UROLOGIC NURSING / June 2005 / Volume 25 Number 3 173

Antenatal Hydro n e p h rosis: Trends and Management

Christina Delaney

Is my baby going to be okay?Is my baby going to be hos-pitalized after I deliver? Isthis something I did? What

will this mean for my pre g n a n-cy? These are some of the ques-tions that run through a mother’smind once she is told that thefetus she is carrying has antena-tally detected hydro n e p h ro s i s( A N H ) .

H y d ro n e p h rosis is the dilata-tion of the collecting system of thek i d n e y. The detection rate forANH and other fetal abnorm a l i-ties has dramatically incre a s e dover the last 20 years due to theroutine use of prenatal ultra-sound. Bowes (2002) re p o rt e dthat fetal urinary tract abnorm a l i-ties occur in as many as 1 per 100p regnancies, making it one of themost commonly diagnosed pre n a-tal malformations. The widerange of management and tre a t-ment options for ANH often leavehealth care providers and familieswith questions about the appro-priateness of re f e rral to a pediatricu rologist and the need for postna-tal screening. Pre and postnatalmanagement, radiologic findings,and treatment options will be dis-

H y d ro n e p h rosis is the dilatation of the collecting system of the kid-

n ey. Prenatal ultrasound has significantly increased the detection

rate for fetal abnormalities during the past 20 ye a rs . The wide range

of management and treatment options for antenatal hy d ro n e p h ro s i s

often leave health care prov i d e rs and families with questions about

the appropriateness of referral to a pediatric urologist and the need

for postnatal screening. Pre and postnatal manage m e n t , r a d i o l o g i c

f i n d i n g s , and treatment options are rev i ewed and three case scenar-

ios presented.

Christina Delaney, M S N , C P N P, is aNurse Pra c t i t i o n e r, The Pe n n s y l va n i aHospital of The University ofPe n n s y l vania, Philadelphia, PA . At thetime this article was written, she was aNurse Practitioner in Urology, T h eC h i l d r e n ’s Hospital of Philadelphia,Philadelphia, PA .

N o t e : CE Objectives and Eva l u a t i o nFo rm appear on page 184.

cussed and three case scenariosp resented.

Definition and IncidenceT h e re are various ways to

grade and measure the kidney tod e t e rmine the amount of ANH. Acollaborative eff o rt from theSociety of Fetal Urology (SFU)allowed pediatric urologists toa d d ress the controversies in themanagement and natural historyof prenatal hydro n e p h ro s i s( F e rnbach, Maizels, & Conway1993). They developed a systemthat would guide providers toa p p ropriately grade the extent ofh y d ro n e p h rosis. The systems t a rts with grade 0, re p re s e n t i n gno hydro n e p h rosis, to a grade V,re p resenting significant dilationof the renal pelvis and calycesalong with parenchymal thin-ning (see Table 1 and Figure 1).

Most urinary tract abnorm a l-ities are detected during a ro u-tine prenatal ultrasound between18 and 25 weeks gestation.Although most cases of ANH( a p p roximately 80%) are consid-e red to be mild cases and havefavorable outcomes, not all casesresolve. The presence of pre n a t a lcalyceal dilatation is an impor-

tant finding that may demon-strate a need for closer monitor-ing and intervention postnatally.

Clinical resolution of mildcases without treatment oftenoccurs. A study by the Universityof Connecticut re p o rted thatwhen mild hydro n e p h ro s i s(grade II or less) was identifieda n t e n a t a l l y, resolution occurre din just over half of the instances,with just 10% worsening prior tod e l i v e ry (Bowes, 2002). Anotherstudy by the Royal LondonSchool of Medicine found that81% of patients diagnosed withmild hydro n e p h rosis had clini-cal resolution without postnatali n t e rvention (Sairam, Al-Habib,& Thilaganathan, 2001).

Clinical resolution of mores e v e re cases is less common. Whenthe University of Connecticutdetected moderate hydro n e p h ro s i s(grade IV or higher), the majority ofpatients did not improve prior tod e l i v e ry (Bowes, 2002). Similarly,the Royal London School ofMedicine discovered that whenthe diagnosis of moderate to severeh y d ro n e p h rosis was made, up too n e - t h i rd re q u i red postnatal surg i-cal interventions (Sairam et al.,2001).

