切换至 "中华医学电子期刊资源库"
高级检索
中华妇幼临床医学杂志(电子版)

中华妇幼临床医学杂志(电子版) ›› 2019, Vol. 15 ›› Issue (03) : 275 -282. doi: 10.3877/cma.j.issn.1673-5250.2019.03.007

所属专题： 文献；

论著

MRI对胎儿先天性膈疝的诊断价值
宋燕1, 谢淋旭1, 宁刚1,†(), 孙艳1   
  1. 1. 四川大学华西第二医院放射科、出生缺陷与相关妇儿疾病教育部重点实验室，成都　610041
  • 收稿日期:2019-01-17 修回日期:2019-04-29 出版日期:2019-06-01
  • 通信作者: 宁刚

Diagnostic value of MRI in fetal congenital diaphragmatic hernia

Yan Song1, Linxu Xie1, Gang Ning1,†(), Yan Sun1   

  1. 1. Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
  • Received:2019-01-17 Revised:2019-04-29 Published:2019-06-01
  • Corresponding author: Gang Ning
  • About author:
    Corresponding author: Ning Gang, Email:
  • Supported by:
    National Key Research and Development Project(2017YFC0109004, 2018YFC1002202, 2017YFC0113905)
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

宋燕, 谢淋旭, 宁刚, 孙艳. MRI对胎儿先天性膈疝的诊断价值[J]. 中华妇幼临床医学杂志(电子版), 2019, 15(03): 275-282.

Yan Song, Linxu Xie, Gang Ning, Yan Sun. Diagnostic value of MRI in fetal congenital diaphragmatic hernia[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2019, 15(03): 275-282.

目的

探讨MRI在胎儿先天性膈疝(CDH)诊断及预后评估中的应用价值。

方法

选择2014年12月至2018年3月，于四川大学华西第二医院进行胎儿MRI检查后，被诊断为CDH的15例胎儿为研究对象，纳入病例组。选取同期于本院进行MRI检查，排除其他疾病，并且与病例组胎儿胎龄相匹配的15例正常胎儿作为对照，纳入对照组。比较2组胎儿MRI检查项目，如左肺体积(LLV)、右肺体积(RLV)及肺总体积(TLV)，并且观察病例组胎儿疝口位置、疝内容物、有无肝脏疝入及其疝入体积。对病例组胎儿进行随访，记录其出生后手术治疗及预后情况。计算每例CDH胎儿的实测肺总体积与预期肺总体积比值[TLV(o/e)]。2组胎儿LLV、RLV及TLV比较，采用Mann-Whitney U检验。本研究遵循的程序符合四川大学华西第二医院人体试验委员会制定的标准，经过该伦理委员会批准(批准文号：2014伦理审批第41号)。病例组与对照组胎儿母亲年龄、接受MRI检查时的胎龄分别比较，差异均无统计学意义(P>0.05)。

结果

① 2组胎儿LLV、RLV及TLV比较：病例组胎儿LLV、RLV及TLV分别为1.1 cm3(0.6～4.3 cm3)、15.0 cm3(9.5～24.3 cm3)、16.5 cm3(10.6～28.6 cm3)，均显著小于对照组胎儿的21.7 cm3(11.7～32.8 cm3)、29.1 cm3(11.7～32.8 cm3)、58.6 cm3(30.4～86.0 cm3)，2组分别比较，差异均有统计学意义(Z＝7.521、6.536、22.734，P<0.001)。②病例组15例CDH胎儿的MRI影像学表现为：左侧膈肌存在不同程度缺损，腹腔脏器(肝、脾、肾、胃、小肠、直肠等)通过缺损膈肌疝入胸腔，左肺受压，纵隔右移，部分胎儿右肺受压。其中，6例伴有肝脏疝入，5例伴有脾疝入，1例伴有左肾疝入。6例伴有肝脏疝入的CDH胎儿中，1例存活，肝脏疝入体积为5.1 cm3；2例引产终止妊娠，肝脏疝入体积分别为15.1、14.1 cm3；3例出生后死亡，肝脏疝入体积分别为9.0、15.2、47.1 cm3。③病例组胎儿结局：15例CDH胎儿中，5例引产终止妊娠，其TLV(o/e)为0.17～0.33；剖宫产术分娩者为10例，其中新生儿存活为6例，其TLV(o/e)为0.18～0.55，出生后死亡为4例，其TLV(o/e)为0.17～0.27。④经剖宫产术分娩的10例胎儿中，8例于生后接受外科手术治疗，6例为开腹手术，2例为胸腔镜手术，术中可见疝口位置，均与MRI诊断一致，而术中所见疝内容物，则与MRI诊断不完全一致。

