SPSS 16.0 statistic software.
Results:Confirmed by postnatal US and other clinical examinations, of 198 kidneys with hydronephrosis,139 (70.20%) were physiological hydronephrosis and 59 (29.80%) were pathological hydronephrosis. Score≤3, all were physiological hydronephrosis and≥8 were pathological hydronephrosis. Score was 4、5、6、7, the ratio of pathological hydronephrosis was 10.53%(2/19)、26.67%(4/15)、45.45%(5/11)、83.33%(10/12) respectively. The higher the score, the higher the ratio of fetal pathological hydronephrosis. Area under the curve (AUC) of PAPD, RPT, PM, US score was 0.897 (minimum),0.957,0.944 and 0.982 (maximum) respectively, and there was significant difference between AUC of US score and each of the other three (p<0.05). US score was the best approach for differential diagnosis of fetal hydronephrosis. By using the left-upper point (score 5) of the curve as the best diagnosis cutoff value, that is, cases with scores≤5 was diagnosed as physiological hydronephrosis, whereas scores≥6 as pathological, the sensitivity, specificity, PPV, NPV, consistency rate, and YI was 89.83%, 94.24%,86.89%,95.62%,92.93% and 0.8407 respectively. Conclusions:Prenatal US score is easy to be obtained by measuring some data of kidney and can effectively differentiate fetal physiological and pathological hydronephrosis because of quantization and aggregate analysis of three factor which were closely related to the severity of hydronephrosis. It was a new quantitative method to evaluate the prognosis of fetal hydronephrosis, and should be disseminated and applied clinically.
PartⅡ:Study on the Correlation Between Serum Progesterone of Pregnant Woman and Fetal Physiological Hydronephrosis
Objective:to analyze that pregnant woman serum progesterone was one of the reason of fetal physiological hydronephrosis or not.
Methods:Study group included 37 pregnant woman with fetal physiological hydronephrosis confirmed by postnatal US,30 fetuses without hydronephrosis were control group. All the women were not hydronephrosis before pregnancy.2ml venous blood of women was obtained and was centrifuged to detect progestational hormone. Then we examined and recoreded the women s changes of kidneies:it was normal when without pelviectasis or PAPD<10mm, and hydronephrosis when PAPD≥10mm.1～2 month after parturition, the mother and infant were underwent US exam and their kidneys were measured and recorded. The progesterone of two groups were compared via Logistic test and gestational week as concomitant variable. The changes of kidney in two groups were contrasted by chi square test.
Results:The level of serum progesterone in two groups continually increased following the gestational week. The group of fetal physiological hydronephrosis:37 cases, serum progesterone of pregnant woman was 159ng/ml～230.9ng/ml, average 189.06±18.76ng/ml; there was 11 hydronephrosis in women. The control group:30 cases,157ng/ml～235ng/ml, and average 190.9±20.16ng/ml; 8 hydronephrosis in women. There was not statistically significant within the two groups not only on serum progesterone (X2=0.0171, P=0.8950) but also on the changes of the two group woman (P >0.05)
Conclusion:Serum progesterone is not one of the cause of fetal physiological hydronephrosis, although it can chalasia the smooth muscle in pelvis and ureter of pregnant woman. It shoule be the different sensitivity for progestational hormon to lead to pelviectasis or hydronephrosis.
PartⅢ:Control Study on Fetal Disease of Urinary System Using Ultrasound and MRI
Objective:to contrast the value to diagnose fetal hydronephrosis and other urinary system abnormity with US and MRI, to discuss which diseases need to do MRI examination.
Methods:46 fetuses with urinary system abnormity diagnosed by prenatal US were underwent MRI within 48 hours. Similarities and Differences were compared with US and MRI diagnosis and the outcome after birth.
Result:Among all the 46 cases,20 cases (27 hydronephrosis) were pathological hydronephrosis and 26 were urinary system other abnormities.27 hydronephrosis were all diagnosed by US and MRI. Of all the 12 cases with the lower ureter obstruction, the ratio of US diagnosis on ureteropelvic junction、ureter dilatation、ureterovesical junction was 50%(6/12)、83.33 (10/12)、0; but that of MRI was 41.67%(5/12)、66.67%(8/12)、25% (3/12). Among 26 cases with urinary system other abnormity,16 cases were correctly diagnosed by US and MRI,4 cases were correctly diagnosed only by US,6 cases were correctly diagnosed only by MRI. There was not statistically significant within the two imaging methods (X2=0.1, P=0.7518) via X2 test of paired comparison.
Conclusion:Normally, the diagnosis of fetal urinary system abnormity depend on US, but when oligohydramnios、plump woman、influence by fetal position and skeleton shadowing, it is necessary to perform fetal MRI.
Main Innovative Points
1、Based on the clinical demand, this study first used US score to differential diagnosis fetal physiological pathological hydronephrosis. It can greatly increase the diagnostic sensitivity and specificity of fetal pathological hydronephrosis due to aggregate analysis of three factor which were closely related to the severity of hydronephrosis. So US score is a simple、practical and accurate new method which is worthwhile for clinic application.
2、We first study on the correlation between serum progesterone in pregnant woman and fetal physiological hydronephrosis,and denied the causal relation between them. Deeply discusses was undertaken about the reason of fetal physiological hydronephrosis.
