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Chapter 38 ■ The Fetal Abdominal Wall and Gastrointestinal Tract 1347
UC
O
A
C
B
FIGURE 38-24. Bladder exstrophy. A, Transvaginal
sonogram at 16 weeks shows an abdominal wall defect, located
low in the abdomen. The bladder was not visualized. B, Postmortem photograph shows bladder exstrophy; UC, umbilical cord.
C, Bladder exstrophy (arrow) in a different fetus.
1348 PART IV ■ Obstetric Sonography
FIGURE 38-25. Omphalocele-exstrophy–imperfo-
rate anus–spinal defects (cloacal exstrophy).
T2-weighted MR image of twins. The upper twin was normal
with normal amniotic fluid. The lower twin had oligohydramnios
with a lower anterior abdominal wall defect (arrow).
CONCLUSION
A wide spectrum of abdominal abnormalities can be
detected in utero. Appropriate description of these
abnormalities is important to assess for associated structural abnormalities. Since many abdominal abnormalities are associated with aneuploidy and syndromes,
genetic counseling is important. Follow-up for growth
and assessment of interval progression of bowel obstruction in many abnormalities are also important.
Acknowledgments
Many thanks to Aaron and Evan Brown for their valuable technical support.
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CHAPTER 39
The Fetal Urogenital Tract
Katherine W. Fong, Julie E. Robertson, and Cynthia V. Maxwell
Chapter Outline
THE NORMAL URINARY TRACT
Embryology
Sonographic Appearance
Amniotic Fluid Volume
URINARY TRACT
ABNORMALITIES
Bilateral Renal Agenesis
Unilateral Renal Agenesis
Renal Ectopia
Horseshoe Kidney
Renal Cystic Disease
Multicystic Dysplastic Kidney
Obstructive Cystic Renal
Dysplasia
Autosomal Recessive (Infantile)
Polycystic Kidney Disease
Autosomal Dominant (Adult)
Polycystic Kidney Disease
Syndromes Associated with Renal
Cystic Disease
Hyperechogenic (Bright) Kidneys
Simple Renal Cysts
Renal Neoplasm
Adrenal Mass
Upper Urinary Tract Dilation
Hydronephrosis
Ureteropelvic Junction Obstruction
Vesicoureteral Junction Obstruction
(Primary Nonrefluxing Megaureter)
Evaluation of the fetal urogenital tract is an integral
part of the obstetric ultrasound examination. Sonography depicts normal developmental anatomy and allows
detection and characterization of many genitourinary
abnormalities. In addition, assessment of the amniotic
fluid volume often provides important prognostic information regarding fetal renal function. Accurate and early
prenatal diagnosis is important because this may influence obstetric and neonatal management.
Urinary tract anomalies account for 33% of all malformations detected by routine prenatal sonography.
A systematic sonographic approach is proposed, which
includes a search for associated anomalies and detailed
evaluation of renal structure and function.
THE NORMAL URINARY TRACT
Duplication Anomalies
Vesicoureteral Reflux
Lower Urinary Tract (Urethral)
Obstruction
In Utero Intervention:
Vesicoamniotic Shunting
Bladder Exstrophy
THE GENITAL TRACT
Normal Genitalia
Abnormal Genitalia
Hydrometrocolpos
Ovarian Cysts
pattern, giving rise to the ureter, renal pelvis, calyces, and
collecting tubules. Through interaction with the metanephric mesoderm, the ureteric bud induces the formation of nephrons. In early embryonic life, the kidneys
are located in the pelvis, but they “ascend” to their adult
position by the 11th menstrual week. At this gestation,
the kidneys start to produce urine.
By the ninth menstrual week, the cloaca (caudal part
of hindgut) is divided by the urorectal septum into the
rectum posteriorly and the urogenital sinus anteriorly
1
(Fig. 39-1). The urinary bladder, the female urethra, and
most of the male urethra develop from the urogenital
sinus and the surrounding splanchnic mesenchyme. Initially, the bladder is continuous with the allantois, but
this structure soon constricts and becomes a fibrous cord,
the urachus, which extends from the apex of the bladder
to the umbilicus.
Embryology
The permanent kidney (metanephros) is the third in a
series of excretory organs in the human embryo, forming
after the pronephros and mesonephros.
