Antenatal counselling and postnatal management of obstructive uropathy dr. ramesh
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Transcript of 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…….!