越来越多的资料表明,在所有先天性畸形中胎儿泌尿系统异常的发病率已上升为第一位,其中肾积水为最常见的超声表现,发病率为0.9%-2.5%。现阶段,超声仍是诊断胎儿畸形首选的、不可替代的检查方法。胎儿肾积水的超声诊断并不难,国际上已有两种定义和分类的常用方法：即肾盂前后径(pelvic anterior posterior diameter:PAPD)和胎儿泌尿协会(the Society for Fetal Urology:SFU)分级。但对评估胎儿肾积水的预后来说,这两种方法均欠准确。肾盂前后径过于简单,准确性差,国内外大量文献报道了定义胎儿肾积水的不同界值,如4mm、5mm、7mm、8mm、9mm、10mm、12mm、15mm等,但无论哪一界值,总有部分胎儿肾积水会于生后消失,即为生理性肾积水；也总有部分会于生后加重而需要手术,即属于病理性肾积水,没有哪一个PAPD界值能有效鉴别这两种情况。SFU分级则过于笼统烦杂,缺乏定量分析,例如肾盂扩张、肾盏可见、肾盏扩张、肾盂肾盏严重扩张等,只能凭检查者的主观判断而缺乏客观量化标准。
总之,无论用哪种方法来定义胎儿肾积水,无论怎样调整孕周以及PAPD界值,总有大量的交叉病例。如果不能有效地鉴别这些交叉病例,部分正常胎儿就会因过度诊断而误诊为肾积水,导致盲目引产；部分胎儿会因诊断不足造成漏诊,引致医疗纠纷。临床中岂待准确评估胎儿肾积水预后的新方法。我国现阶段医患关系紧张,而计划生育和优生优育政策又对超声医师提出了更高的要求,不容许有大的漏诊误诊。我们医院设有全省最大的产前诊断中心,担负着全省胎儿畸形的会诊任务……这几方面的原因促使我们研究了这个课题,目的是有效鉴别诊断胎儿生理性与病理性肾积水,以指导产前干预和产后处理,为孕妇及其家庭提供更准确的信息。
胎儿病理性肾积水的产生原因已较明确,但胎儿生理性肾积水的原因还只是几种假说,缺乏临床对照研究。其中输尿管功能性收缩和一过性解剖性狭窄属理论推断,很难实验证实；但孕妇体内孕酮的影响、母体水和作用均可通过研究证实,但尚无报道。
磁共振对胎儿中枢神经系统异常的诊断价值已得到肯定,但超声与磁共振诊断胎儿泌尿系统畸形的对照研究的报道尚少,对胎儿肾积水的磁共振诊断价值尚缺乏专题研究。
第一部分超声评分法鉴别诊断胎儿生理性与病理性肾积水的价值
目的：通过对胎儿肾积水的大样本临床资料的分析,研究超声评分法鉴别诊断胎儿生理性与病理性肾积水的价值。
方法：对158例晚孕期肾积水(PAPD≥10mm)胎儿进行超声检查、超声评分和追踪随访。超声评分参数包括PAPD、肾实质厚度和肾盂肾盏形态；肾盂肾盏的形态学分级参考SFU分级系统,并对其进行半定量化改良。根据肾积水的严重程度不同,将3项参数分别进行超声评分(0-3分),并累计每只肾脏的超声总评分。根据随访结果(包括产后超声及其他检查、手术病理及引产解剖病理),将胎儿肾积水分为生理性和病理性肾积水,并绘制3项超声参数与超声评分法鉴别诊断两种胎儿肾积水的操作者特征(ROC)曲线,经Z-检验对4条ROC曲线下面积进行配对比较,找出最佳曲线及诊断胎儿病理性肾积水的最佳截断值和相应的灵敏度、特异度等。所有数据均采用SPSS 16.0统计软件包进行录入和处理。
结果：158例胎儿,共198只肾积水,其中139只(70.20%)为生理性肾积水,59只(29.80%)为病理性肾积水。超声评分≤3分,均为生理性肾积水；评分≥8,均为病理性肾积水。评分为4、5、6、7分,病理性肾积水的比例分别为10.53%(2/19)、26.67%(4/15)、45.45%(5/11)、83.33%(10/12)。超声评分越高,病理性肾积水的比例越大。超声评分诊断胎儿病理性肾积水的曲线下面积最大(0.982),与PAPD (0.897)、肾实质厚度(0.957)、肾盂肾盏形态(0.944)的曲线下面积比较有明显的统计学差异(P<0.05),即超声评分为鉴别诊断胎儿生理性与病理性肾积水的最好方法。曲线的最左上方点超声评分5分为诊断的最佳截断值,其灵敏度、特异度、阳性预测值、阴性预测值、粗一致率及約登指数分别为89.83%,94.24%,86.89%,95.62%,92.93%和0.8407。
结论：超声评分法将与胎儿肾积水程度密切相关的三个因素进行量化并综合分析,能有效地鉴别诊断胎儿生理性与病理性肾积水。它简单实用,准确性高,是一种评估胎儿肾积水预后的的新方法,值得临床推广应用。
第二部分孕母血清孕酮水平与胎儿生理性肾积水原因的相关性分析
目的：研究胎儿生理性肾积水是否与孕母血清孕酮水平升高有关,探讨胎儿生理性肾积水的原因。
方法：37例在我院行超声检查、并经产后证实胎儿为生理性肾积水的孕妇为研究组,30例正常妊娠(胎儿肾集合系统无分离)的孕妇为对照组,孕周尽量与研究组一致,孕妇妊娠前查体均无肾积水。抽取两组孕妇的空腹静脉血2ml,离心后检测孕妇血清孕酮水平并记录。同时超声检查并记录两组孕妇的双肾情况：肾盂无分离或肾盂分离<10mm者视为正常,肾盂分离≥1Omm为肾积水。于分娩后1-2个月对母婴二人进行超声复查,证实孕期为胎儿生理性肾积水者录入资料,否则除外。以孕周作为协变量(消除孕周的影响),对两组孕妇血清孕酮值进行Logistic回归检验；经卡方检验对两组孕妇分娩前后双肾情况进行比较,双尾,P<0.05为有统计学意义。
结果：两组孕妇血清孕酮值均随孕周的增加持续升高。胎儿生理性肾积水组：37例,孕妇血清孕酮值159ng/ml～230.9ng/ml,平均189.06±18.76ng/ml；孕妇11只肾积水。对照组：30例,孕妇血清孕酮值157ng/ml～235ng/ml,平均190.9±20.16ng/ml；孕妇8只肾积水。经Logistic回归检验,两组的孕酮值无统计学意义(X2=0.0171,P=0.8950)；经卡方检验,两组孕妇的肾积水情况亦无统计学差异(P>0.05)。
结论：胎儿生理性肾积水的原因并非孕妇体内孕酮水平升高,而可能与胎儿泌尿系统发育过程中细微解剖结构(起搏细胞)与功能的不完善、不协调有关。
第三部分超声与磁共振对胎儿肾积水等泌尿系统疾病的对比研究
目的：对照研究超声与磁共振检查对胎儿肾积水等泌尿系统疾病的诊断价值,探讨磁共振对胎儿泌尿系统的哪些疾病具有辅助诊断意义。
方法：对46例在我院经超声诊断为泌尿系统畸形的胎儿,48小时内行MRI检查。比较超声与磁共振诊断的异同,并与出生后的临床诊断与处理结果进行比较。
结果：胎儿病理性肾积水20例(27只),泌尿系统其他畸形26例。超声对肾积水、肾盂输尿管接合处、扩张的输尿管及输尿管膀胱接合处的诊断或显示率分别是100%(27/27)、50%(6/12)、83.33(10/12)、0；磁共振对四者的诊断或显示率分别为100% (27/27)、41.67%(5/12)、66.67%(8/12)、25%(3/12)。26例胎儿泌尿系统其他畸形中,16例超声与磁共振诊断皆正确,4例超声正确而磁共振不正确,6例超声不正确而磁共振正确。经配对卡方检验,两者比较无统计学差异(X2=0.1,P=0.7518)。
结论：正常情况下,胎儿泌尿系统畸形的诊断依赖于超声检查,但在羊水过少、孕妇腹壁肥厚、胎儿体位影响或骨骼声影遮挡等致超声显像不清时,胎儿泌尿系统畸形的磁共振检查是必要的。
创新点
1、本研究立足于临床的需要,首次提出应用超声评分法鉴别诊断胎儿生理性与病理性肾积水。超声评分法将与胎儿肾积水程度密切相关的3个因素进行综合分析,极大地提高了诊断的灵敏度(90%)与特异度(94%),希望能在临床上推广应用。
2、首次对胎儿生理性肾积水与孕母血清孕酮水平进行了相关研究,认为胎儿生理性肾积水的原因并非孕妇体内孕酮水平升高,并对胎儿生理性肾积水的产生原因作了深入地探讨,提出了自己的看法。
Background and purpose
More and more literatures showed that morbility of fetal urinary system abnormity had been the first in all the congenital abnormalities, which the most common ultrasonic appearance was hydronephrosis. The morbility of fetal hydronephrosis is 0.9%～2.5%. Now, ultrasound (US) is still the first and irreplaceable imageology method to diagnose fetal abnormality. Although it is easy to diagnose fetal hydronephrosis and there are two methods to define and classified it, I.e. pelvic anterior posterior diameter (PAPD) and the Society for Fetal Urology (SFU) grade. The two methods are not accurate to evaluate the fetal hydronephrosis prognosis. There are different cutoff value, such as 4mm、5mm、7mm、8mm、9mm、10mm、12mm、15mm, but PAPD is too simple and insufficient. After birth, there are always some fetal hydronephrosis to vanish which was called physiological hydronephrosis, and also some fetal hydronephrosis to aggravate which was called pathological hydronephrosis. No PAPD cutoff value can identify the two conditions. SFU grade is indiscriminate and insufficient of quantitive analysis, as pelviectasis、visible of renal calyces、calycectasis ad. only depending on the subjective judgment of inspector.