2
In the seventh
menstrual week, the metanephros begins to develop
from two sources: the metanephric diverticulum (ureteric bud) and the metanephric mass of intermediate
mesoderm (Fig. 39-1). The ureteric bud is an outgrowth
from the mesonephric duct, near its entrance into the
cloaca. It elongates and branches in a dichotomous
Sonographic Appearance
In the first trimester the fetal kidneys are best examined
by transvaginal sonography. The kidneys are seen as oval,
hyperechoic structures in the paravertebral regions, with
a small, central sonolucent area caused by fluid in the
renal pelvis
3
(Fig. 39-2, A). By 12 to 13 weeks of gesta-
tion, the kidneys could be visualized in 99% of cases
with combined transabdominal and transvaginal sonog-
4
In the second trimester the kidneys often appear
raphy.
as isoechoic structures adjacent to the fetal spine on
1353
Urogenital
sinus
Mesonephros
Mesonephric
duct
Metanephric
diverticulum
Urorectal
septum
Cloacal
membrane
A
Allantois
B
Mesonephric
duct
Mesonephros
Metanephric
diverticulum
(ureteric bud)
Vesical
part
Pelvic part
Phallic part
Rectum
C D
Genital tubercle
Mesonephric
duct
Mesonephros
Metanephros
Urinary bladder
Ureter
Rectum
Urorectal
septum
Urogenital
sinus
E F
Mesonephros
Mesonephric
duct
Metanephros
(primordium of
permanent kidney)
Ureter
Gonad
Mesonephros
Metanephros
Ureter
Mesonephric
duct
Pelvic part
of urogenital
sinus
Urachus
Uterine
tube
Kidney
Testis
Ureter
Ductus
deferens
Clitoris
Kidney
Ovary
Uterus
Vagina
Urinary
bladder
Penis
Spongy
urethra
G H
FIGURE 39-1. Embryology of the urinary tract. Diagrams show division of the cloaca into the urogenital sinus and rectum;
absorption of the mesonephric ducts; development of the permanent kidneys (metanephroi), urinary bladder, urethra, and urachus; and
changes in the location of the ureters. A, Lateral view of the caudal half of a 5-week-old embryo. B, D, and F, Dorsal views. C, E, G,
and H, Lateral views. The stages shown in G and H are reached by the 12th week. (From Moore KL, Persaud TVN: The developing
human: clinically oriented embryology. 7th ed. Philadelphia, 2003, Saunders.)
Chapter 39 ■ The Fetal Urogenital Tract 1355
A
C
FIGURE 39-2. Normal appearance of kidneys at different gestational ages. A, Transvaginal scan at 13 weeks of
gestation in the coronal plane shows normal kidneys (calipers), which appear hyperechoic, with small central sonolucent areas caused by
fluid in the renal pelves. B, Transabdominal scan at 19 weeks in the transverse plane shows the kidneys (arrows) as paired isoechoic
structures adjacent to the fetal spine. C and D, Longitudinal and transverse scans at 33 weeks show the kidney well outlined by perinephric
fat, with normal corticomedullary differentiation. The pyramids (arrowheads) are hypoechoic. There is a small amount of fluid in the
central collecting system (black arrow).
B
D
transabdominal sonography (Fig. 39-2, B). As the fetus
matures, corticomedullary differentiation becomes more
obvious, especially in the third trimester (Figs. 39-2, C
and D). The renal pyramids orient in anterior and pos-
terior rows and are hypoechoic relative to the renal
cortex. In the third trimester the renal cortex is isoechoic
or slightly hyperechoic to liver and spleen. With fat
deposition in the perinephric region, an echogenic
border develops, and the kidney becomes better delineated. Normal fetal lobations are often visible and give
the kidneys an undulating contour.
The kidneys grow throughout pregnancy. Table 39-1
provides a nomogram of renal lengths at 14 to 42
weeks of gestation.
5
The often-quoted rule of thumb that
“renal length in millimeters approximates gestational age
in weeks” only applies to a narrow gestational age range
of 18 to 21 weeks. There are also published charts of
renal anterior-posterior diameter, transverse diameter,
and volume.
5
Sometimes, it is difficult to define the exact
renal borders, especially at the upper pole, because of
shadowing from ribs or poor distinction from the adrenal
gland. Fetal breathing can aid in renal visualization. It is
also important to avoid using an oblique section through
the kidney for measurement. The renal/abdominal
circumference ratio remains constant at 0.27 to 0.30
throughout pregnancy.
6
The calyces are not normally visualized, but some
fluid is typically seen in the renal pelvis. The highly
characteristic renal pelvic echo is often the key to
finding the kidneys in the second trimester. Measurements of the renal pelvis are discussed in the section on
hydronephrosis. The normal ureter is 1 to 2 mm in
diameter and is not normally visible.
