Antenatal counselling and postnatal management of obstructive uropathy dr. ramesh
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Antenatal counselling and postnatal management of obstructive uropathy dr. ramesh
- 1. Dr. S. Ramesh Professor & Head, Pediatric Surgery, Indira Gandhi Institute of Child Health, Bangalore OBSTRUCTIVE UROPATHY COUNSELING (ANTENATAL) & MANAGEMENT (POSTNATAL)
- 2. 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
- 5. 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
- 6. 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
- 7. Antenatal counseling • Reassurance and dispel misconceptions • Reasonable differential diagnoses • Information of the natural history of the disease • Antenatal recommendations • Postnatal management plan
- 8. 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
- 9. Antenatal Options •No intervention: Regular USG (Vast Majority) •Termination of pregnancy (up to 23 weeks) •Early induction of labor •Prenatal intervention
- 10. Prenatal interventions Interventions • Shunting • Serial aspiration • Amnioinfusion • Fetoscopic/endoscopic valve ablation Indications • Male fetus • Second trimester • Bilateral disease • Reasonable fetal urinary indicators • Progressive oligohydramnios
- 11. 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%
- 12. Counseling Simplified •Hydronephrosis - Unilateral or Bilateral?
- 13. Counseling Simplified •Hydronephrosis - Unilateral or Bilateral? • Unilateral Hydronephrosis • Reassurance + Post- natal Evaluation
- 14. Counseling Simplified •Hydronephrosis - Unilateral or Bilateral? • Unilateral Hydronephrosis • Reassurance + Post- natal Evaluation • Unilateral Hydro-ureterohephrosis
- 15. Counseling Simplified •Hydronephrosis - Unilateral or Bilateral? • Unilateral Hydronephrosis • Reassurance + Post- natal Evaluation • Unilateral Hydro-ureterohephrosis • Ureterocele / Duplication – • Reassurance + Post-natal Evaluation
- 16. 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
- 17. Counseling Simplified •Hydronephrosis - Unilateral or Bilateral? • Bilateral Hydronephrosis
- 18. Counseling Simplified •Hydronephrosis - Unilateral or Bilateral? • Bilateral Hydronephrosis • Liquor volume Normal • Reassurance+ Serial Imaging + Post- natal Evaluation
- 19. Counseling Simplified •Hydronephrosis - Unilateral or Bilateral? • Bilateral Hydronephrosis • Liquor volume Normal • Reassurance+ Serial Imaging + Post- natal Evaluation • Bilateral Hydro-ureteronephrosis
- 20. 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
- 21. 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
- 22. Counseling Simplified • Posterior Urethral Valves
- 23. Counseling Simplified • Posterior Urethral Valves • Liquor volume Normal – Continue pregnancy + Serial USGs + Review
- 24. 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/s Deliver & Rx ex-utero Adequate Pre-natal Counseling by Pediatric Surgeon Essential
- 25. 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)
- 26. 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
- 27. 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 HN SFU Grade 3 – 4 APD > 10mm No intervention Ultrasound every 3 mts until resolution # Unilateral Bilateral Unilateral Bilateral MCU Diuretic renograph y 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
- 28. Antenatal HUN Post natal USG; initial scan in 1st week Unilateral Bilateral MCU No reflux Reflux Non-obstructive non refluxing megaureter PUV VUJO Ureterocele Physiological Primary VUR PUV Duplication anomalies
- 29. 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…….!
- 30. 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…….!
- 31. 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…….!
- 32. 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…….!