C

O

N

T

I

N

U

I

N

G

E

D

U

C

A

T

I

O

N

174 UROLOGIC NURSING / June 2005 / Volume 25 Number 3

P renatal FindingsWhen parents present pre n a-

tally to the pediatric uro l o g yo ffice their anxiety level is usual-ly high. They look to the nursepractitioner or health carep rovider for not only comfort i n gw o rds, but also for inform a t i o nrelated to pre and postnatal man-agement. It is very important forthe provider to review the pre n a-tal ultrasound and re p o rts withthe family and explain what thefindings mean. During the visitthe family may express feelingsof confusion and appre h e n s i o n .

It is essential for them toknow that there is a high false-positive rate when determ i n i n gANH. The nurse practitionerneeds to determine the antero -posterior renal pelvic diameter(APRPD) at diff e rent gestationalages to classify the amount ofANH. Based on these findings,recommendations for followupt reatment will be developed. If thekidney(s) have mild hydro-n e p h rosis (SFU grade II or less),t h e re is a high likelihood of re s o-lution. However, if there is a mod-erate-to-severe hydronephrosis(SFU grade III or higher), the out-come is unclear. There is still alack of consensus or what degre eof ANH will reliably predict sig-nificant postnatal pathology.

Inquiring about amnioticfluid levels is necessary sinceantenatal intervention is consid-e red if the fluid levels are low.N o rmal fetal lung development isexpected in the presence of nor-mal amniotic fluid levels.H o w e v e r, when oligohydramnios(low levels of amniotic fluid) iso b s e rved, there is concern aboutp u l m o n a ry development andmaturation. If lung immaturity isdocumented, early deliveryshould be considered. If signifi-cant bladder outlet obstruction isnoted, fetal surg e ry may be indi-cated (Morin et al., 1996).

Etiology and RelatedTre a t m e n t

D e t e rmining a list of poten-tial diagnoses and likely out-comes will enable the nurse prac-titioner or health care provider togive appropriate counseling.Although the debate continuesover which cause is more pre v a-lent, the two most common caus-es of ANH are vesicouretericreflux (VUR) and ure t e r a l - p e l v i co b s t ruction (UPJO). In a studyw h e re 298 (72%) fetuses wereidentified having dilatation totheir kidneys, only 28% had post-natal dilatation. Of the patientswith persistent hydro n e p h ro s i s ,VUR was seen in 14 infants (3%)and UPJO was seen in 23 infants(6%), making UPJO the most com-mon cause of ANH (Gunn, Mora,& Pease, 1995).

In contrast, Tibballs and DeB ruyn (1996), and Dudley andcolleagues (1997) made the obser-vation that VUR is the most com-mon cause of ANH. They believethat the lower incidences of pri-m a ry VUR re c o rded in earlierseries probably reflect the selec-tive use of voiding cys-t o u re t h e rography (VCUG) and theover diagnosis of UPJ obstru c t i o n .Routine use of VCUG in theirseries showed an incidence of18.4% and 18.2%, re s p e c t i v e l y.Other potential diagnoses includeposterior urethral valves (PUV),multi-cystic dysplastic kidney

C

O

N

T

I

N

U

I

N

G

E

D

U

C

A

T

I

O

N

F i g u re 1.Ultrasound Grading of

H y d ro n e p h ro s i s

S o u rc e : F e rnbach et al., 1993

Grade 0

Grade I

Grade II

Grade II

Grade III

Grade IV

Table 1.The Society of Fetal Urology Grading System for

Antenatally Detected Hydro n e p h ro s i s

G r a d e

0

I

I I

I I I

I V

Central Renal Complex (= Pelvis)

I n t a c t

Mild splitting = dilation

Moderate splitting but complex, confined within real bord e r

Marked splitting, pelvis dilated outsiderenal bord e r, and calyces dilated

F u rther pelvicalyceal dilation

Renal Pare n c h y m aT h i c k n e s s

N o rm a l

N o rm a l

N o rm a l

N o rm a l

T h i n

S o u rc e : F e rnbach et al., 1993

UROLOGIC NURSING / June 2005 / Volume 25 Number 3 179

(MCDK), ureteroceles, megau-re t e r, and extra renal pelvis.