结论

MRI检查可明确CDH胎儿的疝口位置及疝内容物，测量胎肺及肝脏疝入体积，对胎儿健侧肺发育不良及预后评估具有重要价值。

关键词: 磁共振成像, 疝，横膈，先天性, 胎肺体积, 外科手术, 肝脏疝入, 胎儿
Objective

To study the application value of MRI in diagnosis and prognosis evaluation of fetal congenital diaphragmatic hernia (CDH).

Methods

A total of 15 cases of fetuses from December 2014 to March 2018 who received fetal MRI and were diagnosed as fetal CDH in West China Second University Hospital, Sichuan University were selected research subjects and enrolled into case group. Meanwhile another 15 cases of normal fetuses who received fetal MRI during the same period in the same hospital and whose gestational age were matched with case group were selected as control group. By MRI left lung volume (LLV), right lung volume (RLV) and total lung volume (TLV) of the two groups were measured, and the position of the fetal hernia, hernia contents, liver hernia and hernia volume of the case group were observed. The postnatal surgery and prognosis of fetuses in case group were recorded. Observed-to-expected total lung volume [TLV(o/e)] was calculated for each CDH fetus. Mann-Whitney U test was used to compare LLV, RLV and TLV between two groups. The procedures followed in this study were in line with the standards set by the Human Trials Committee of West China Second University Hospital, Sichuan University, and were approved by the ethics committee [Approval No. 2014(41)]. The maternal age and gestational age of fetuses in case group and control group were compared respectively, and the differences were not statistically significant (P>0.05).

Results

①The LLV, RLV and TLV of fetuses in case group were 1.1 cm3 (0.6-4.3 cm3), 15.0 cm3 (9.5-24.3 cm3), and 16.5 cm3 (10.6-28.6 cm3), respectively, which were significantly smaller than those of 21.7 cm3 (11.7-32.8 cm3), 29.1 cm3 (11.7-32.8 cm3), and 58.6 cm3 (30.4-86.0 cm3) in control group, and all the differences between two groups were statistically significant (Z=7.521, 6.536, 22.734; P<0.001). ②MRI showed that there were different degrees of defects in the left diaphragm of all CDH fetuses in case group, abdominal organs hernia (liver, spleen, kidney, stomach, small intestine, rectum, etc.), and their left lungs were compressed, their mediastinum shifted right, and some fetuses with right lung under compression. Among them, six cases were with hepatic hernia, five cases with splenic hernia, and 1 case with left renal hernia. Among six cases of CDH fetuses with hepatic hernia, one case survived with a hepatic hernia volume of 5.1 cm3; two cases were induced for termination of pregnancy with liver hernia volumes of 15.1 cm3 and 14.1 cm3, respectively; three cases died after birth with liver hernia volumes of 9.0 cm3, 15.2 cm3 and 47.1 cm3, respectively. ③Among the 15 CDH fetuses in case group, five fetuses were induced for termination of pregnancy with TLV(o/e) of 0.17-0.33, and ten cases were delivered by cesarean section, six cases of which were survived with TLV(o/e) of 0.18-0.55, and four cases of which died after birth with TLV(o/e) of 0.17-0.27. ④Among the ten fetuses delivered by cesarean section, eight cases received surgical treatment after birth, six cases received laparotomy, and two cases received thoracoscopic surgery. The location of orificium hernialis found during surgery was consistent with MRI diagnosis, while the intraoperative hernia contents were not completely consistent with MRI diagnosis.

Conclusions

MRI examination can determine the position of orificium hernialis and hernia contents of CDH fetus, and measure the volumes of fetal lung and liver hernia, also it is of great value for the evaluation of uninjured side pulmonary dysplasia and prognosis of CDH fetus.

