ANTENATAL GENITOURINARY ANOMALIES Evaluation and Management

ANTENATAL HYDRONEPHROSIS Evaluation and ManagementTHE GENITOURINARY TRACT
Abnormal bladder development Obstructed
THE GENITOURINARY TRACT
THE GENITOURINARY TRACT
Collecting system
Not always indicative of obstruction
Pattern may imply etiology
Hydronephrosis…………………….16 wks
Fetal bladder
Urinary tract dilation:
greater
Gynecol, 1991)
1999; Kent A et al., Prenat Diagn,
2000)
SFU
AP
HYDRONEPHROSIS
Grade Calyceal Dilatation Size of Pelvis (mm) I Normal calyces <10
II Normal calyces 10-15
III Slight dilatation >15
IV Moderate dilatation >15
V Severe dilatation & >15
Kidney: Degree of dilation
Renal parenchyma echogenecity / thickness
Hydronephrosis ?
N= 268 (2.3%)
80% Resolved Antenatally
20% Persisted @ birth
14% Abx.
11% Death
Increased collagen
Prenatal
Postnatal
presentation
Ureterocele/duplicated systems
Bolduc J Urol 2002
PUV
Kousidis G et al BJUInt 2008
Moderate improvement renal function long-term
UPPER TRACT
“mild” – 12% UT pathology
“severe” – 88% UT pathology
Nguyen HT et al JPU 2010
Does prenatal
ultrasound change
refluxing units
0.9 years boys / 2.1 years girls
Conclusion: Prenatal VUR high grade /
males/ bilateral /renal dysplasia / high
resolution rate
PRENATAL IMPACT
ZERIN STUDY
PRENATAL IMPACT
ZERIN STUDY
Prenatal ultrasound increases detection
year period
Corresponding decrease of symptomatic
BENEFIT OF PRENATAL
Preservation of renal function
Prevents compression deformities
With or without hydronephrosis
Bilateral renal agenesis / hypoplasia
Increased perinatal demise
PRENATAL ULTRASOUND:
PREDICTIVE FACTORS
FACTORS PREDICTIVE OF
Renal function
Other anomalies
PROGNOSTIC CRITERIA
NORMAL VALUES
Evaluating Prenatal Hydronephrosis ?
Evaluation: Ultrasound at >7 – 10 days
Mild Moderate/Severe
Ultrasound and VCUG prior to discharge
Treatment of valves, obstructive ureterocele
Antibiotic prophylaxis - non-obstructive lesions
urethral atresia, Prune Belly, PCKD, renal
cysts
PRENATAL
Sacrococcygeal teratoma
Intestinal duplication
Ureterocele
Predictors of postnatal outcome
Insufficient AF inhibits lung branching
VARIABLES EFFECTING POSTNATAL
intervention
Obstructive nephropathy
system
Reversibility???????????????
FACTORS PREDICTIVE OF
Distensibility of collecting system
Parenchymal echogenicity
FETAL URINARY
Obstruction / reversibility
sensitivity 100%
specificity 60%
sensitivity 87%
specificity 80%
Nicolini, OB GYN, 1993
echogenicity
Cl > 90 m Eq / L
Osm > 210 mOsm / L
B-microglobulin > 2 mg / L
Calcium > 8 mg / dl
Reduced lung / thoracic area
PRENATAL INTERVENTION
based]
or without intervention lacking
Defined benefits re: outcome not obvious
Conflict of interest
Most abnormalities best managed postnatally
PRENATAL INTERVENTION
MATERNAL RISK
Risk for premature labor following hysterotomy / intervention
Risk for compromising future reproductive potential
PRENATAL INTERVENTION
Multiple sequential
intervention
renal function
renal insufficiency
outcome
“Just because it can be done, should it be done?”
Technology changing
2. Termination of pregnancy
Appears in less than 20 weeks
3. Early delivery
Little change in renal function
Life-enhancing therapy
5-8 mm (88%); 9-15 mm (10%); > 15 mm (2%)
100% R
15% R
25% I
W 12%
THE GENITOURINARY TRACT