antenatal counselling and postnatal management of obstructive uropathy dr. ramesh

Dr. S. RameshProfessor & Head, Pediatric Surgery,

Indira Gandhi Institute of Child Health,Bangalore

OBSTRUCTIVE UROPATHY COUNSELING

(ANTENATAL) & MANAGEMENT (POSTNATAL)

Antenatal Hydronephrosis•Hydronephrosis ≠ Obstruction•Most common birth defect detected (0.5 – 5 % of all

pregnancies)•High Sensitivity, but Low Specificity•>50% of cases are transient or physiologic • Parental Anxiety, Clinician dilemma,• Social Misgivings•Unreasonable expectations

Some Basics

Slight splitting of central renal complex; normal parenchyma

Splitting of central renal complex with extension into nondilated calyces; normal parenchyma

Wide splitting of renal pelvis, dilated outside renal border; dilated calyces with normal parenchyma

Large dilated calyces; thinning of parenchyma to < 50% of opposite kidney

Natural history• 88 % of patients with mild ANH resolve in utero or neonatal period •Degree of ANH predicts the severity of postnatal HN • 30% of patients with moderate or severe ANH persisting in 3rd trimester require postnatal surgery

Antenatal counseling• Reassurance and dispel misconceptions• Reasonable differential diagnoses• Information of the natural history of the disease• Antenatal recommendations• Postnatal management plan

General Guidelines• Imaging to be repeated every 4-6 weeks•Frequency depends on the severity of HN•USG in 3rd trimester – valuable•Severe obstruction warranting antenatal intervention – < 5% of all detected anomalies

Antenatal Options •No intervention: Regular USG (Vast Majority)•Termination of pregnancy (up to 23 weeks)•Early induction of labor•Prenatal intervention

Prenatal interventionsInterventions• Shunting• Serial aspiration• Amnioinfusion• Fetoscopic/

endoscopic valve ablation

Indications•Male fetus• Second trimester • Bilateral disease• Reasonable fetal urinary indicators• Progressive oligohydramnios

Vesico-amniotic Shunting•Technique• Seldinger technique• Pigtail shunt – Rodeck shunt

•Complications• Shunt blockage; migration Preterm labor; urinary ascitis Chorioamnionitis; iatrogenic gastroschisis; IUD

•Outcome• Perinatal survival 47%

Counseling Simplified•Hydronephrosis - Unilateral or Bilateral?

Counseling Simplified•Hydronephrosis - Unilateral or Bilateral?• Unilateral Hydronephrosis• Reassurance + Post- natal Evaluation

Counseling Simplified•Hydronephrosis - Unilateral or Bilateral?• Unilateral Hydronephrosis• Reassurance + Post- natal Evaluation• Unilateral Hydro-ureterohephrosis

Counseling Simplified•Hydronephrosis - Unilateral or Bilateral?• Unilateral Hydronephrosis• Reassurance + Post- natal Evaluation• Unilateral Hydro-ureterohephrosis• Ureterocele / Duplication – • Reassurance + Post-natal Evaluation

Counseling Simplified•Hydronephrosis - Unilateral or Bilateral?• Unilateral Hydronephrosis• Reassurance + Post- natal Evaluation• Unilateral Hydro-ureterohephrosis• Ureterocele / Duplication – • Reassurance + Post-natal Evaluation

•Multicystic Dysplatic Kidney•Reassurance + Post- natal Evaluation

Counseling Simplified•Hydronephrosis - Unilateral or Bilateral?• Bilateral Hydronephrosis

Counseling Simplified•Hydronephrosis - Unilateral or Bilateral?• Bilateral Hydronephrosis• Liquor volume Normal• Reassurance+ Serial Imaging + Post- natal Evaluation

Counseling Simplified•Hydronephrosis - Unilateral or Bilateral?• Bilateral Hydronephrosis• Liquor volume Normal• Reassurance+ Serial Imaging + Post- natal Evaluation

• Bilateral Hydro-ureteronephrosis

Counseling Simplified•Hydronephrosis - Unilateral or Bilateral?• Bilateral Hydronephrosis• Liquor volume Normal• Reassurance+ Serial Imaging + Post- natal Evaluation