In short, there are always a great deal of overlap cases no matter how to gauge the cutoff and pregnancy weeks with each method. If we can not identify efficiently the overlap cases, the outcome was:high false positive rate owing to misdiagnosis will cause unnecessary anxiety or blind termination of pregnancy for the pregnant women, whereas low sensitivity may cause missed diagnosis and possible lawsuit for the doctors. It is important to find a new method which can evaluate the prognosis of fetal hydronephrosis. The doctor-patient relationship is strained at the present stage, the policy of family planning and prenatal and postnatal care require US doctors to do better. The biggest prenatal diagnosis and consultation center of province is in our hospital......All was the reasons to carry out the study. The purpose of differential diagnosis of fetal physiological and pathological hydronephrosis is to guide prenatal intervention and postnatal management and provide the more accurate informations for pregnant woman
The reason of fetal pathological hydronephrosis is identified, but that of fetal physiological hydronephrosis is still hypothesis and lack of clinical control study. The theory deduction of ureter functional retract and temporary stricture can not be confirmed by experiment. It can be confirmed by experiment for progestin and hydration of pregnant woman, but no report.
The diagnostic value for magnetic resonance imaging (MRI) to diagnose fetal central nervous system was confirmed, but there were little control study to compare the value of diagnosis fetal hydronephrosis with US and MRI, and no apecial study to report the diagnostic value for MRI to diagnose fetal hydronephrosis.
PartⅠ:Differential Diagnosis of Fetal Physiological and Pathological Hydronephrosis Using Ultrasound Score
Objective:to research the differential diagnosis value of fetal physiological and pathological hydronephrosis using US score through the analysis of fetal large sample clinical data.
Methods:158 fetuses (198 kidneys) with hydronephrosis (PAPD≥10mm) after 28 weeks' gestation were diagnosed by prenatal US in our hospital, then give the cases US score and follow-up. The parameters included PAPD, renal parenchyma thickness (RPT), pelvicaliceal morphology (PM). PM was graded according to our improved and semi-quantitative SFU grading system. The three parameters were graded from 0 to 3 score according to the severity of hydronephrosis and the total US score of each kidney was obtained by adding the scores of three parameters. All the cases were allocated to two groups (physiological and pathological hydronephrosis) based on the postnatal US and other clinical examinations. The data of prenatal PAPD, RPT, PM, US score and postnatal outcome were added up and four receiver operating characteristic (ROC) curves were obtained. Then we made pairwise comparison of ROC curves via Z test and revealed the best ROC curves and cutoff value, sensitivity, specificity, et.al. All data analyses were conducted with SPSS 16.0 statistic software.
Results:Confirmed by postnatal US and other clinical examinations, of 198 kidneys with hydronephrosis,139 (70.20%) were physiological hydronephrosis and 59 (29.80%) were pathological hydronephrosis. Score≤3, all were physiological hydronephrosis and≥8 were pathological hydronephrosis. Score was 4、5、6、7, the ratio of pathological hydronephrosis was 10.53%(2/19)、26.67%(4/15)、45.45%(5/11)、83.33%(10/12) respectively. The higher the score, the higher the ratio of fetal pathological hydronephrosis. Area under the curve (AUC) of PAPD, RPT, PM, US score was 0.897 (minimum),0.957,0.944 and 0.982 (maximum) respectively, and there was significant difference between AUC of US score and each of the other three (p<0.05). US score was the best approach for differential diagnosis of fetal hydronephrosis. By using the left-upper point (score 5) of the curve as the best diagnosis cutoff value, that is, cases with scores≤5 was diagnosed as physiological hydronephrosis, whereas scores≥6 as pathological, the sensitivity, specificity, PPV, NPV, consistency rate, and YI was 89.83%, 94.24%,86.89%,95.62%,92.93% and 0.8407 respectively. Conclusions:Prenatal US score is easy to be obtained by measuring some data of kidney and can effectively differentiate fetal physiological and pathological hydronephrosis because of quantization and aggregate analysis of three factor which were closely related to the severity of hydronephrosis. It was a new quantitative method to evaluate the prognosis of fetal hydronephrosis, and should be disseminated and applied clinically.
PartⅡ:Study on the Correlation Between Serum Progesterone of Pregnant Woman and Fetal Physiological Hydronephrosis
Objective:to analyze that pregnant woman serum progesterone was one of the reason of fetal physiological hydronephrosis or not.
Methods:Study group included 37 pregnant woman with fetal physiological hydronephrosis confirmed by postnatal US,30 fetuses without hydronephrosis were control group. All the women were not hydronephrosis before pregnancy.2ml venous blood of women was obtained and was centrifuged to detect progestational hormone. Then we examined and recoreded the women s changes of kidneies:it was normal when without pelviectasis or PAPD<10mm, and hydronephrosis when PAPD≥10mm.1～2 month after parturition, the mother and infant were underwent US exam and their kidneys were measured and recorded. The progesterone of two groups were compared via Logistic test and gestational week as concomitant variable. The changes of kidney in two groups were contrasted by chi square test.
Results:The level of serum progesterone in two groups continually increased following the gestational week. The group of fetal physiological hydronephrosis:37 cases, serum progesterone of pregnant woman was 159ng/ml～230.9ng/ml, average 189.06±18.76ng/ml; there was 11 hydronephrosis in women. The control group:30 cases,157ng/ml～235ng/ml, and average 190.9±20.16ng/ml; 8 hydronephrosis in women. There was not statistically significant within the two groups not only on serum progesterone (X2=0.0171, P=0.8950) but also on the changes of the two group woman (P >0.05)
Conclusion:Serum progesterone is not one of the cause of fetal physiological hydronephrosis, although it can chalasia the smooth muscle in pelvis and ureter of pregnant woman. It shoule be the different sensitivity for progestational hormon to lead to pelviectasis or hydronephrosis.
PartⅢ:Control Study on Fetal Disease of Urinary System Using Ultrasound and MRI
Objective:to contrast the value to diagnose fetal hydronephrosis and other urinary system abnormity with US and MRI, to discuss which diseases need to do MRI examination.