Ve s i c o u reteric reflux. VUR isone of the most common emerg-ing diagnoses for the cause ofANH. VUR is the re t rograde pas-sage of urine into the ure t e r ( s )and/or kidney(s) when the blad-der fills and/or empties (seeF i g u re 2). A VCUG is the onlyradiology study that can tru l yd e t e rmine if VUR is present. Itinvolves the catheterization andinfusion of fluid into the bladder.If VUR is present, fluid will enterthe ureters and/or the kidneysduring filling and/or emptying.When reflux is identified, theamount of reflux is graded usingThe International Reflux StudyClassification (Lebowitz, Olbing,Parkkulainen, Smellie, & Ta m m i n e n -Mobius, 1985) grading tool (seeTable 2). Based on the degree ofreflux, a followup plan can beestablished. Most infants arem o n i t o red conservatively withantibiotic prophylaxis and obser-v a t i o n .

U reteral-pelvic junction ob -s t ru c t i o n . UPJO is an obstru c t i o nat the ureteral pelvic junction.M o re often an intrinsic stenosisassociated with the ureter isfound, but an insertion anomalyof the ure t e r, or a crossing vessel(usually an accessory re n a la rt e ry) can also lead to this pro b-lem (see Figure 3). The diagnosisis usually suspected when thereis hydro n e p h rosis, the absence ofu reteral dilatation, a norm a lappearing bladder, and norm a lamniotic fluid levels. Dudley andcolleagues (1997) found thatt h re e - q u a rters of fetuses with anAPRPD >15 mm seemed to bediagnosed with an UPJ obstru c-tion, compared with none of thefetuses with an APRPD <15 mm.

D i u retic renography (MAG IIIRenal Scan) is a functional studythat can help determine whetheru r i n a ry obstruction is present inpersistent hydro n e p h rosis. A MAGIII Renal scan involves the infusionof a radioisotope and use of agamma camera to determine the

C

O

N

T

I

N

U

I

N

G

E

D

U

C

A

T

I

O

N

F i g u re 2. I n t e rnational System of Radiographic Grading of

Ve s i c o u reteric Reflux

S o u rc e : Lebowitz et al., 1985

Table 2.The International Reflux Study Committee Classification

G r a d e

I

I I

I I I

I V

V

D e s c r i p t i o n

Reflux into ure t e r, no dilation

Level of kidney, no dilation

Mild to moderate dilation, minimal calyceal blunting

Moderate dilation, loss of angles of fornices, papillary impre s-sion in calyces still visible

G ross dilation and tort u o s i t y, impressions of papillae no longerp re s e n t

S o u rc e : Lebowitz et al., 1985

F i g u re 3.U re t e ropelvic Junction Obstru c t i o n

UPJ obstru c t i o n

K i d n e y

U re t e r

B l a d d e r

U re t e r a lo r i f i c e

S o u rc e : Original work of the author.

180 UROLOGIC NURSING / June 2005 / Volume 25 Number 3

total and individual renal function.Healthy kidneys should functionsymmetrically (for example, kid-neys should each contribute 50%of the total function). If the func-tion of the affected side dro p sbelow 40%, this may re p re s e n trenal impairment. The renal scanalso looks at the drainage time ofthe urine from the renal pelvis intothe ureter(s) and or bladder. Thisgives an indication of the possibil-ity and extent of obstruction. If theurine moves quickly through thesystem with or without the admin-istration of a diuretic (usuallyf u rosemide [Lasix®]) patients aresaid to have a dilated nonobstru c t-ing system. If the washout of theurine is delayed, then the patient isstudied for an obstru c t i o n .

The debate continues withthe postnatal management ofpatients with UPJO. The initialthought was to surgically corre c tall infants with a suspected UPJOto pre s e rve renal function. Morere c e n t l y, as long as the functionremains stable, observation with-out surg e ry has taken pre c e-dence. The Society of FetalU rology established a multi-cen-ter prospective, randomizedstudy of unilateral high-gradeh y d ro n e p h rosis in asymptomaticinfants less than 6 months of age.T h i rty-two patients from ten cen-ters met the criteria of pre s u m e do b s t ruction. The patients weredivided into two groups: surg e ryand observation. The surg e ryg roup had improvement inh y d ro n e p h rosis and stabilizationof renal function at 6 months and1 year. In the observation gro u p ,renal function deteriorated in25% of the cases and cro s s e dover to surg e ry, but the re m a i n-ing 75% remained stable. There s e a rchers concluded that thes u rgical patients’ grade ofh y d ro n e p h rosis and drainagep a t t e rn improved significantlywhen compared to the observ a-tion group (Palmer, Maizels,C a rtwright, Fernbach, & Conway,1998).

