Study On Fetal Disease Of Urinary System Using Ultrosound Score,Biochemical Indicator And MRI

Background and purposeMore 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 womanThe 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 ScoreObjective: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 HydronephrosisObjective: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 MRIObjective: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 Points1,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.