Methods:46 fetuses with urinary system abnormity diagnosed by prenatal US were underwent MRI within 48 hours. Similarities and Differences were compared with US and MRI diagnosis and the outcome after birth.
Result:Among all the 46 cases,20 cases (27 hydronephrosis) were pathological hydronephrosis and 26 were urinary system other abnormities.27 hydronephrosis were all diagnosed by US and MRI. Of all the 12 cases with the lower ureter obstruction, the ratio of US diagnosis on ureteropelvic junction、ureter dilatation、ureterovesical junction was 50%(6/12)、83.33 (10/12)、0; but that of MRI was 41.67%(5/12)、66.67%(8/12)、25% (3/12). Among 26 cases with urinary system other abnormity,16 cases were correctly diagnosed by US and MRI,4 cases were correctly diagnosed only by US,6 cases were correctly diagnosed only by MRI. There was not statistically significant within the two imaging methods (X2=0.1, P=0.7518) via X2 test of paired comparison.
Conclusion:Normally, the diagnosis of fetal urinary system abnormity depend on US, but when oligohydramnios、plump woman、influence by fetal position and skeleton shadowing, it is necessary to perform fetal MRI.
Main Innovative Points
1、Based on the clinical demand, this study first used US score to differential diagnosis fetal physiological pathological hydronephrosis. It can greatly increase the diagnostic sensitivity and specificity of fetal pathological hydronephrosis due to aggregate analysis of three factor which were closely related to the severity of hydronephrosis. So US score is a simple、practical and accurate new method which is worthwhile for clinic application.
2、We first study on the correlation between serum progesterone in pregnant woman and fetal physiological hydronephrosis,and denied the causal relation between them. Deeply discusses was undertaken about the reason of fetal physiological hydronephrosis.
引文
1. Elder JS. Antenatal hydronephrosis:Fetal and neonatal management. Pediatr Clin North Am 1997;44:1299-1321.
2. Fong KW, Ryan G(1998)"The fetal urogenital tract."In:Rumack CM, Wilson SR, Charboneau JW eds. Diagnostic ultrasound,2nd ed. Mosby, St Louis, pp 1093-1121.
3. Scott JE, Renwick M. Urological abnormalities in the northern regionfetal abnormality survey. Arch Dis Child 1993;68:22-26.
4. Shokeir A, Nijman R. Antenatal hydronephrosis:changing concepts in diagnosis and subsequent management. BJU Int 2000; 85:987-994.
5. Martin C, Damell A, Duran C, et al. Mangetic resonance imaging of the intrauterine fetal genitourinary tract:normal anatomy and pathology. Abdom Imaging 2004;29:286-302.
6. Sairam S, Al-Habib A, Sasson S, et al. Natural history of fetal hydronephrosis diagnosed on midtrimester uktrasound. Utrasound Obstet Gynecol 2001;17:191-196.
7. Fernbach SK, Maizels M, Conway JJ. Ultrasound grading of hydronephrosis: introduction to the system used by the Society of Fetal Urology. Pediatr Radiol 1993;23:478-480.
8. Coelho GM, Bouzada MC, Pereira AK, et al. Outcome of isolated antenatal hydronephrosis:a prospective cohort study. Pediatr Nephrol 2007; 22 (10):1727-1734.
9. Tao G, Yew DT, Gu T, et al. Sex-related differences in the anteroposterior diameter of the foetal cisterna magna. Clin Radiol 2008;63(9):1015-1018.
10. Griffiths PD, Widjaja E, Paley MN,et al. Imaging the fetal spine using in utero MR:diagnostic accuracy and impact on management. Pediatr Radiol 2006;36:927-933.
11. Levine D, Barnes PD, Robertson RR, et al. Fast MR imaging of fetal central nervous system abnormalities. Radiology 2002;229:51-61.
12. Veyrac C, Couture A, Saguintaah M, Baud C. MRI of fetal GI tract abnormalities. Abdom Imaging 2004;29:411-420.
13. Dietrich RB, Cohen J. Fetal MR imaging. Magn Reson Imaging Clin North Am 2006;14:503-522.
14. Siemens DR, Prouse KA, Mac Neily AE, et al.Antenatal hydronephrosis thresholds of renal pelvic diameter to predict insignificant postnatal pelviectasis. Tech Urlo 1998;4:198-201.
15. Madell J, Blyth BR, Peters CA, et al. Structural genitourinary defects detected in utero. Radiology 1991; 178:193-196.
16. Adra AM, Mejides AA, Dennaoui MS, et al. Fetal pyelectasis:is it always "physiologic"? Am J Obstet Gynecol 1995; 173 (4):1263-1266.
17. Uzounian JG, Castro MA, Fresquez M, et al. Prognostic significance of antenatally detected fetal pyelectasis. Ultrasound Obstet Gynecol 1996;7:424-428.
18. Blachar A, Blachar Y, Livnre PM, et al. Clinical outcome and followup of prenatal hydronephrosis. Pediatr Nephrol 1994;8:30-35.
19. Arger PH, Coleman BG, Mintz MC, et al. Routine fetal genitourinary tract screening. Radiology 1985; 156:485-487.
20. Wollenberg A, Neuhaus TJ, Willi UV, et al. Outcome of fetal renal pelvic dilatation diagnosed during the third trimester. Ultrasound Obstet Gynecol 2005;25(5):483-488.
21. Adra AM, Mejides AA, Dennaoui MS, et al. Fetal pyelectasis:is it always "physiologic"? Am J Obstet Gynecol 1995; 173 (4):1263-1266.
22.Langer B, Simeoni U, Montoya Y, et al. Antenatal diagnosis of upper urinary tract dilation by ultrasonography. Fetal Diagn Ther 1996;11(3):191-198.
23. Koff SA, Campbell KD.The nonoperative management of unilateral neonatal hydronephrosis:natural history of poorly functioning kidneys. J of Urol 1994;152:593-599.
24. Koff SA, Campbell K. Nonoperative management of unilateral neonatal neonatal hydronephrosis. J of Urol 1992;148:525-526.
25. Grignon A, Filion R, Filiatrault D, et al. Urinary tract dilatation in utero: classification and clinical applications. Radiology 1986;160:645-647.
26. 卜凡堂,唐淑云.胎儿肾积水12例超声研究.中国超声医学杂志,2001；17(12)：934-936.
27.葛晖,丁中.肾集合系统分离值对预测胎儿肾积水可复性的探讨.淮海医药,2003；21(6)：457-458.
28.接连利,林范余.胎儿泌尿系统畸形的产前超声诊断.医学影像学杂志,2001；11(1)：56.
29. Thomas DF. Prenatally diagnosed urinary tract abnormalities: Long-term outcome. Semin Fetal Neonatal Med 2008 Jun;13(3):189-195
30. Garne E, Loane M, Wellesley D, et al. Eurocat Working Group. Congenital hydronephrosis:prenatal diagnosis and epidemiology in Europe. J Pediatr Urol 2009 Feb;5(1):47-52.