In contrast, the depart m e n t

of pediatrics in New Delhi, India,s u p p o rts initial observation in allof their cases of moderate-to-s e v e re bilateral ANH with a sus-pected UPJO. They followed 16patients who met their criteriaand found only 25% (4) re q u i re dc o rrection during a followup peri-od of 3 years. They concluded thath y d ro n e p h rosis will spontaneous-ly resolve or improve in 78% ofthose observed by 2 years and onlya few will re q u i re surgical manage-ment (Bajpai & Chandrasekharam,2002). Unfort u n a t e l y, there are nodefinitive guidelines for managingm o d e r a t e - t o - s e v e re hydro n e p h ro-sis in the face of a possible UPJO.This underscores the need for thel o n g - t e rm followup of thesepatients.

Posterior urethral valves.P ro g ressive, moderate-to-severeh y d ro n e p h rosis and the pre s e n c eof a thickened bladder wall withpoor emptying in a male fetus isusually indicative of posterioru rethral valves. PUV are oftendescribed as leaflets or sail-liketissues that are found in the pos-terior urethra which obstru c t su r i n a ry flow from the bladdert h rough the urethra. Thiso b s t ruction initiates a backflowof pre s s u re from the bladder intothe kidneys and causes hydro-n e p h rosis, which may eventuallylead to renal damage.

Once the diagnosis of PUV issuspected, these patients arec a refully monitored both pre andp o s t n a t a l l y. As long as the amni-otic fluid level continues to staywithin a normal range, thesebabies can be brought to fullt e rm. If there is evidence of oligo-hydramnios, the risk of pul-m o n a ry hypoplasia increases andantenatal intervention may bec o n s i d e red. A urethral cathetershould be placed immediatelyafter birth if PUV is suspected.The catheter will help facilitateu r i n a ry drainage and decre a s ep re s s u re in the kidneys. A pedi-atric urologist should be consult-ed for appropriate management.U n f o rt u n a t e l y, about one-third of

these patients, despite antenataldiagnosis and close monitoring,will still develop renal insuff i-ciency or end-stage renal disease.

Multi-cystic dysplastic kidney.MCDK is another urinary anomalythat can be detected on a pre n a t a lultrasound. MCDK is diagnosedwhen the renal parenchyma iscompletely replaced by multiplenoncommunicating cysts of vari-ous sizes with no diff e re n t i a t e drenal cortex (see Figure 4). The kid-neys are nonfunctioning, there areno proximal ureters, and there is nocommunication from the perc e i v e dcysts into the renal pelvis. MCDK isnot associated with inherited poly-cystic kidney disease.

Due to the significant dilata-tion seen on the ultrasound,MCKD may be difficult to diff e r-entiate from a UPJO on both preand postnatal ultrasound, mak-ing postnatal managementimperative. The diagnosis ofMCDK should be confirmed witha renal scan (isotope scan),which will reveal that the kidneyhas little to no function. In addi-tion, a VCUG is perf o rmed tolook for evidence of VUR into thecontralateral kidney. This occurs18% to 20% of the time. Mostinfants and children with MCDKa re followed by serial ultrasoundevaluations of the kidney looking

C

O

N

T

I

N

U

I

N

G

E

D

U

C

A

T

I

O

N

F i g u re 4.Multicystic Dysplastic

K i d n e y

S o u rce: Original work of the author.

K i d n e y

UROLOGIC NURSING / June 2005 / Volume 25 Number 3 181

for it to shrink or involute.Involution of the kidney maytake several years. If involutiondoes not occur or if the patients u ffers from pain and/or highblood pre s s u re, a surg i c a ln e p h rectomy may be considere d .

U re t e ro c e l e s . U re t e ro c e l e sa re a cystic dilatation of the ter-minal intravesical segment of theu re t e r. They are commonly asso-ciated with duplicated collectingsystems. Ure t e roceles mayremain entirely within the blad-der (intravesical) or extendt h rough the bladder neck (extrav-esical). In a duplex system, theectopic ureter drains the upperpole moiety, entering the bladderwall below the normal lowerpole ure t e r. It may be obstru c t e dby the ure t e rocele, resulting inu p p e r-pole hydro n e p h rosis.

The diagnosis of ure t e ro c e l e scan be made by a postnatal ultra-sound if it was not seen pre n a t a l l y.But, a VCUG is necessary to showwhether VUR is present into thel o w e r-pole or the ectopic ure t e r.These patients are usually tre a t e ds u rgically with transurethral endo-scopic puncture of the ure t e ro c e l e .