Key words: Magnetic resonance imaging, Hernia, diaphragmatic, congenital, Fetal lung volume, Surgical procedures, operative, Liver hernia, Fetus
表1 病例组与对照组胎儿肺体积比较[cm3，M(P25～P75)]
组别 例数 LLV RLV TLV
病例组 15 1.1(0.6～4.3) 15.0(9.5～24.3) 16.5(10.6～28.6)
对照组 15 21.7(11.7～32.8) 29.1(11.7～32.8) 58.6(30.4～86.0)
Z值 ? 7.521 6.536 22.734
P值 ? <0.001 <0.001 <0.001
图1 先天性膈疝胎儿产前MRI影像学表现[图1A：T2WI序列肝脏呈稍低信号(白色箭头所示)；图1B：T2WI序列胃泡呈明显高信号(黑色箭头所示)；图1C：T2WI序列脾脏呈低信号(红色箭头所示)，小肠呈高信号(黄色箭头所示)，结肠呈低信号(白色箭头所示)；图1D：T1WI序列结肠呈高信号(白色箭头所示)]
图2 先天性膈疝患儿产前、出生后及治疗后MRI影像学表现(图2A：胎龄为30＋1周时，产前MRI检查结果显示，胎儿左侧膈疝，胃泡、大部分小肠及部分结肠疝入胸腔；图2B：出生后胸、腹部X射线摄片检查结果显示，直肠、结肠内高密度影，肠管及胃泡疝入胸腔，双肺野显示不清，纵隔右移；图2C：经治疗后，胸、腹部X射线摄片检查结果显示，肠管、胃泡等腹腔脏器复位，左肺复张良好，纵隔居中)
表2 15例先天性膈疝胎儿MRI检查、手术治疗及结局分析
胎儿(No.) 诊断胎龄(周) 剖宫产术分娩/引产终止妊娠胎龄(周) MRI检查所见疝内容物 术中所见疝内容物 手术治疗方式 TLV(o/e) 肝脏疝入体积(cm3) 结局
1 30＋1 38＋2 胃泡、大部分小肠及部分结肠 全部小肠、部分结肠及脾 开腹手术 0.35 0 存活
2 36 38 胃泡、小肠及大部分结肠 肝左叶、脾、胃、横结肠及部分小肠 开腹手术 0.31 0 存活
3 38＋5 38＋5 胃泡、大部分小肠及结肠 胃、小肠及肝左叶 胸腔镜手术 0.22 0 存活
4 29＋4 35＋5 胃泡、脾、肝左外侧段与部分小肠及结肠 部分肝左叶、脾、胃及小肠 胸腔镜手术 0.55 5.1 存活
5 38 38＋6 小肠及升结肠 脾、副脾、大部分小肠、横结肠、乙状结肠及大网膜等，伴肠旋转不良 开腹手术 0.28 0 存活
6 37＋3 38＋2 胃泡、脾、全部小肠与大部分结肠及部分左肾 脾、全部小肠、部分结肠、右侧肾上腺及部分肾 开腹手术 0.18 0 存活
7 30＋5 34＋3 胃泡、大部分小肠及部分结肠 肝左叶、脾、胃、小肠、大部分结肠 开腹手术 0.22 0 死亡
8 30＋4 37 胃泡、肝左叶、脾、大部分小肠及部分结肠，伴胃扭转 外院手术，左侧膈肌完全缺如，疝内容物不清楚 开腹手术 0.27 47.1 死亡
9 27＋1 40＋4 胃泡、脾、肝左叶外侧段与大部分小肠及结肠，伴胃扭转 － － 0.17 9.0 死亡
10 33＋3 40＋2 胃泡、小肠与大部分结肠、肝左叶 － － 0.17 15.2 死亡
11 30＋6 32＋5 胃泡、小肠及大部分结肠 － － 0.33 0 引产
12 24＋3 24 胃泡、大部分小肠及结肠 － － 0.32 0 引产
13 26＋2 27＋2 胃泡、脾、肝左叶与大部分小肠及结肠，伴胃扭转 － － 0.17 15.1 引产
14 26＋1 27 胃泡、小肠与大部分结肠及肝左叶 － － 0.32 14.1 引产
15 26＋4 27＋3 左侧膈肌消失，胃泡、小肠及部分结肠 － － 0.24 0 引产
[1]
王学军，刘文英. 先天性膈疝合并肺动脉高压的发病机制及其临床诊疗研究进展[J/CD]. 中华妇幼临床医学杂志(电子版), 2012, 8(1): 73-77.
[2]
Moore KL, Persaud TVN, Torchia MG. The developing human: clinically oriented embryology[M]. 10th ed. Philadelphia: Saunders, 2016: 198-215.
[3]
Prayer D, Adam A, Avni F, et al. Fetal MRI[M]. Berlin Heidelberg: Springer-Verlag, 2011: 329-342.
[4]
Hattori T, Hayakawa M, Ito M, et al. The relationship between three signs of fetal magnetic resonance imaging and severity of congenital diaphragmatic hernia[J]. J Perinatol, 2017, 37(3): 265-269.
[5]