31. Moore KL, Persaud TVN. The urogenital system. In:The developing human:clinically oriented embryology,5th ed. Philadelphia:WB Saunders,1993.265-303
32. Gubler MC, Dahmane F, Dommergues M et al. Les malformations et maladies renales a revelation prenatale. Ann Pathol 1997;17:240-250.
33.成令中主编.组织学与胚胎学,第3版.北京：人民卫生出版社,1994.284-285.
34.吴阶平主编.泌尿外科.济南：山东科学技术出版社,1993.273-275.
35. Toiviainen-Salo S, Garel L, Grignon A, et al. Fetal hydronephrosis:is there hope for consensus? Pediatr Radiol 2004;34:519-529.
36. Granum PA. THe genitourinary tract. In:Nyberg DA, Mahcxiey BS, Pretouius DH, eds. Diagnostic ultrasound in fetal anomalies. Chicago: YearBookMedical,1990, pp:433-491.
37. Twining P. Urinary tract abnormalities.In:Twining P, McHugo JM, Pilling DW (eds) Textbook of fetal abnormalities,1st edn. Churchill Livingstone, London,2000, pp:269-314.
38. Thornburg LL, Pressman EK, Chelamkuri S, et al. Third trimester ultrasound of fetal pyelectasis:predictor for postnatal surgery. J Pediatr Urol 2008 Feb;4(1):51-54.
39. Pates JA, Dashe JS. Prenatal diagnosis and management of hydroephrosis. Early Hum Dev 2006 Jan;82(1):3-8.
40. Woodward M, Frank D. Postnatal management of antenatal hydronephrosis. BJU Int 2002;89:149-156.
41. Ismaili K, Hall M, Piepsz A, et al. Primary vesicoureteral reflux detected in neonates with a history of fetal renal pelvis dilatation:a prospective clinical and imaging study. J Pediatr 2006 Feb;148 (2):222-227.
42.赵亚利,段云友.胎儿肾、脑动脉的彩色多普勒监测及其临床意义.第四军医大学学报,1995；16(2)：120-122.
43. Platt JF, Rubin JM, Ellis HM, et al. Duplex Doppler US of the kidney: differentiation of obstructive from non-obstructive dilatation. Radiology 1989;171:515-517.
44. Sholeir AA, Provoost AP, El-Azab M, et al. Renal Doppler ultrasound in children with normal upper urinary tracts:effect of fasting. Hydration with normal saline and furosemide administration. Urology 1996;47:740-744.
45. Anderson N, Clautice-Engel T, Allan R, et al. Detection of obstructive uropathy in the fetus:predictive value of sonographic measurements of renal pelvic diameter at various gestational ages. AJR 1995; 164:719-723.
46. Coplen D. Prenatal intervention for hydronephrosis. J Urol 1997; 157: 2270-2277
47. Coplen DE, Hare JY, Zderic SA, et al.10-year experience with prenatal intervention for hydronephrosis. J Urol 1996;156:1142-1145.
48. Fagerquist M, Fagerquist U, Oden A, et al. Fetal urine production and accuracy when estimating fetal urinary bladder volume. Ultrasound Obstet Gynecol 2001;17:132-139.
49. Babcook CJ, Silvera M, Drake C, et al. Effect of maternal hydration on mild fetal pyelectasis. J Ultrasound Med 1998;17:536-544.
50. Robinson JN, Tice K, Kolm P, et al. Effect of maternal hydration on fetal renal pyelectasis. Obstet Gynecol 1998;92:137-141.
51.任世奇,王栩,唐宝军,等.微板式化学发光酶免疫分析法临床测定人血清中孕酮.分析化学研究报告,2008；6(36)：729-734.
52. Schumacher M, Guennoun R, Stein DG, et al. Progesterone:therapeutic opportunities for neuroprotection and myelin repair. Pharmacol Ther 2007;116(1):97-106.
53. Vink R, Nimmo AJ. Multifunctional drugs for head injury. Neurotherapeutics 2009;6(1):28-42.
54.司道文,刘江,孟景山,等.孕酮对大鼠创伤性脑损伤后的神经保护作用.华西药学杂志,2010；25(3)：293-295。
55.乐杰.妇产科学[M].北京：人民卫生出版社,2003：171.
56.左茂翠.妊娠并发肾盂积水26例分析. 医学信息2007；20(12)：2090-2091.
57. Hsia TY, Shortliffe LM. The effect of pregnancy on urinary tract dynamics. J Urol 1995;154(2):684.
58. Levine D, Barnes PD, Madsen JR. et al. Fetal CNS anomalies revealed on ultrafast MR imaging. AJR 1999;172:813-818.
59. Levime D, Barnes PD. Cortical maturation in normal and abnormal fetuses as assessed with prenatal MR imaging. Radiology 1999;210:751-758.
60. Yamashita Y, Namimoto T, Abe Y, et al. MR imaging of the fetus by a HASTE squence. AJR 1997;168:513-519.
61. Slovis TL, Sty JR, Heller JO. imaging of the pediatric urinary tract. Philadelphia:WB Saunders;1989. pp:72-97.
62. Barss VA, Benacerraf BR, Frigoletto FD. Jr. Second trimester oligohydramnios, a predictor of poor fetal outcome. Obstet Gynecol 1984;64:608-610.
63. Bronshteim M, Yoffe N, Brandes JM, et al. First and early second trimester diagnosis of fetal urinary tract anomalies using transvaginal sonography. Penat Diagn 1990;10(7):653-666.
64. Martin C, Darnell A, Duran C, et al. Magnetic resonance imaging of the intrauterine fetal genitourinary tract:normal anatomy and pathology. Abdom Imaging 2004;29(3):286-302.
65. Saguintaah, M, Couture, A, Veyrac, C et al. MRI of the fetal gastrointestinal tract. Pediatr Radiol 2002;32:395-404
66. Jacqueline TC, Romald MR, Kevin PM, et al. MRI of fetal genitourinary anomalies. AJR 2003;181(5):1381-1385.
67. Kleiner B, Callen PW, Filly FA. Sonographic analysis of the fetus with uretero-pelvic junction obstruction. Am J Radiol 1987; 148:359-363。
68. Shinmoto, H, Kashima, K, Yuasa, Y et al. MR Imaging of non-CNS fetal abnormalities:a pictorial essay. Radiographics 2000;20:1227-1243.
69.陈静.磁共振成像在胎儿异常中的临床应用研究.中国医科大学学报，2008；37(5)：670-672.
70. Liu, HY, Dhillon, HK, Yeung, CK et al. Clinical outcome and management of prenatally diagnosed primary megaureters. J Urol 1994; 152:614-617.
71. Cendron M, Dalton ME, Crombleholme TM. Prenatal diagnosis and management of the fetus with hydronephrosis. Semin Perinatol 1994;18: 163-181.
72. Hayden SA, Russ PD, Pretorius DH, et al. Posterior urethral obstruction. Prenatal sonographic findings and clinical outcome in fourteen cases. J Ultrasound Med 1988;7:371-375.