P r i m a ry megaure t e r. P r i m a rym e g a u reter is the presence of ane n l a rged ureter with or withoutconcomitant dilation of theupper pole collecting system.T h e re are four diff e rent types:n o n refluxing obstructed, re f l u x-ing obstructed, nonre f l u x i n gn o n o b s t ructed, and re f l u x i n gn o n o b s t ructed. The diagnosisagain can be made by the postna-tal ultrasound revealing a dilatedu reter greater than 7 mm. AVCUG study determines whetheror not there is VUR pre s e n t .

The nonrefluxing, obstru c t e dm e g a u reter is thought to becaused by an abnormality in thedistal ureteral muscle, whichcauses an aperistaltic segment.This leads to physiologico b s t ruction. In some cases, thei n s e rtion of the ureter into thebladder will be abnormal andurine will reflux up the ure t e rbut will not be able to drain back

C

O

N

T

I

N

U

I

N

G

E

D

U

C

A

T

I

O

N

T h ree Scenarios for an Antenatal Hydro n e p h rosis DiagnosisA 34-year-old female just ending her second trimester is waiting anx-

iously in examination room 3. Her 20-week prenatal ultrasound re v e a l e dthat her fetus has bilateral hydro n e p h rosis. The anterior-posterior re n a lpelvic diameter of the right kidney is 10 mm and the left kidney is 9 mm.T h e re does not seem to be any type of bladder wall thickening. By re p o rt ,her amniotic fluid levels have always been within normal limits. Thus far,it has been an uncomplicated pre g n a n c y. The following scenarios describet h ree diff e rent possible outcomes for the full-term neonate later delivere d .

Scenario 1

The postnatal ultrasound reveals bilateral mild hydro n e p h rosis (gradeI) without bladder wall thickening. The child should be discharged on low-dose prophylactic antibiotics, and a VCUG should be set up in the next 6weeks. The primary care provider can manage these patients. This is thet reatment outcome for approximately 80% of neonates previously diag-nosed with ANH. Although this has been the standard practice of care, cur-re n t l y, these guidelines for perf o rming VCUG on each patient are being re -examined. Mild hydro n e p h rosis is the most controversial of all the gradesof ANH.

Scenario 2

The postnatal ultrasound reveals unilateral moderate-to-severeh y d ro n e p h rosis (grade II or higher) without bladder wall thickening. It isa p p ropriate at this time to make a re f e rral to a pediatric urologist. A VCUGand another renal and bladder ultrasound should be scheduled in the next4 to 6 weeks. When the infant is discharged from the hospital, pare n t sshould be told to continue the antibiotic prophylaxis, and the need forpostnatal evaluation with a pediatric urologist should be re i n f o rced. Thefamily should contact the primary health care provider if they note the fol-lowing: letharg y, decreased oral intake, fever, or decrease in urine output.These symptoms may indicate a urinary tract infection, UPJO, or sepsis.When the family meets with the pediatric urology team, a MAG III re n a lscan may be ord e red to further delineate the renal anatomy or to assessrenal function. This outcome is seen in about 10% to 15% of neonatesdiagnosed previously with ANH.

Scenario 3

The postnatal ultrasound reveals moderate-to-severe bilateralh y d ro n e p h rosis and a thickened bladder wall. It is appropriate at this timeto immediately place a catheter. If the catheter cannot be placedt r a n s u re t h r a l l y, a suprapubic catheter should be inserted. A voiding cys-t o u re t h e rogram is perf o rmed to rule out PUV. If present, a pediatric uro l o-gist should be consulted. Depending on the health and size of the infant,t r a n s u rethral endoscopic valve ablation versus a vesicostomy is consid-e red. This is a possible outcome for less than 5% of neonates diagnosedp reviously with antenatal hydro n e p h ro s i s .

Case Study

down, indicating a re f l u x i n go b s t ructed ure t e r. In other cases,urine will freely drain, demon-strating a refluxing nonobstru c t-ed ure t e r. Finally some may nei-ther reflux nor have obstru c t i o n ,but dilatation persists and mayindicate a nonfluxing nonob-s t ructed ure t e r.

