| Background and purposeFetal abnormal ultrasound performances of the biliary system include: non-visualization of gall bladder (NVGB), abnormal size of gallbladder, echoic material intra gallbladder, anomal location of the gallbladder and biliary cystic malformation (BCM), etc.The relevant literatures on many years abroad about ultrasound in fetal biliary system had been reviewed. Due to the limitation of number in documents and research subjects, different studies may conclude in large difference. Systematic researches in Orient populations were rarely reported.Among the causes of fetal NVGB, gallbladder contraction is the most common cause. Till today, it is still poorly understood in the rules, maintaining time and the mechanism of fetal gallbladder contraction.Prenatal abnormality of BCM is caused by cystic dilatation of the biliary tree. Cystic biliary atresia (CBA) and choledochal cyst (CC) are included which may have the similar ultrasonic features and clinical symptoms. They should be differentiated with duodenal atresia, mesenteric cyst, liver cyst, large gallbladder, left-sided gallbladder, and other cystic lesions of the right upper quadrant. The connections between the cysts and dilated cystic duct and/or hepatic ducts were the decisive signs in BCM prenatal diagnosis. In the prenatal ultrasound examination, the occurrence rate of these signs in the fetal BCM is not very clear.Recentaly, fetal amniotic fluid digestive enzymes detection has been increasingly used to assist in clinical prenatal diagnosis in BA and other serious diseases. Although it has limited specificity for the prenatal diagnosis in BA, but there still has no a new alternative diagnosis methods nowadays. Asians have relatively high risk of BA. The ultrasound doctors have come to realize that fetal NVGB and BCM may be associated with BA, but it still need further study. Therefore the establishment of normal reference values of amniotic fluid GGT is necessary.In general, the following issues are worthy of attention, and to be discussed in depth:1. Furtherstudy of the incidence of abnormal fetal gallbladder, especially NVGB in clinical, and related etiologies.2. The duration of fetal gallbladder contraction.3. How to evaluate diagnose efficiency of existing ultrasound signs on BCM disease, and how to improve prenatal diagnosis rate of BCM.4. Sonographic findings offetal CC and CBA are similar, and how to identify them in prenatal ultrasound scan.5. It’s necessary to establish our own amniotic fluid GGT reference value, to improve the prenatal diagnosis rate of BA.Part I:Ultrasound characteristics of BCM and screening out the ultrasound signs with diagnostic value in prenatal diagnosis of BCMObjective:1. To screen out the signs and combinations with higher specificity and sensitivity from the common signs used in BCM prenatal diagnosis.2. To summarize thefetal ultrasonic characteristics and clinical outcome in BCM diseases.Methods:1.30cases of fetal abdominal cystic lesions as the object of study were followed-up by ultrasound. Performance rate of each BCM related ultrasonic signs in each group were compared. These signs included:the cyst located in the right-upper abdomen (A), the cyst located sub-porta hepatis (B), the cyst was not gallbladder (C), the cyst had no septum (D), the cyst connected to the gallbladder (E), the cyst connected to the dilated hepatic ducts (F), the lower end of the cyst terminates at the midline of upper-abdomen, in front of the spine (G), the upper top of the cyst close to the gallbladder neck (H). The efficacy of each sign and signs combinations were evaluated by the diagnostic test. We use diagnostic index as a reference to screen out the signs and signs-combinations with the most valuable.2To summarize antenatal ultrasound characteristics of BCM cases, and to analysis the ultrasound findings and clinical outcomes in followed-up cases.Results:1signs A and D showed no significant difference between the BCM (16cases) and NBCM (14cases) groups; signs B, F, G had the most significant statistical difference in two groups.2. Diagnostic test showed that:the single sign B, F, G and19signs-combinations haddiagnostic efficacy. Signs-combinations B and H, E or F, E or G, B and D, F or G, E or F or G with diagnostic index higher than1.9000,and the last three combinations reached to2.0000.3.66.7%BCM fetus with prenatal expression of sign F had obstructive jaundice after birth.4. The length and width of CCs had significant differencebefore and after birth. In one case of type Ⅲ CB A did not change in prenatal ultrasound, and even decreased in size after birth. The gallbladdersof CC cases were normal. But in the III type CBA case, fetal gallbladder nonvisualized prenatally.Conclusions:1. When the fetal cyst was located beneath the porta hepatis and was not the gallbladder, BCM could be diagnosed. Sign G might be another significant ultrasonic sign in BCM prenatal diagnosis.2. BCM cases with hepatic duct dilatation in prenatal ultrasound may occur obstructive jaundice after birth.3. BCM combined with NVGB or gallbladder dysplasia prenatally, and cyst in a decreasing trend after birth, the possibility of CBA should be considered.Part Ⅱ Ultrasonic study of of fetal gallbladder abnormalsObjective:1. To study the clinical significance of ultrasonic abnormal of fetal