1、1,ANTENATAL HYDRONEPHROSIS,HASAN FARSI,2,What would you do if you have:,32-week fetus with normal amniotic fluid and suspected ureteropelvic junction. 36-week fetus with suspected posterior urethral valves without oligohydramnios. 23-week fetus with suspected PUV and oligohydramnios with bladder ele
2、ctrolytes suggestive of good renal function.,3,Amniotic Fluid,Lungs are correctly formed only in the presence of sufficient amniotic fluidTransudate of maternal plasma Diffusion across fetal skin Fetal urine is 1st produced by the end of 9th week Concentration ability by 12-14th week After 18th week
3、 all amniotic fluid is fetal urine,UCNA Feb. 1995;21-30,4,Structural Abnormalities & Antenatal US,Detection of renal abnormalities with antenatal ultrasonography 1st reported in the 70s. Most renal abnormalities are detected at 1820 weeks of gestation 1% 50% CNS 20% GU 15% GI 8% Cardiopulmonary,5, C
4、ontinue Structural Abnormalities & Antenatal US,2-9/1000 birth M:F=2:1 5087% hydronephrosis Maximum anteroposterior diameter of renal pelvisMulticystic dysplastic kidney, autosomal recessive polycystic kidney disease, renal agenesis and dysplasia, bladder exstrophy, adrenal hyperplasia, neuroblastom
5、a, mesoblastic nephroma and genital abnormalities,6,The Society of Fetal Urology Grading System for ANH,7,Grades of Hydronephrosis,Mild hydronephrosis: Pelvic APD 1.5 cm and caliectasis with no parenchymal atrophy Severe hydronephrosis: Pelvic APD 1.5 cm, caliectasis and cortical atrophy,BJU Inter v
6、olume 85 Page 987 - May 2000,8,Grades of ANH,grade I: the pelvic APD is 1 cm with normal calycesgrade II, APD 11.5 cm with normal calycesgrade III, APD 1.5 cm with slight caliectasisgrade IV, APD 1.5 cm with moderate caliectasisgrade V, APD 1.5 cm with severe caliectasis and cortical atrophy,Grignon
7、 A, Radiology 1986; 160: 645 7,9,RPD Measurement & Incidence of ANH,18766 Atenatal scans from Bristol UK (RPD=5mm) ANH 0.59%6292 Antenatal scans from Stoke-on-Trent UK (RPD 10mm) ANH 0.65% 6810 Scans from India (RPD 10mm) ANH 0.64 Indian Pediatrics 2001; 38: 1401-1404,10,The Final Urological Diagnos
8、is of 426 live-born Infants with Significant Prenatally Detected Uropathy,British Journal of Urology volume 81 Page 8 - April 1998,11,Post Urethral Valves: Antenatal US,12,Prognosis & Severity of ANH,Prognosis 160(3): 645-7Outcome of fetal renal pelvic dilatation (Surgery or UTI): Mild dilation 0% M
9、oderate dilatation 23% Severe hydronephrosis 64%,Ultrasound Obstet Gynecol. 2005 May;25(5):483-8.,13,Diagnosis & Severity of ANH,Mild hydronephrosis (RPD 59 mm) the most likely diagnosis is VURMore marked hydronephrosis (RPD 10 mm, and especially if 15 mm) PUJ obstruction is the most common cause,14
10、,Prognostic Factors of Fetal Hydronephrosis,Severity Laterality Ureteric dilatation Renal parenchymal changes Abnormalities of bladder size, thickness and emptying The presence of concomitant oligohydramnios,15,Unfavorable Prognostic Factors,Prolonged oligohydramnios Renal cortical cysts Urinary con
11、tents: Na =or100mEq/L Cl90mEq/L Osmolarity210mmol Elevated urinary B2-microglobulin Reduced lung area & thoracic or abdominal circumference,16,Antenatal Counseling,Enormous distress to parents Communication difficulties between the relevant specialists Limited understanding of the natural history Ma
12、ny anomalies may have no long term consequence,17,Resolution of ANH,18 weeks,32 weeks,18,Fetal Intervention,No intervention: Regular US Termination of pregnancy (up to 23 weeks) Induction of labor Prenatal interventionOnly at an experienced institution under approved protocols,19,Intervention,Male f
13、etus Second trimester Severe hydroureteronephrosis Bilateral Reasonable fetal urinary indicators Progressive oligohydramnios.,20,Prenatal Intervention for Urinary Obstruction,For most fetuses intervention is not necessary Decompression will restore amniotic fluid- prevent development of fetal pulmon
14、ary hypoplasia ? Arrest or reverse renal cystic dysplastic changes,21,Vesicoamniotic Shunting:,Technique Vesicostomy or pyelostomy Pigtail shunt Complications: Shunt blockage or migration, preterm labor, urinary ascitis, chorioamnionitis, iatrogenic gastroschisis, intrauterine death Outcome: Perinat
15、al survival 47% Post renal insufficiency 87.5%,22,Prenatal Evaluation and Treatment for Fetal Lower Urinary Tract Obstruction“,The long term outcomes for shunts in fetal bladder outlet obstruction: Etiology: Posterior urethral valves 39% Urethral atresia 22% Prune Belly Syndrome 39%. Outcome: More t
