Antenatal counselling and postnatal management of obstructive uropathy dr. ramesh

This is the powerpoint presentation of a talk on Antenatal Counselling and post natal management of Obstructive uropathy

1. Dr. S. R amesh Professor & H ead, Pediatric S urgery, Indira G andhi I nstitute of Child Health, B angalore 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

3. 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

4. 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 3 rd trimester require postnatal surgery

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

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

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

8. Prenatal interventions Interventions Shunting Serial aspiration Amnioinfusion Fetoscopic /endoscopic valve ablation Indications Male fetus Second trimester Bilateral disease Reasonable fetal urinary indicators Progressive oligohydramnios

9. 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%

10. Counseling Simplified Hydronephrosis - Unilateral or Bilateral ?

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

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

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

14. 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

15. Counseling Simplified Hydronephrosis - Unilateral or Bilateral ? Bilateral Hydronephrosis

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

17. Counseling Simplified Hydronephrosis - Unilateral or Bilateral ? Bilateral Hydronephrosis Liquor volume Normal Reassurance+ Serial Imaging + Post- natal Evaluation Bilateral Hydro- ureteronephrosis

18. 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

19. 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

20. Counseling Simplified Posterior Urethral Valves

21. Counseling Simplified Posterior Urethral Valves Liquor volume Normal – Continue pregnancy + Serial USGs + Review

22. 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

23. 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)

24. 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

25. Post natal USG – Initial scan in 1 st 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 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

26. Antenatal HUN Post natal USG; initial scan in 1 st week Unilateral Bilateral MCU No reflux Reflux Non-obstructive non refluxing megaureter PUV VUJO Ureterocele Physiological Primary VUR PUV Duplication anomalies

27. 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 …….!

28. 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 …….!

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 …….!

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