胎儿肾积水的产前超声诊断及预后评估

目的 探讨胎儿肾积水的产前超声诊断的临床意义及其预后评估价值.方法 2004年12月至2005年11月在浙江大学医学院附属妇产科医院就诊的妊娠20周以上的9526例单胎孕妇行常规产前超声检查,发现胎儿肾盂前后径≥8 mm者诊断为肾积水而纳入本研究.并按Grignon分级法进行分级,定期检查和记录妊娠结局,直至分娩.结果 (1)胎儿肾积水的发生率及Grignon分级:9526例中共有162例胎儿发生肾积水,发生率为1.7%.于肾积水高峰期行Grignon分级,1级71例,2级59例,3级7例.4级3例,5级22例.(2)发生肾积水的孕周分布:初次发现胎儿肾积水的孕周平均为(33±5)周.肾积水程度达到最高峰的孕周平均为(36±3)周.110例(68%)胎儿肾积水在妊娠期即自行消失,消失孕周平均为(37±4)周.(3)不良妊娠结局:162例肾积水胎儿中有不良妊娠结局40例(25%),其中11例初次发现于孕20～24周中有3例(27%),20例初次发现于孕25～28周中有6例(24%),53例初次发现于孕29～32周中有14例(26%),48例初次发现于孕33～36周中有11例(23%),30例初次发现于孕37～40周中有6例(20%).胎儿肾积水Grignon分级越高,不良妊娠结局发生率也越高,3级及以上者不良妊娠结局发生率达100%.(4)随访结果 :分娩健康新生儿122例(75%,122/162),为110例出生前肾积水自行消失者和12例出生后1周内肾积水自行消失者,随访2年以上其生长发育正常,无泌尿系统后遗症;分娩肾积水新生儿20例(12%,20/162),为出生后1周内超声复查仍存在肾积水者,其中Grignon分级在3级及以下者11例,肾积水消失时间在出生后3个月至12个月不等,患儿生长发育均与同龄儿无明显差异,无泌尿系统症状.结论 胎儿肾积水初次发现的孕周越早,程度越严重,胎儿预后越差.应用Grignon分级法对胎儿肾积水程度进行分级可用于评估肾积水胎儿的预后,以指导临床处理.

Prenatal diagnosis and prognosis of fetal nephrohydrosis

Objective To explore the clinical significance of prenatal ultrasonic diagnosis of fetal nephrohydrosis and its prognosis.Methods Prenatal ultrasanography was performed on 9526 women at more than 20 weeks gestation,and 162 women whose anteroposterior diameter of the renal pelvis was≥8 mm were included in this study.The grade of fetal nephrohydrosis was classified according to Grignon grading method.The changes in fetal nephrohydrosis were observed regularly until delivery.Results(1)The incidence of fetal encephalic fluid and Grignon grade:there were 162 fetuses with fetal nephrohydrosis among 9526 fetuses,with an incidence of 1.7%.The numbers of fetuses with Grades 1 to 5 were 71,59,7,3 and 22,respectively.(2)The distribution in gestafional weeks of fetal nephrohydrosis:generally,fetal nephrohydrosis was first diagnosed at(33±5)weeks,and the maximum degree of nephrohydrosis was observed at(36±3)weeks.One hundred and ten fetuses with nephrohydrosis recovered during the process of gestation,at about(37±4)weeks.(3)Poor terminations of pregnancy:there were 40(25%)fetuses with poor terminations among totally 162 cases.Among these 40 fetuses,3(27%)were first diagnosed at 20 to 24 weeks within 11 fetuses,6(24%)were first diagnosed at 25 to 28 weeks within 20 fetuses,14(26%)were first diagnosed at 29 to 32 weeks within 53 fetuses,11(23%)were first diagnosed at 33 to 36 weeks within 48 fetuses,and 6(20%)were first diagnosed at 37 to 40 weeks within 30 fetuses,The results demonstrate that high grade of fetal nephrohydrosis according to Grignon grading method indicates a poorer prognosis of the fetus.(4)Follow-up results:there were 122(75%,122/162)live and healthy neonates in total,including 110 neonates whose nephrohydrosis recovered prior to birth and 12 neonates whose nephrohydrosis recovered within 1 week after birth.These neonates all developed well without any urinary sequela within the first 2 years.There were also 20(12%,20/162)hydronephrotic neonates who were still diagnosed as nephrohydrosis within 1 week after birth,including 11 fetuses graded below Grignon grade 3,whose nephrohydrosis recovered 3 to 12 months after birth and who developed well without any urinary symptoms.Conclusions The study demonstrates that hydronephrotic fetuses who are diagnosed at earlier gestational weeka and with higher grading have poore prognosis.The Grignon grading method can be used in the prenatal evaluation of fetal nephrohydrosis to predict the prognosis of the fetus.