73. Avni EF, Hall M, Collier F, et al. (2001) Anomalies of the renal pelvis and ureter. In:Fotter, R eds., Medical radiology. Diagnostic imaging. Pediatric uroradiology, Springer-Verlag, New York, pp 61-90.
74. Alamo L, Tarek L, Pierre S, et al. Fetal MRI as complement to US in the diagnosis and characterization of anomalies of the genito-urinary tract. Eur J Radiol 2009;28:[Epub ahead of print].
75.董素贞.胎儿泌尿生殖系统的磁共振诊断.中国医学影像技术,2008；24(1)：118-122.
76. Spielmann AL, Freed KS, Spritzer CE. MRI of conjoined twins illustrating advances in fetal imaging. Journal of computer assisted tomography 2001;25:88-90.
1.Tao G, Yew DT, Gu T, et al. Sex-related differences in the anteroposterior diameter of the foetal cisterna magna. Clin Radiol 2008;63(9):1015-1018.
2.Griffiths PD, Widjaja E, Paley MN,et al. Imaging the fetal spine using in utero MR:diagnostic accuracy and impact on management. Pediatr Radiol 2006;36:927-933.
3.Levine D, Barnes PD, Robertson RR, et al. Fast MR imaging of fetal central nervous system abnormalities. Radiology 2002;229:51-61.
4.Levine D, Barnes PD, Madsen JR. et al. Fetal CNS anomalies revealed on ultrafast MR imaging. AJR 1999;172:813-818.
5.Levime D, Barnes PD. Cortical maturation in normal and abnormal fetuses as assessed with prenatal MR imaging. Radiology 1999;210:751-758.
6.Yamashita Y, Namimoto T, Abe Y, et al. MR imaging of the fetus by a HASTE squence. AJR 1997;168:513-519.
7.Slovis TL, Sty JR, Heller JO. imaging of the pediatric urinary tract. Philadelphia:WB Saunders;1989. pp:72-97.
8.Barss VA, Benacerraf BR, Frigoletto FD Jr. Second trimester oligohydramnios, a predictor of poor fetal outcome. Obstet Gynecol 1984;64:608-610.
9.Bronshteim M, Yoffe N, Brandes JM, et al. First and early second trimester diagnosis of fetal urinary tract anomalies using transvaginal sonography. Penat Diagn 1990;10(7):653-666.
10.Martin C, Darnell A, Duran C, et al. Magnetic resonance imaging of the intrauterine fetal genitourinary tract:normal anatomy and pathology. Abdom Imaging 2004;29(3):286-302.
11.Saguintaah, M, Couture, A, Veyrac, C et al. MRI of the fetal gastrointestinal tract. Pediatr Radiol 2002;32:395-404
12.Jacqueline TC, Romald MR, Kevin PM, et al. MRI of fetal genitourinary anomalies. AJR 2003;181(5):1381-1385.
13.Kleiner B, Callen PW, Filly FA. Sonographic analysis of the fetus with uretero-pelvic junction obstruction. Am J Radiol 1987;148:359-363
14.Shinmoto H, Kashima K, Yuasa Y et al. MR Imaging of non-CNS fetal abnormalities:a pictorial essay. Radiographics 2000;20:1227-1243.
15.陈静.磁共振成像在胎儿异常中的临床应用研究.中国医科大学学报,2008；37(5)：670-672.
16.Liu HY, Dhillon HK, Yeung CK et al. Clinical outcome and management of prenatally diagnosed primary megaureters. J Urol 1994; 152:614-617.
17.Cendron M, Dalton ME, Crombleholme TM. Prenatal diagnosis and management of the fetus with hydronephrosis. Semin Perinatol 1994;18: 163-181.
18.Hayden SA, Russ PD, Pretorius DH, et al. Posterior urethral obstruction. Prenatal sonographic findings and clinical outcome in fourteen cases. J Ultrasound Med 1988;7:371-375.
19.Avni EF, Hall M, Collier F, et al. (2001) Anomalies of the renal pelvis and ureter. In:Fotter, R eds, Medical radiology. Diagnostic imaging. Pediatric uroradiology, Springer-Verlag, New York, pp 61-90.
20.Alamo L, Tarek L, Pierre S, et al. Fetal MRI as complement to US in the diagnosis and characterization of anomalies of the genito-urinary tract. Eur J Radiol 2009;28:[Epub ahead of print].
21.董素贞.胎儿泌尿生殖系统的磁共振诊断.中国医学影像技术,2008；24(1)：118-122.
22.Spielmann AL, Freed KS, Spritzer CE. MRI of conjoined twins illustrating advances in fetal imaging. Journal of computer assisted tomography 2001;25:88-90.
2. Fong KW, Ryan G(1998)"The fetal urogenital tract."In:Rumack CM, Wilson SR, Charboneau JW eds. Diagnostic ultrasound,2nd ed. Mosby, St Louis, pp 1093-1121.
3. Scott JE, Renwick M. Urological abnormalities in the northern regionfetal abnormality survey. Arch Dis Child 1993;68:22-26.
4. Shokeir A, Nijman R. Antenatal hydronephrosis:changing concepts in diagnosis and subsequent management. BJU Int 2000; 85:987-994.
5. Martin C, Damell A, Duran C, et al. Mangetic resonance imaging of the intrauterine fetal genitourinary tract:normal anatomy and pathology. Abdom Imaging 2004;29:286-302.
6. Sairam S, Al-Habib A, Sasson S, et al. Natural history of fetal hydronephrosis diagnosed on midtrimester uktrasound. Utrasound Obstet Gynecol 2001;17:191-196.
7. Fernbach SK, Maizels M, Conway JJ. Ultrasound grading of hydronephrosis: introduction to the system used by the Society of Fetal Urology. Pediatr Radiol 1993;23:478-480.
8. Coelho GM, Bouzada MC, Pereira AK, et al. Outcome of isolated antenatal hydronephrosis:a prospective cohort study. Pediatr Nephrol 2007; 22 (10):1727-1734.
9. Tao G, Yew DT, Gu T, et al. Sex-related differences in the anteroposterior diameter of the foetal cisterna magna. Clin Radiol 2008;63(9):1015-1018.
10. Griffiths PD, Widjaja E, Paley MN,et al. Imaging the fetal spine using in utero MR:diagnostic accuracy and impact on management. Pediatr Radiol 2006;36:927-933.
11. Levine D, Barnes PD, Robertson RR, et al. Fast MR imaging of fetal central nervous system abnormalities. Radiology 2002;229:51-61.
12. Veyrac C, Couture A, Saguintaah M, Baud C. MRI of fetal GI tract abnormalities. Abdom Imaging 2004;29:411-420.
13. Dietrich RB, Cohen J. Fetal MR imaging. Magn Reson Imaging Clin North Am 2006;14:503-522.
14. Siemens DR, Prouse KA, Mac Neily AE, et al.Antenatal hydronephrosis thresholds of renal pelvic diameter to predict insignificant postnatal pelviectasis. Tech Urlo 1998;4:198-201.
15. Madell J, Blyth BR, Peters CA, et al. Structural genitourinary defects detected in utero. Radiology 1991; 178:193-196.