Extra renal pelvis. The crite-ria for extra renal pelvis re m a i nu n c l e a r. It is a common diagnosisand can be seen as antenatalh y d ro n e p h rosis, which re s o l v e sprior to delivery or persists post-n a t a l l y, only to resolve over time.It is also called transient hydro-n e p h rosis, since it seems to come

182 UROLOGIC NURSING / June 2005 / Volume 25 Number 3

and go over time and has no sig-nificant morbidity. Extra re n a lpelvis is usually mild and mayre p resent normal physiologicchanges to the kidney prior tob i rth or an obstructed kidney thatmay have corrected itself prior tod e l i v e ry. Until the process ofANH is understood, this diagno-sis may never be fully explained.H o w e v e r, it is still benign inn a t u re and resolves in 70% to80% of most cases.

P renatal CounselingDespite prenatal ultrasound

and improved technology fors c reening, the impact of earlydetection on the clinical out-comes remains unclear.T h e re f o re, it is imperative tod e t e rmine the functional signifi-cance of the dilatation of theupper tract(s) and provide appro-priate counseling for aff e c t e dfamilies without engenderinganxiety and unnecessary testing.P roviding the initial contactbetween the expecting motherand the pediatric urology team isi m p o rtant in building a tru s t i n gr a p p o rt. One of the benefits top renatal counseling is the posi-tive correlation with postnatalfollowup visits. Jaswon and col-leagues (1999) found that pare n t swho attended prenatal counsel-ing were more likely to attendpostnatal evaluation. Of the 49%of parents who attended counsel-ing, only 10% failed to attendpostnatal followup appoint-ments. This contrasts with a 20%f a i l u re rate from those pare n t swho were not counseled.

Education is the primary goalof the pediatric urology specialistvisit. It is important to review thevarious etiologies for the ANHand to determine an appro p r i a t epostnatal management plan.I n f o rmation from this visitshould be communicated to thep r i m a ry health care pro v i d e r.

Postnatal ManagementAt birth, the infant should be

s t a rted on a low dose of antibiot-

ic prophylaxis. Amoxicillin (25mg/kg) once per day is the antibi-otic of choice of infants under 2months of age. After 2 months,sulfamethoxazole (Bactrim®) (2mg/kg) can be initiated. Bactrimis not started prior to 2 monthsbecause the sulfamethoxazolebinds to the neonatal biliru b i nand can cause an overall rise inthe bilirubin leading to kern-i c t e ru s .

For all patients with ANH, anultrasound of the kidneys andbladder should be perf o rmed 48hours after the birth unless thesuspicion of PUV is present. Theultrasound is delayed because ofthe low glomerular filtration rateand relative oliguria in the new-b o rn. The lack of urine pro d u c-tion may underestimate thed e g ree of renal dilatation. Evenin the face of obstruction, thekidney may look normal. Theideal time to study infants is at 1week of life, but this may denythe neonate the advantage of in-hospital evaluation. The advan-tages include parental conve-nience and compliance, the imme-diacy of a diagnosis, and impro v e dcommunication between the hos-pital and the primary health carep rovider for appropriate postnatalc a re and re f e rr a l s .

If a VCUG reveals a VURgrade III-V, re f e rral to a pediatricu rologist is indicated. If theVCUG reveals a grade I-II, the pri-m a ry care provider can continueto manage the infant. If while onp rophylactic antibiotics theinfant has a bre a k t h rough UTI,re f e rral to a pediatric uro l o g i s tmay be considered. The primaryhealth care provider should fol-low VUR results until completeresolution is determ i n e d .

If the VCUG reveals no VUR,the primary care provider cancontinue to manage the infantand repeat the renal and bladderultrasound at 3 months of age. Ifthe hydro n e p h rosis is stable orresolving, doubling the followuptime between renal and bladderultrasounds (for example, 3

months, 6 months, yearly) isindicated. Followup should becontinued until the infant ist h rough potty training or untilresolution occurs. If theh y d ro n e p h rosis resolves, fol-lowup can be discontinued. Incontrast, if the hydro n e p h ro s i si n c reases, re f e rral to a pediatricu rologist is appro p r i a t e .

Nursing ImplicationsDue to the increasing detec-

tion of ANH, proper pre andpostnatal management guide-lines for both families and prima-ry care providers are essential.A p p ropriate parental counselingt h roughout the whole pro c e s sf rom the nurse practitionershould alleviate fears and anxi-ety for the families. Although thenatural history of ANH continuesto be confusing, guidelines canassist the health care providers forthis family to effectively mange alllevels of ANH care. Pregnancy is atime in a family’s life whereheightened emotions and anxietya re present. Although antenatalh y d ro n e p h rosis is one of the morecommon diagnoses, it should bem o n i t o red throughout the pre g-nancy and after the birth of theinfant. When families are seen pre-n a t a l l y, the nurse is able to teachand counsel the pare n ts .