• Bilateral Hydro-ureteronephrosis• Bladder Normal - Ureterocele / Duplication – • Reassurance + Post-natal Evaluation

Counseling Simplified•Hydronephrosis - Unilateral or Bilateral?• Bilateral Hydronephrosis• Liquor volume Normal• Reassurance+ Serial Imaging + Post- natal Evaluation

• Bilateral Hydro-ureteronephrosis• Bladder Normal - Ureterocele / Duplication – • Reassurance + Post-natal Evaluation• Bladder Thick Walled – ? P.U. Valves• Liquor volume + Other parameters

Counseling Simplified•Posterior Urethral Valves

Counseling Simplified•Posterior Urethral Valves• Liquor volume Normal

– Continue pregnancy + Serial USGs + Review

Counseling Simplified•Posterior Urethral Valves• Liquor volume Normal

– Continue pregnancy + Serial USGs + Review• Liquor Volume Reducing

– Fetal Urine Sampling – Options – Intervention v/s

MTP v/sDeliver & Rx ex-utero

Adequate Pre-natal Counseling by Pediatric Surgeon Essential

Counseling Simplified•Posterior Urethral Valves• Liquor volume Normal

– Continue pregnancy + Serial USGs + Review• Liquor Volume Reducing

– Fetal Urine Sampling – Options – Intervention v/s MTP

•Duplications / UVJO / Fusion Anomalies / Ureterocele etc.• Reassurance + Post- natal Evaluation (If Liquor volme normal)

Postnatal evaluation

• Clinical Examination to r/o PU Valves• Appropriate counseling • Postnatal USG performed < 48 hrs – unreliable• Plan to be tailored based on USG findings• VCUG if ureteral dilation • Isotope Scintigraphy – 4-6 weeks postnatally

Post natal USG – Initial scan in 1st week; repeat at 4 – 6 wks

No hydronephrosis SFU Grade 0 APD < 7mm

Mild hydronephrosis SFU Grade 1 – 2 APD 7 – 10mm

Moderate to severe HNSFU Grade 3 – 4 APD > 10mm

No intervention

Ultrasound every 3 mts until resolution #

Unilateral Bilateral

Unilateral Bilateral

MCU Diuretic

renography

No reflux Reflux

MCU

No reflux Reflux

Non obstructive Obstructive

Worsening parameters Intervention if differential function is low or declines on follow-up

Antenatal HN

Antenatal HUN

Post natal USG; initial scan in 1st week

Unilateral

Bilateral

MCU

No reflux Reflux

Non-obstructive non refluxing megaureterPUVVUJOUreterocelePhysiological

Primary VURPUVDuplication anomalies

Take Home Messages•Hydronephrosis ≠ Obstruction•No indication for any intervention / termination in• Unilateral Disease• Bilateral Disease with normal Liquor Volume•Antenatal Interventions• Selected Cases• Selected Centres•Pre-natal counseling• Realistic & Re-assuring• Involve Pediatric Surgeon, ObGyn & Sonologist…….!

Take Home Messages•Hydronephrosis ≠ Obstruction•No indication for any intervention / termination in• Unilateral Disease• Bilateral Disease with normal Liquor Volume•Antenatal Interventions• Selected Cases• Selected Centres•Pre-natal counseling• Realistic & Re-assuring• Involve Pediatric Surgeon, ObGyn & Sonologist…….!

Take Home Messages•Hydronephrosis ≠ Obstruction•No indication for any intervention / termination in• Unilateral Disease• Bilateral Disease with normal Liquor Volume•Antenatal Interventions• Selected Cases• Selected Centres•Pre-natal counseling• Realistic & Re-assuring• Involve Pediatric Surgeon, ObGyn & Sonologist…….!

Take Home Messages•Hydronephrosis ≠ Obstruction•No indication for any intervention / termination in• Unilateral Disease• Bilateral Disease with normal Liquor Volume•Antenatal Interventions• Selected Cases• Selected Centres•Pre-natal counseling• Realistic & Re-assuring• Involve Pediatric Surgeon, ObGyn & Sonologist…….!

doctorsramesh@gmail.com