Rypens F, Metens T, Rocourt N, et al. Fetal lung volume: estimation at MR imaging-initial results[J]. Radiology, 2001, 219(1): 236-241.
[6]
Kastenholz KE, Weis M, Hagelstein C, et al. Correlation of observed-to-expected MRI fetal lung volume and ultrasound lung-to-head ratio at different gestational times in fetuses with congenital diaphragmatic hernia[J]. Ajr Am J Roentgenol, 2016, 206(4): 856-866.
[7]
Debus A, Hagelstein C, Kilian AK, et al. Fetal lung volume in congenital diaphragmatic hernia: association of prenatal mr imaging findings with postnatal chronic lung disease[J]. Radiology, 2013, 266(3): 887-895.
[8]
Zamora IJ, Olutoye OO, Cass DL, et al. Prenatal MRI fetal lung volumes and percent liver herniation predict pulmonary morbidity in congenital diaphragmatic hernia (CDH)[J]. J Pediatr Surg, 2014, 49(5): 688-693.
[9]
Russo FM, Eastwood MP, Keijzer R, et al. Lung size and liver herniation predict the need for extracorporeal membrane oxygenation but not pulmonary hypertension in isolated congenital diaphragmatic hernia: a systematic review and Meta-analysis[J]. Ultrasound Obstet Gynecol, 2017, 49(6): 704-713.
[10]
卢洪涛，李清. 产前超声检查诊断胎儿先天性膈疝[J]. 中国医学影像技术，2014, 30(12): 1893-1896.
[11]
肖祎炜，汪小丽，张嫣，等. 产前超声和MRI诊断先天性膈疝的应用价值[J]. 中国超声医学杂志，2017, 33(4): 319-321.
[12]
Benachi A, Cordier AG, Cannie MK, et al. Advances in prenatal diagnosis of congenital diaphragmatic hernia[J]. Semin Fetal Neonatal Med, 2014, 19(6): 331-337.
[13]
Barnewolt CE, Kunisaki SM, Fauza DO, et al. Percent predicted lung volumes as measured on fetal magnetic resonance imaging: a useful biometric parameter for risk stratification in congenital diaphragmatic hernia[J]. J Pediatr Surg, 2007, 42(1): 193-197.
[14]
张勇，杨汉丰，杜勇. 先天性膈疝产前诊断及预后的影像学评价研究进展[J/CD]. 中华妇幼临床医学杂志(电子版), 2010, 6(2): 123-125.
[15]
祝菁，杨祖菁，刘明，等. MRI测量胎儿肺体积在评估先天性膈疝预后中的价值[J/CD]. 中国产前诊断杂志(电子版), 2012, 4(1): 8-11.
[16]
Snoek KG, Reiss IK, Greenough A, et al. Standardized postnatal management of infants with congenital diaphragmatic hernia in Europe: the CDH EURO consortium consensus - 2015 update[J]. Neonatology, 2016, 110(1): 66-74.
[17]
Coughlin MA, Werner NL, Gajarski R, et al. Prenatally diagnosed severe CDH: mortality and morbidity remain high[J]. J Pediatr Surg, 2016, 51(7): 1091-1095.