During postnatal manage-ment, it is important for thenurse to continue to monitor andto confirm that the familiesreceive appropriate followup andc a re. The benefits to diagnosingantenatal hydro n e p h rosis is auseful way to find the patientswho usually would present witha urinary tract infection and/or am o re serious diagnosis and canhopefully save some of the initialfebrile urinary tract infection orany other serious morbidity tothe genital urinary system.

R e f e re n c e sBajpai, M., & Chandrasekharam, V. S .

(2002). Nonoperatiave managementof neonatal moderate to severe bilat-eral hydro n e p h rosis. The Journal ofU ro l o g y, 167(2), 662-665.

•

C

O

N

T

I

N

U

I

N

G

E

D

U

C

A

T

I

O

N

UROLOGIC NURSING / June 2005 / Volume 25 Number 3 183

Bowes, W.A. (2002). Evaluation and fol-low-up of fetal hydro n e p h ro s i s .Obstetrical and GynecologicalS u rv e y, 57(5), 269-270.

D u d l e y, J.A., Haworth, J.M., Mcgraw,M.E., Frank, J.D., & Ti z a rd, E.J.(1997). Clinical relevance and impli-cations of antenatal hydro n e p h ro s i s .A rchives of Disease in ChildhoodFetal & Neonatal Edition, 76(1), 31F-3 4 F.

F e rnbach, S.K., Maizels, M., & Conway,J.J. (1993). Ultrasound grading ofh y d ro n e p h rosis: Introduction to thesystem by the Society of FetalU ro l o g y. Pediatric Radiology, 23( 6 ) ,4 7 8 - 4 8 0 .

Gunn, T.R., Mora, J.D., & Pease, P. (1995).F e t u s - p l a c e n t a - n e w b o rn: antenataldiagnosis of urinary tract abnorm a l i-ties by ultrasonography after 28weeks’ gestation: Incidence and out-come. American Journal ofObstetrics and Gynecology, 172( 2 ) ,4 7 9 - 4 8 6 .

Jaswon, M.S., Dibble, L., Puri, S., Davis,J., Young, J., Dave, R., & Morgan, H.(1999). Prospective study of out-come in antentally diagnosed re n a lpelvis dilatation. A rchives ofDisease in Childhood Fetal &Neonatal Edition, 80(2), 135F-138F.

Lebowitz, R.I., Olbing, H., Parkkulainen,K . V., Smellie, J.M., & Ta m m i n e n -Mobius, T.E. (1985). Intern a t i o n a lsystem of radiographic grading ofv e s i c o u reteric reflux: The intern a-tional reflux study in childre n .Pediatric Radiology, 15, 1 0 5 - 1 0 9 .

Morin, L., Cendron, M., Crobleholme, T. ,G a rmel, S.H., Klauber, G.T., &D’Alton, M.E. (1996). Minimalh y d ro n e p h rosis in the fetus: Clinicalsignificance and implications formanagement. The Journal ofU ro l o g y, 155(6), 2047-2049.

P a l m e r, L.S., Maizels, M., Cartwright, P. C . ,F e rnbach, S.K., & Conway, J.J. (1998).S u rg e ry versus observation for manag-

ing obstructive grade 3 to 4 unilateralh y d ro n e p h rosis: A re p o rt form thesociety for fetal uro l o g y. The Journal ofU ro l o g y, 159(1), 222-228.

Sairam, S., Al-Habib, A., & Thilaganathan,B. (2001). Natural history of fetalh y d ro n e p h rosis diagnosed on mid-trimester ultrasound. Ultrasound inObstetrics and Gynecology, 17(3), 191-1 9 6 .

Tibballs, J.M., & De Bruyn, R. (1996)P r i m a ry vesicoureteric reflux – Howuseful is postnatal ultrasound?A rchives of Disease in Childhood,7 5(5), 444-447.

Additional ReadingE l d e r, J.S. (1992). Importance of antenatal

diagnosis of vesicoureteric re f l u x :C o m m e n t a ry. The Journal ofU ro l o g y, 148, 1 7 5 0 - 1 7 5 4 .

C

O

N

T

I

N

U

I

N

G

E

D

U

C

A

T

I

O

N