16. Adra AM, Mejides AA, Dennaoui MS, et al. Fetal pyelectasis:is it always "physiologic"? Am J Obstet Gynecol 1995; 173 (4):1263-1266.
17. Uzounian JG, Castro MA, Fresquez M, et al. Prognostic significance of antenatally detected fetal pyelectasis. Ultrasound Obstet Gynecol 1996;7:424-428.
18. Blachar A, Blachar Y, Livnre PM, et al. Clinical outcome and followup of prenatal hydronephrosis. Pediatr Nephrol 1994;8:30-35.
19. Arger PH, Coleman BG, Mintz MC, et al. Routine fetal genitourinary tract screening. Radiology 1985; 156:485-487.
20. Wollenberg A, Neuhaus TJ, Willi UV, et al. Outcome of fetal renal pelvic dilatation diagnosed during the third trimester. Ultrasound Obstet Gynecol 2005;25(5):483-488.
21. Adra AM, Mejides AA, Dennaoui MS, et al. Fetal pyelectasis:is it always "physiologic"? Am J Obstet Gynecol 1995; 173 (4):1263-1266.
22.Langer B, Simeoni U, Montoya Y, et al. Antenatal diagnosis of upper urinary tract dilation by ultrasonography. Fetal Diagn Ther 1996;11(3):191-198.
23. Koff SA, Campbell KD.The nonoperative management of unilateral neonatal hydronephrosis:natural history of poorly functioning kidneys. J of Urol 1994;152:593-599.
24. Koff SA, Campbell K. Nonoperative management of unilateral neonatal neonatal hydronephrosis. J of Urol 1992;148:525-526.
25. Grignon A, Filion R, Filiatrault D, et al. Urinary tract dilatation in utero: classification and clinical applications. Radiology 1986;160:645-647.
26. 卜凡堂,唐淑云.胎儿肾积水12例超声研究.中国超声医学杂志,2001；17(12)：934-936.
27.葛晖,丁中.肾集合系统分离值对预测胎儿肾积水可复性的探讨.淮海医药,2003；21(6)：457-458.
28.接连利,林范余.胎儿泌尿系统畸形的产前超声诊断.医学影像学杂志,2001；11(1)：56.
29. Thomas DF. Prenatally diagnosed urinary tract abnormalities: Long-term outcome. Semin Fetal Neonatal Med 2008 Jun;13(3):189-195
30. Garne E, Loane M, Wellesley D, et al. Eurocat Working Group. Congenital hydronephrosis:prenatal diagnosis and epidemiology in Europe. J Pediatr Urol 2009 Feb;5(1):47-52.
31. Moore KL, Persaud TVN. The urogenital system. In:The developing human:clinically oriented embryology,5th ed. Philadelphia:WB Saunders,1993.265-303
32. Gubler MC, Dahmane F, Dommergues M et al. Les malformations et maladies renales a revelation prenatale. Ann Pathol 1997;17:240-250.
33.成令中主编.组织学与胚胎学,第3版.北京：人民卫生出版社,1994.284-285.
34.吴阶平主编.泌尿外科.济南：山东科学技术出版社,1993.273-275.
35. Toiviainen-Salo S, Garel L, Grignon A, et al. Fetal hydronephrosis:is there hope for consensus? Pediatr Radiol 2004;34:519-529.
36. Granum PA. THe genitourinary tract. In:Nyberg DA, Mahcxiey BS, Pretouius DH, eds. Diagnostic ultrasound in fetal anomalies. Chicago: YearBookMedical,1990, pp:433-491.
37. Twining P. Urinary tract abnormalities.In:Twining P, McHugo JM, Pilling DW (eds) Textbook of fetal abnormalities,1st edn. Churchill Livingstone, London,2000, pp:269-314.
38. Thornburg LL, Pressman EK, Chelamkuri S, et al. Third trimester ultrasound of fetal pyelectasis:predictor for postnatal surgery. J Pediatr Urol 2008 Feb;4(1):51-54.
39. Pates JA, Dashe JS. Prenatal diagnosis and management of hydroephrosis. Early Hum Dev 2006 Jan;82(1):3-8.
40. Woodward M, Frank D. Postnatal management of antenatal hydronephrosis. BJU Int 2002;89:149-156.
41. Ismaili K, Hall M, Piepsz A, et al. Primary vesicoureteral reflux detected in neonates with a history of fetal renal pelvis dilatation:a prospective clinical and imaging study. J Pediatr 2006 Feb;148 (2):222-227.
42.赵亚利,段云友.胎儿肾、脑动脉的彩色多普勒监测及其临床意义.第四军医大学学报,1995；16(2)：120-122.
43. Platt JF, Rubin JM, Ellis HM, et al. Duplex Doppler US of the kidney: differentiation of obstructive from non-obstructive dilatation. Radiology 1989;171:515-517.
44. Sholeir AA, Provoost AP, El-Azab M, et al. Renal Doppler ultrasound in children with normal upper urinary tracts:effect of fasting. Hydration with normal saline and furosemide administration. Urology 1996;47:740-744.
45. Anderson N, Clautice-Engel T, Allan R, et al. Detection of obstructive uropathy in the fetus:predictive value of sonographic measurements of renal pelvic diameter at various gestational ages. AJR 1995; 164:719-723.
46. Coplen D. Prenatal intervention for hydronephrosis. J Urol 1997; 157: 2270-2277
47. Coplen DE, Hare JY, Zderic SA, et al.10-year experience with prenatal intervention for hydronephrosis. J Urol 1996;156:1142-1145.
48. Fagerquist M, Fagerquist U, Oden A, et al. Fetal urine production and accuracy when estimating fetal urinary bladder volume. Ultrasound Obstet Gynecol 2001;17:132-139.
49. Babcook CJ, Silvera M, Drake C, et al. Effect of maternal hydration on mild fetal pyelectasis. J Ultrasound Med 1998;17:536-544.
50. Robinson JN, Tice K, Kolm P, et al. Effect of maternal hydration on fetal renal pyelectasis. Obstet Gynecol 1998;92:137-141.
51.任世奇,王栩,唐宝军,等.微板式化学发光酶免疫分析法临床测定人血清中孕酮.分析化学研究报告,2008；6(36)：729-734.
52. Schumacher M, Guennoun R, Stein DG, et al. Progesterone:therapeutic opportunities for neuroprotection and myelin repair. Pharmacol Ther 2007;116(1):97-106.
53. Vink R, Nimmo AJ. Multifunctional drugs for head injury. Neurotherapeutics 2009;6(1):28-42.
54.司道文,刘江,孟景山,等.孕酮对大鼠创伤性脑损伤后的神经保护作用.华西药学杂志,2010；25(3)：293-295。
55.乐杰.妇产科学[M].北京：人民卫生出版社,2003：171.
56.左茂翠.妊娠并发肾盂积水26例分析. 医学信息2007；20(12)：2090-2091.
57. Hsia TY, Shortliffe LM. The effect of pregnancy on urinary tract dynamics. J Urol 1995;154(2):684.
58. Levine D, Barnes PD, Madsen JR. et al. Fetal CNS anomalies revealed on ultrafast MR imaging. AJR 1999;172:813-818.
59. Levime D, Barnes PD. Cortical maturation in normal and abnormal fetuses as assessed with prenatal MR imaging. Radiology 1999;210:751-758.
