胎儿孤立性腹腔积液的病因诊断及预后分析

Etiological diagnosis and clinical evaluation of isolated fetal ascites

目的 探讨孤立性腹腔积液胎儿的产前检查特点、病因诊断及与围产儿结局的关系。方法 收集2016年6月22日至2018年9月28日于山东大学附属省立医院,经超声检查首次诊断为胎儿孤立性腹腔积液的孕妇36例,其中34例为单胎妊娠,2例双胎妊娠为双胎之一出现腹腔积液,共纳入孤立性腹腔积液胎儿36例。行侵入性产前诊断分别取胎儿脐血、羊水和胎儿腹腔积液,进行细胞遗传学、分子遗传学及生化检查,并评估胎儿侵入性操作对于新生儿预后的影响。分析胎儿孤立性腹腔积液的产前检查特点、病因与其预后之间的相关性。结果 (1)妊娠≥28周首次出现腹腔积液的胎儿与妊娠<28周者的1岁婴儿生存率分别为13/15、9/17,两者比较,差异有统计学意义(P<0.05)。(2)36例胎儿中,产前病因诊断率为31%(11/36),病因总诊断率为53%(19/36),病因不明者为47%(17/36)。产前病因诊断的病例特点为:8例消化道相关疾病胎儿的超声表现为肠管回声增强、肠管扩张、羊水过多;2例巨细胞病毒感染胎儿脐血中的血小板计数均<100×109/L;1例尿道狭窄胎儿的超声表现为巨膀胱及泌尿系统积水。产后明确病因的病例包括:3例乳糜腹胎儿产前表现为持续性腹腔积液;3例消化道相关病因分别为直肠重复畸形并感染、肠系膜狭窄、小肠闭锁;其他病因包括Pierre-Robin综合征、Budd-Chiari综合征各1例。(3)新生儿的总体活产率为72%(26/36),1岁婴儿生存率为61%(22/36)。9/10的接受手术治疗的新生儿结局良好。盆腹腔因素所致腹腔积液的胎儿中,13/16的预后良好。结论 孤立性腹腔积液胎儿的妊娠结局主要取决于其原发病因,消化道疾病是最常见的病因之一。排除染色体异常、宫内感染及行超声检查排除胎儿结构异常后,随着妊娠进展,腹腔积液减少甚至消失者胎儿的结局良好。

Objective To explore the correlation between prenatal clinical data with etiological diagnosis and neonatal outcome in isolated fetal ascites.Methods Totally,36 pregnancy cases diagnosed as isolated fetal ascites by ultrasound in Provincial Hospital Affiliated to Shandong University from June 22nd,2016 to September 28th,2018 were collected.Invasive prenatal diagnosis was performed by taking fetal cord blood,amniotic fluid,and fetal ascites respectively for cytogenetics,molecular genetics and biochemical examination and the impact of intrauterine therapeutic procedures on neonatal outcomes was evaluated as well.The correlation among prenatal examination,pathogeny and prognosis was analyzed by Fisher′s exact test.Results(1)The prognosis of isolated fetal ascites initially presenting≥28 weeks was better than that before 28 weeks,survival rate of 1-year-old were 13/15 and 9/17,respectively,the difference was statistically significant(P<0.05).(2)The etiologic diagnosis rate of ascites before delivery was 31%(11/36),which increased to 53%(19/36)totally after birth.Characteristics of cases which were defined prenatally were as follows:8 cases of digestive tract diseases showed ultrasonic abnormalities,including echogenic bowel,bowel dilatation and polyhydramnios;platelet level in umbilical cord blood of fetuses infected with cytomegalovirus were below 100×109/L in 2 cases;1 case of urinary system malformation showed megalocystis and hydronephrosis.Cases which were defined causes after birth included:3 fetuses with chyloperitonium presented persistent fetal ascites;3 cases of digestive-related causes were rectal duplication with infection,mesentery stenosis,and intestinal atresia;other causes included Pierre-Robin syndrome and Budd-Chiari syndrome.(3)The live birth rate was 72%(26/36)and survival rate of 1-year-old was 61%(22/36).And 9/10 of infants who underwent surgeries got good outcomes.Fetal ascites due to abdominal or pelvic factors turned well in 13/16 of cases.Conclusions The pregnancy outcome of fetal isolated ascites depends mainly on primary causes.Gastrointestinal abnormality is one of the most common causes.Excluded intrauterine infection,chromosomal abnormality and abnormal systemic ultrasonic findings,fetus with reduced ascites as the pregnancy progresses will get good outcome.