gallbladder.2. To study the duration of fetal gallbladder contraction.Methods:1. During2009.1-2013.12,347cases of fetal abnormal gallbladder were diagnosed in our department, including308cases of fetal NVGB,27cases of abnormal echoic materials intra fetal gallbladder (3of them occurred after NVGB),15cases of fetal gallbladder abnormal location. Series ultrasonic followed-up were performed in those cases. Ultrasound combined with clinical and other laboratory examinations to obtain etiological diagnosis.2. Thirty-two cases of fetuses with isolated NVGB accepted the close ultrasound and clinical follow-up. Ultrasound followed-ups were performed in fixed time interval. Summarize and analyze the intervals of NVGB first diagnoses and the gallbladder revisualization (A-B intervals).Results:1. During our research,347cases of fetal gallbladder ultrasound abnormalities were reported in our department, and the diagnostic rate isabout0.6%in outpatient.88.8%were NVGB,7.8%showed echoic materials intra the fetal gallbladder, and4.3%had the abnormal location of gallbladder. There were no significant gender differences.2.89.9%fetal NVGB diagnosed in late pregnancy. Isolated NVGB accounted for91.2%,8.8%were accompanied with other ultrasonic abnormal, and3.9%NVGB wereaccompanied with multiple anomalies.215cases of fetal NVGB succeed in following-up.90.7%of them were diagnosed in late pregnancy. And212casesshowed revisulized gallbladder pre-or postnatally. Ultimately,3cases of NVGB were proved due to congenital biliary abnormalities. They accounted1.4%among followed-up cases. One case was gallbladder agenesis, one case was paucity of interlobular bile duct and one case was type III CBA.3. Twenty-seven cases were diagnosed with echoic material intra fetal gallbladder. Mean gestational weeks was35.7±2.5weeks (range29weeks-39weeks).Three cases (3.7%) were accompanied with multiple ultrasound abnormalities. Twenty-five cases were followed-up,2lcases (84%) proved disappeared within one week after birth.4. Abnormal location of fetal gallbladder occurred in15cases. Persistent right umbilical vein (PRUV)occurred in10cases,50%of them accompanied with cardiac or vascular abnormalities. Two cases were left-sided gallbladder. Situs viscera inversus (SVI)occurred in3and one case confirmed trisomy21.5. The prognosis of NVGB fetus caused by the gallbladder contraction was good. A-B interval (the time intervals between NVGB diagnosed and the time theirgallbladders revisualized) was3days～71days,28.1%≤7days,46.9%between8days～21dyas,25%>21days.The fetal gallbladder can be revisualized within1week after birth. This contraction of the fetal gallbladder may be considered as a physiological procedure.And it had no significant effect on the fetus prognosis.Conclusions:1. Fetal NVGB is the most common abnormality in the gallbladder abnormal.2. Although fetal physiological gallbladder contraction is the most common cause of late pregnancy fetal NVGB, but there is still the biliary system abnormalities associated with multiple anomalies,so it cannot be ignored.3. The paucity of hepatic interlobular bile duct may cause continued NVGB, its clinical significance need to be further studied.4. Abnormal echo intra fetal gallbladder appeared in late pregnancy (especially after the32gestational weeks).84%disappeared within1week after birth, and their prognosis was good.5. Abnormalfetal gallbladder can be accompanined with multiple anomalies and chromosomal abnormality. Therefore, ultrasound fetal gallbladder observation has important clinical significance.6. Continued contraction of fetal gallbladder were mostly physiological phenomenon; and the length of A-B had no significant effect on the prognosis of fetus, its physiological mechanism needs further study.Part Ⅲ:Establishing the normal range of fetal amniotic GGT in20～24gestational weeks and the clinic significance.Objective:To establish normal GGT range of fetal amniotic fluid in20-24weeks of gestation as a reference value for further prenatal diagnosis in BA.Methods:The test used cross-sectional design. Amniotic fluid collected from2009.6～2010.4. The pregnant women were in line with indications of amniocentesis for fetal chromosomal examination. And should meet the following conditions:healthy pregnant women, pregnant women and spouses without chromosomal abnormalities, prenatal ultrasound examination without obvious fetal structural abnormalities (including abnormal amniotic fluid), no fetal chromosomal abnormalities childbirth history, or abnormalities of unknown etiology pregnancy history. The amniotic fluid samples were submitted for karyotyping and GGT quantitative analysis immediately after extraction. GGT values and Log GGT values, credible intervals were calculated and Pearson tests were performed.Results:110cases of normal fetal amniotic fluid were collected during the study.73cases were female fetus. GGT enzyme x±s, Median GGT enzyme values, LogGGT tent to gradually reduce with the gestational age.Conclusion:Value of fetal amniotic fluid GGT enzyme tended to gradually reduce by the gestational age increasing.The establishment of GGT in amniotic fluid of normal fetal20～24gestational weeks is expected to further prenatal diagnosis of biliary atresia on providing new diagnosis reference. |
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