60. Yamashita Y, Namimoto T, Abe Y, et al. MR imaging of the fetus by a HASTE squence. AJR 1997;168:513-519.
61. Slovis TL, Sty JR, Heller JO. imaging of the pediatric urinary tract. Philadelphia:WB Saunders;1989. pp:72-97.
62. Barss VA, Benacerraf BR, Frigoletto FD. Jr. Second trimester oligohydramnios, a predictor of poor fetal outcome. Obstet Gynecol 1984;64:608-610.
63. Bronshteim M, Yoffe N, Brandes JM, et al. First and early second trimester diagnosis of fetal urinary tract anomalies using transvaginal sonography. Penat Diagn 1990;10(7):653-666.
64. Martin C, Darnell A, Duran C, et al. Magnetic resonance imaging of the intrauterine fetal genitourinary tract:normal anatomy and pathology. Abdom Imaging 2004;29(3):286-302.
65. Saguintaah, M, Couture, A, Veyrac, C et al. MRI of the fetal gastrointestinal tract. Pediatr Radiol 2002;32:395-404
66. Jacqueline TC, Romald MR, Kevin PM, et al. MRI of fetal genitourinary anomalies. AJR 2003;181(5):1381-1385.
67. Kleiner B, Callen PW, Filly FA. Sonographic analysis of the fetus with uretero-pelvic junction obstruction. Am J Radiol 1987; 148:359-363。
68. Shinmoto, H, Kashima, K, Yuasa, Y et al. MR Imaging of non-CNS fetal abnormalities:a pictorial essay. Radiographics 2000;20:1227-1243.
69.陈静.磁共振成像在胎儿异常中的临床应用研究.中国医科大学学报，2008；37(5)：670-672.
70. Liu, HY, Dhillon, HK, Yeung, CK et al. Clinical outcome and management of prenatally diagnosed primary megaureters. J Urol 1994; 152:614-617.
71. Cendron M, Dalton ME, Crombleholme TM. Prenatal diagnosis and management of the fetus with hydronephrosis. Semin Perinatol 1994;18: 163-181.
72. Hayden SA, Russ PD, Pretorius DH, et al. Posterior urethral obstruction. Prenatal sonographic findings and clinical outcome in fourteen cases. J Ultrasound Med 1988;7:371-375.
73. Avni EF, Hall M, Collier F, et al. (2001) Anomalies of the renal pelvis and ureter. In:Fotter, R eds., Medical radiology. Diagnostic imaging. Pediatric uroradiology, Springer-Verlag, New York, pp 61-90.
74. Alamo L, Tarek L, Pierre S, et al. Fetal MRI as complement to US in the diagnosis and characterization of anomalies of the genito-urinary tract. Eur J Radiol 2009;28:[Epub ahead of print].
75.董素贞.胎儿泌尿生殖系统的磁共振诊断.中国医学影像技术,2008；24(1)：118-122.
76. Spielmann AL, Freed KS, Spritzer CE. MRI of conjoined twins illustrating advances in fetal imaging. Journal of computer assisted tomography 2001;25:88-90.
1.Tao G, Yew DT, Gu T, et al. Sex-related differences in the anteroposterior diameter of the foetal cisterna magna. Clin Radiol 2008;63(9):1015-1018.
2.Griffiths PD, Widjaja E, Paley MN,et al. Imaging the fetal spine using in utero MR:diagnostic accuracy and impact on management. Pediatr Radiol 2006;36:927-933.
3.Levine D, Barnes PD, Robertson RR, et al. Fast MR imaging of fetal central nervous system abnormalities. Radiology 2002;229:51-61.
4.Levine D, Barnes PD, Madsen JR. et al. Fetal CNS anomalies revealed on ultrafast MR imaging. AJR 1999;172:813-818.
5.Levime D, Barnes PD. Cortical maturation in normal and abnormal fetuses as assessed with prenatal MR imaging. Radiology 1999;210:751-758.
6.Yamashita Y, Namimoto T, Abe Y, et al. MR imaging of the fetus by a HASTE squence. AJR 1997;168:513-519.
7.Slovis TL, Sty JR, Heller JO. imaging of the pediatric urinary tract. Philadelphia:WB Saunders;1989. pp:72-97.
8.Barss VA, Benacerraf BR, Frigoletto FD Jr. Second trimester oligohydramnios, a predictor of poor fetal outcome. Obstet Gynecol 1984;64:608-610.
9.Bronshteim M, Yoffe N, Brandes JM, et al. First and early second trimester diagnosis of fetal urinary tract anomalies using transvaginal sonography. Penat Diagn 1990;10(7):653-666.
10.Martin C, Darnell A, Duran C, et al. Magnetic resonance imaging of the intrauterine fetal genitourinary tract:normal anatomy and pathology. Abdom Imaging 2004;29(3):286-302.
11.Saguintaah, M, Couture, A, Veyrac, C et al. MRI of the fetal gastrointestinal tract. Pediatr Radiol 2002;32:395-404
12.Jacqueline TC, Romald MR, Kevin PM, et al. MRI of fetal genitourinary anomalies. AJR 2003;181(5):1381-1385.
13.Kleiner B, Callen PW, Filly FA. Sonographic analysis of the fetus with uretero-pelvic junction obstruction. Am J Radiol 1987;148:359-363
14.Shinmoto H, Kashima K, Yuasa Y et al. MR Imaging of non-CNS fetal abnormalities:a pictorial essay. Radiographics 2000;20:1227-1243.
15.陈静.磁共振成像在胎儿异常中的临床应用研究.中国医科大学学报,2008；37(5)：670-672.
16.Liu HY, Dhillon HK, Yeung CK et al. Clinical outcome and management of prenatally diagnosed primary megaureters. J Urol 1994; 152:614-617.
17.Cendron M, Dalton ME, Crombleholme TM. Prenatal diagnosis and management of the fetus with hydronephrosis. Semin Perinatol 1994;18: 163-181.
18.Hayden SA, Russ PD, Pretorius DH, et al. Posterior urethral obstruction. Prenatal sonographic findings and clinical outcome in fourteen cases. J Ultrasound Med 1988;7:371-375.
19.Avni EF, Hall M, Collier F, et al. (2001) Anomalies of the renal pelvis and ureter. In:Fotter, R eds, Medical radiology. Diagnostic imaging. Pediatric uroradiology, Springer-Verlag, New York, pp 61-90.
20.Alamo L, Tarek L, Pierre S, et al. Fetal MRI as complement to US in the diagnosis and characterization of anomalies of the genito-urinary tract. Eur J Radiol 2009;28:[Epub ahead of print].
21.董素贞.胎儿泌尿生殖系统的磁共振诊断.中国医学影像技术,2008；24(1)：118-122.
22.Spielmann AL, Freed KS, Spritzer CE. MRI of conjoined twins illustrating advances in fetal imaging. Journal of computer assisted tomography 2001;25:88-90.