胎儿肾积水的产前诊断和生后处理

Prenatal diagnosis and postnatal management of fetal hydronephrosis

目的探讨胎儿肾积水的产前诊断和生后处理。方法回顾性研究2011年1月至2014年12月在浙江省金华市人民医院定期产前检查，且经产前超声检查诊断单胎肾积水孕妇102例。其中单侧87例，双侧15例，共117只肾。孕期及生后定时复查泌尿系统B超，评估肾积水情况并分级。记录并分析产前诊断肾积水者的胎龄大小、肾积水严重程度及生后随访结果。对所获得的数据采用捕述性统计分析。结果102例孕妇年龄20～39岁，平均（28．1±3．7）岁，诊断孕周16～40周，平均（30．4±49）周。产前超声诊断单胎肾积水102例，右侧肾积水35例，左侧52例，双侧15例。孕中期诊断肾积水59例（双肾11例），其中轻度28例（双肾5例），中度24例（双肾3例），重度4例（双肾1例），引产3例。孕晚期诊断43例（双肾4例），其中轻度22例（双肾2例），中度17例（双肾1例），重度2例，引产2例。生后48h第1次复查超声图像，共41例（双肾5例）仍存在肾积水，其中1级19例（双肾2例），2级11例（双肾2例），3级7例，4级4例（双肾1例）。孕中期和孕晚期诊断，至生后仍存在肾积水者分别为18例（双肾2例）和23例（双肾3例）。产前胎儿肾积水消退率53．8％（63／117），其中孕中期消退率为64．3％（45／70），孕晚期消退率为38．3％（18／47）。生后随访中，1～2级、3级和4级中分别有2例（6．7％，2／30，均为2级、单肾）、4例（4／7，均为单。肾）和4例（双肾1例）行于术治疗。对3-4级患儿（共11例，其中1例为双肾）随访发现，9只患肾需要手术干预，肾积水常见病因为肾盂输尿管交界处狭窄（6／9），此外还可见输尿管狭窄（1／9）、膀胱输尿管交界处狭窄（1／9）及后尿道瓣膜（1／9）。结论胎儿肾积水在出生前大多数能自行消退，而出生后肾积水需定期连续超声监测。1～2级肾积水大部分能自行缓解，3-4级需密切随访和评估肾功能。若肾积水出现症状、进行性加重、明确病理性梗阻或分肾功能〈40％等情况，需及早手术干预。

Objective To investigate the prenatal diagnosis and postnatal management of fetal hydronephrosis. Methods One hundred and two cases （87 unilateral and 15 bilateral, with a total of 117 kidneys） of fetal hydronephrosis in singleton pregnancy were diagnosed by prenatal ultrasonography in Jinhua People＇s Hospital between January 2011 and December 2014. During pregnancy and postpartum, all cases were routinely examined by genitourinary ultrasound for the classification of severity of hydronephrosis. The age of gestation at diagnosis of fetal hydronephrosis, the classification of hydronephrosis and postnatal follow-up outcome were recorded and retrospectively analyzed by descriptive statistical analysis. Results Of the 102 pregnancies, the mean gravida age and gestational age at diagnosis of fetal hydronephrosis was （28.1 ± 3.7） years （20-39 years） and （30.4±4.9） gestational weeks （16-40 gestational weeks）, respectively. One hundred and two cases （35 right, 52 left and 15 bilateral） of fetal hydronephrosis were diagnosed by antenatal ultrasonography. In the second trimester, 59 cases （11 bilateral） of fetal hydronephrosis were diagnosed, including 28 mild （five bilateral）, 24 moderate （three bilateral）, four severe （one bilateral） and three terminated ones. In the third trimester, 43 cases （four bilateral） were diagnosed, including 22 mild （two bilateral）, 17 moderate （one bilateral）, two severe and two terminated ones. All these patients were re-examined by ultrasonography at 48 hours postpartum, and hydronephrosis was still present in 41 cases （five bilateral）, including 19 grade 1 （two bilateral）, 11 grade 2 （two bilateral）, seven grade 3 and four grade 4 （one bilateral）. From the second and third trimester to postnatal period, there were 18 （two bilateral） and 23 （three bilateral） cases of hydronephrosis, respectively. The regression rate of prenatal hydronephrosis was 53.8% （63/117）, including 64.3% （45/70） in the second trimester and 38.3% （18/47） in the third trimester. During postnatal follow-up period, two cases （6.7%, 2/30, unilateral） of grade 2, four grade 3 （4/7, unilateral） and four grade 4 （one bilateral） underwent surgery. Eleven cases of grade 3-4 hydronephrosis （one bilateral） were followed up and nine kidneys were treated with surgery due to ureteropelvic junction obstruction （6/9）, ureter stricture （1/9）, vesicoureteral stricture （1/9） and posterior urethral valves （1/9）. Conclusions Although the majority of cases of fetal hydronephrosis spontaneously regress, postnatal hydronephrosis should be monitored timely and continuously by ultrasound. In particular, grade 3 4 hydronephrosis should be followed up to evaluate renal functions. If hydronephrosis presents with symptoms, progressive aggravation, pathological obstruction, or differential renal function 〈 40%, early surgical intervention should be provided to improve renal functions.