By using transvaginal sonography, the bladder can
be seen as early as 11 weeks of gestation.
weeks, the bladder is visualized in 98% of cases using
both transabdominal and transvaginal sonography.
3
By 12 to 13
4
The
bladder is thin walled and situated anteriorly in the
1356 PART IV ■ Obstetric Sonography
20 w
TABLE 39-1. RENAL LENGTHS AT 14-42
WEEKS’ GESTATION
Fixed Centiles
WEEK N
14 3 7.5 8.0 9.3 10.8 11.6
15 3 8.8 9.5 11.0 12.8 13.7
16 2 10.2 11.0 12.7 14.8 15.8
17 12 11.6 12.5 14.5 16.8 18.1
18 10 13.1 14.1 16.3 18.9 20.3
19 15 14.6 15.6 18.2 21.1 22.6
20 15 16.1 17.2 20.0 23.2 24.9
21 15 17.5 18.8 21.8 25.4 27.2
22 14 19.0 20.4 23.6 27.4 29.4
23 16 20.4 21.9 25.4 29.5 31.6
24 17 21.8 23.4 27.1 31.5 33.8
25 18 23.1 24.8 28.8 33.4 35.8
26 20 24.4 26.2 30.4 35.3 37.8
27 24 25.6 27.5 31.9 37.1 39.7
28 18 26.8 28.7 33.4 38.7 41.5
29 19 27.9 29.9 34.7 40.3 43.2
30 19 28.9 31.0 36.0 41.8 44.8
31 23 29.9 32.1 37.2 43.2 46.3
32 23 30.8 33.0 38.3 44.5 47.7
33 22 31.6 33.9 39.4 45.7 49.0
34 19 32.4 34.7 40.3 46.8 50.2
35 20 33.1 35.4 41.1 47.8 51.2
36 23 33.7 36.1 41.9 48.7 52.2
37 14 34.2 36.7 42.6 49.4 53.0
38 17 34.7 37.2 43.2 50.1 53.8
39 13 35.1 37.6 43.7 50.7 54.4
40 14 35.4 38.0 44.1 51.2 54.9
41 26 35.7 38.3 44.5 51.6 55.4
42 17 36.0 38.6 44.8 52.0 55.7
From Chitty LS, Altman DG. Charts of fetal size: kidney and renal pelvis
measurements. Prenat Diag 2003;23:891-897.
N = Number of fetuses for each week of gestation.
3rd 10th 50th 90th 97th
pelvis. The umbilical (superior vesical) arteries run
lateral to the bladder as they course toward the umbilicus
(Fig. 39-3). The hourly fetal urine production increases
with advancing gestation, from a mean value of 4 to
5 mL/hr at 20 weeks to 52 to 56 mL/hr at 40 weeks.
7,8
Three-dimensional (3-D) ultrasound measurements
demonstrate reproducible urine production rates based
on bladder volumes, but tend to estimate higher rates
in the third trimester compared to the standard twodimensional (2-D) technique.
volume
increases from a mean value of 1 mL at 20 weeks
9,10
The maximum bladder
to 36 mL at 41 weeks.7 The normal bladder fills and
empties (either partially or completely) approximately
every 25 minutes (range, 7-43 min). Therefore, changes
in bladder volume should be observed during the course
of the obstetric sonogram.
Amniotic Fluid Volume
Evaluation of amniotic fluid volume (AFV) provides
important information about fetal renal and placental
function. Evaluation of AFV is a key component of fetal
biophysical assessment. After 16 weeks, fetal urine production becomes the major source of amniotic fluid.
11
Several methods are used to assess AFV. Subjective
assessment can be combined with semiquantitative techniques, such as measurement of the largest single pocket
(free of umbilical cord and fetal small parts) and amni-
otic fluid index (AFI). Intraobserver and interobserver
studies have shown that the subjective assessment of
AFV by experienced sonographers is reliable.
12
Signifi-
cant oligohydramnios results in compression of the fetus,
12 w
B
A
FIGURE 39-3. Normal urinary bladder. A, Sagittal image of a 12-week fetus. Note normal urinary bladder (arrow). B, Power
Doppler image of the umbilical arteries (arrows) at 20 weeks’ gestation helps in the identification of any questionable fluid-filled structure
in the pelvis as the urinary bladder (B).
B
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