16、han 45% had a GFR of 70ml/min 22% had renal insufficiency 33% were ultimately on dialysis 33% had a transplant,Society for Fetal Urology 35th Biannual Meeting 2005,23,Fetal Cystoscopy,US guided 1.3mm fetoscope Cannula thru maternal then fetal abdomen then fetal bladder Laser ablation of valves Resul
17、ts 9 fetuses:4 success 2 viable at birth 1 died age 4 months from bronchopneumonia and one died age 3 m from necrotizing enterocolitis,24,A survey instrument was mailed to all members of the Society for Fetal Urology. 7 case scenarios that addressed critical decision points in patients with antenata
18、lly detected genitourinary abnormalities. A total of 112 of 188 Society for Fetal Urology members (60%) completed the survey.,J UROL Vol. 164, 10521056, September 2000,25,32-week fetus with normal amniotic fluid and suspected ureteropelvic junction: 99% observation & serial US 36-week fetus with sus
19、pected posterior urethral valves without oligohydramnios: Most respondents elected no intervention 27% induce early delivery,26,continue,23-week fetus with suspected PUV and oligohydramnios with bladder electrolytes suggestive of good renal function: Intervene antenatally using a vesicoamniotic shun
20、t (71%) Serial aspiration (7%) Amnioinfusion (7%).,27,Conclusion,Situations that warrant antenatal intervention for a genitourinary abnormality are exceedingly low and may include: Cases of oligohydramnios Suspected favorable renal function Absence of life threatening congenital abnormalities.In cas
21、es with normal amniotic fluid antenatal intervention is not recommended regardless of the detected abnormality.,28,continue Conclusion,No evidence exists demonstrating the benefit of antenatal intervention in terms of renal function and only in a select number of cases will it benefit pulmonary func
22、tion. To our knowledge no scientific data exist that demonstrate the long-term benefit of early delivery of cases with antenatally detected, genitourinary abnormalities.,29,Postnatal Investigations,Abdominal mass Deficient abdominal wall Undescended testes Palpable bladder Renal profile US within 1
23、week (earlier ? false because of the physiological oliguria),30,When to perform US post delivery,Renal obstruction may be underestimated or missed on a renal sonogram obtained 6 days after birth. A sonogram obtained 6 weeks after birth is more specific for detecting obstruction.,AJR Am J Roentgenol.
24、 1995 Apr;164(4):963-7.,31,continue Postnatal Investigations,Is it unilateral or bilateral? Is it solitary kidney? Are there associated anomalies? ? Prophylactic antibiotics Hydronephrosis =obstruction,32,Intrauterine Resolution of ANH:- Classification of 778 neonatal scans for evaluation of ANH,Tab
25、le 1. Classification of 778 neonatal scans, 92% referred with antenatal pyelectasis,Table 1. Classification of 778 neonatal scans, 92% referred with antenatal pyelectasis,Australasian Radiology volume 47 Page 354 - December 2003,33,Fate of ANH,34,Transient Hydronephrosis,30-50% of ANH Etiology ?: In
26、sufficient maturation of UPJ Insufficient maturation of VUJ Increased fetal urinary output (46 times greater before than after delivery) Partial or transient anatomical or functional obstructions, e.g. fetal ureteric folds,35,New Investigative Modalities for Post natal Evaluation of ANH,MR urography
27、: MR urography alone was found to be comparable with conventional combination studies of DRS and US or urography. Renal dysplasia Doppler derived renal resistive index measures (RI) The results of this study do not support the clinical use of Doppler ultrasound studies in the diagnostic work-up of c
28、ongenital hydronephrosis,36,Dudley, J A et al. Arch. Dis. Child. Fetal Neonatal Ed. 1997;76:F31-F34,Repeat US in 3-6m,37,Persistent Hydronephrosis without Obstruction,10-15% 50% resolves by 12 months Needs long time follow-up,38,Take Home Messages,Antental hydronephrosis is not uncommon With the hig
29、h percentage of history of consanguinity, the incidence might be higher in Saudi Arabia The Obstetrician should be vigilant in looking for it during the routine antenatal visits.,39,.continue Take Home Messages,No evidence exists demonstrating the benefit of antenatal intervention in terms of renal function and only in a select number of cases will it benefit pulmonary function. To our knowledge no scientific data exist that demonstrate the long-term benefit of early delivery of cases with antenatally detected, genitourinary abnormalities.,40,Thank You,