[18]
肖祎炜，汪小丽，张嫣，等. 产前超声和MRI诊断先天性膈疝的应用价值[J]. 中国超声医学杂志，2017, 33(4): 319-321.
[19]
Francesca FM, De Coppi P, Allegaert K, et al. Current and future antenatal management of isolated congenital diaphragmatic hernia[J]. Semin Fetal Neonatal Med, 2017, 22(6): 383-390.
[20]
刘文英. 先天性膈疝的临床诊治进展[J]. 临床小儿外科杂志，2017, 16(1): 1-3.
[21]
吴雨昊，况虹宇，吕铁伟. 微创手术及开放手术治疗先天性膈疝效果的Meta分析[J]. 临床小儿外科杂志，2017, 16(1): 18-25.
[22]
原丽科，唐晶，俞钢. 产前MRI在评估胎儿膈疝的应用及研究进展[J]. 临床小儿外科杂志，2016，15(3): 292-294.
[23]
蒋敏姬. 产前超声诊断胎儿先天性膈疝67例[J]. 中国医学创新，2014, 11(3): 50-51.
[1] 武玺宁, 欧阳云淑, 张一休, 孟华, 徐钟慧, 张培培, 吕珂. 胎儿心脏超声检查在抗SSA/Ro-SSB/La抗体阳性妊娠管理中的应用[J]. 中华医学超声杂志（电子版）, 2023, 20(10): 1056-1060.
[2] 杨水华, 何桂丹, 覃桂灿, 梁蒙凤, 罗艳合, 李雪芹, 唐娟松. 胎儿孤立性完全型肺静脉异位引流的超声心动图特征及高分辨率血流联合时间-空间相关成像的应用[J]. 中华医学超声杂志（电子版）, 2023, 20(10): 1061-1067.
[3] 丁建民, 秦正义, 张翔, 周燕, 周洪雨, 王彦冬, 经翔. 超声造影与普美显磁共振成像对具有高危因素的≤3 cm肝结节进行LI-RADS分类诊断的前瞻性研究[J]. 中华医学超声杂志（电子版）, 2023, 20(09): 930-938.
[4] 赵红娟, 赵博文, 潘美, 纪园园, 彭晓慧, 陈冉. 应用多普勒超声定量分析正常中晚孕期胎儿左心室收缩舒张时间指数[J]. 中华医学超声杂志（电子版）, 2023, 20(09): 951-958.
[5] 张莲莲, 惠品晶, 丁亚芳. 颈部血管超声在粥样硬化斑块易损性评估中的应用价值[J]. 中华医学超声杂志（电子版）, 2023, 20(08): 816-821.
[6] 张璟璟, 赵博文, 潘美, 彭晓慧, 毛彦恺, 潘陈可, 朱玲艳, 朱琳琳, 蓝秋晔. 胎儿超声心动图测量McGoon指数在评价胎儿肺血管发育中的应用[J]. 中华医学超声杂志（电子版）, 2023, 20(08): 860-865.
[7] 旺久, 陈军, 朱霞, 米玛央金, 赵胜, 陈欣林, 李建华, 王双. 山南市妇幼保健院开展胎儿系统超声筛查的效果分析[J]. 中华医学超声杂志（电子版）, 2023, 20(07): 728-733.
[8] 徐鹏, 李军, 高巍伦, 王峥, 庞珅, 李春妮, 朱霆. 快速旋转扫查法在胎儿超声心动图检查中的应用价值[J]. 中华医学超声杂志（电子版）, 2023, 20(07): 761-766.
[9] 谭芳, 杨娇娇, 沈玉琴, 李炎菲海, 王海蕊, 范思涵, 纪学芹. 胎儿心脏定量分析技术对正常胎儿心脏形态及收缩功能的评价[J]. 中华医学超声杂志（电子版）, 2023, 20(06): 598-604.
[10] 罗刚, 泮思林, 陈涛涛, 许茜, 纪志娴, 王思宝, 孙玲玉. 超声心动图在胎儿心脏介入治疗室间隔完整的肺动脉闭锁中的应用[J]. 中华医学超声杂志（电子版）, 2023, 20(06): 605-609.
[11] 黄佳, 石华, 张玉国, 胡佳琪, 陈茜. 胎儿左头臂静脉正常与异常超声图像特征及其临床意义[J]. 中华医学超声杂志（电子版）, 2023, 20(06): 610-617.
[12] 袁泽, 庄丽. 超声检测胎儿脐动脉和大脑中动脉血流对胎儿宫内窘迫的诊断价值[J]. 中华医学超声杂志（电子版）, 2023, 20(06): 618-621.
[13] 刘林峰, 王增涛, 王云鹏, 钟硕, 郝丽文, 仇申强, 陈超. 足底内侧皮瓣联合甲骨皮瓣在手指V度缺损再造中的临床应用[J]. 中华损伤与修复杂志(电子版), 2023, 18(06): 480-484.
[14] 韩宇, 张武, 李安琪, 陈文颖, 谢斯栋. MRI肝脏影像报告和数据系统对非肝硬化乙肝患者肝细胞癌的诊断价值[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 669-673.
[15] 程相阵. 腹茧症9例诊治分析并文献复习[J]. 中华临床医师杂志(电子版), 2023, 17(9): 968-971.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号