Thomas C. Winter, MD Director of Abdominal Imaging ••Goals...

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The Fetal Genitourinary SystemThomas C. Winter, MD

Professor of Radiology & OB-GYNDirector of Abdominal Imaging

University of Utah

The Fetal Genitourinary System

•Goals•Normal Anatomy•Specific Anomalies•In Utero Therapy

Disclosures

•Speakers’ Bureau, GE Ultrasound•Spouse: Ex-CEO and stock in microwave ablation company

Goals

•Always document bladder, kidneys, and AF volume•Questions to be answered‣Is oligohydramnios present?‣Is the urinary tract dilated?‣Is renal size/shape/echogenicity abnormal?‣Are renal cysts present?‣Are associated anomalies present?

1. Is Oligohydramnios Present?

•DRIPS‣ Demise‣ Renal‣ IUGR/Indomethacin‣ Post Maturity‣ SROM

2. Is the Urinary Tract Dilated?

•Where? Unilateral vs bilateral. Proximal vs distal (UPJ, UVJ, PUV)•Has it decompressed? (ascites, urinoma)•Extrinsic cause? (hydrocolpos, SCT, other pelvic masses)•Dilatation does not always signify obstruction (reflux, MCMCIH)

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3. Is Renal Size, Shape, or Echogenicity Abnormal?

•Size•~ [(Age in weeks) + 5] (mm)•Shape (mesoblastic nephroma, duplex system)•Echogenicity•Renal dysplasia•Genetic (PCKD)

4. Are Renal Cysts Present?

•Obstructive uropathy #1‣Renal dysplasia or MCDK•Numerous syndromes•Incidental isolated cyst•Pitfalls‣Small perinephric urinoma‣Infundibulopelvic stenosis mimicking cysts‣Hypoechoic medullary pyramids

5. Are Associated Anomalies Present?

If you see a fetal abnormality of any type, keep looking!!!

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•Goals•Physics•Specific Anomalies•In Utero Therapy



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Amniotic Fluid Volume•Objective measurement requires amniocentesis c dye or

isotope•Normal 3rd trimester AFV is < 1000cc•Before 16 weeks, AFV may be normal without renal function (skin)•Normal AFV in 2nd half of gestation implies at least one functioning kidney•Normal AFV signifies good prognosis in the setting of a GU abnormality•Although most GU abnormalities cause oligohydramnios, some cause paradoxical polyhydramnios (Unilateral UPJ/MCDK, MN, MCMCIHS)

Sonographic Assessment of AFV:Subjective

• Oligohydramnios‣ Obvious lack of fluid‣ Fetal crowding• Polyhydramnios‣ “Swimming” fetus‣ Fetal trunk normally touches anterior uterine wall in 3rd• Trust experience rather than “quantitative” methods. No

benefit to quantitative methods (Magann 2001)• But “objective” methods offer including reproducibility, easily communicated levels of fluid volume, and the ability to follow trends (OB & Gyn December 2016)

Sonographic Assessment of AFV:Single Deepest Pocket (SDP)

•Oligohydramnios [2 cm]‣ <=3 cm (Halpern et al)‣ <= 1 cm (Manning et al)‣ <= 0.5 cm (Mercer et al)•Polyhydramnios [8 cm]‣ > 8 to 16 cm•Measure to the cord, not through it to the base of

the pocket (Magann 2002)

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Sonographic Assessment of AFV:Amniotic Fluid Index•Sum of deepest pocket in all four quadrants free of

umbilical cord•Normal AFI is between 5-8 and 20-24 cm‣Always normal between 10 and 20 cm‣ EGA dependent and potentially population dependent (Lei

1998) and dependent on presentation (Brost 1999)‣ AFI probably increases continually until near term

(Magann 1997)• Both AFI and SDP are far from accurate in assessing abnormal AFV (Magann 2000). Neither technique does well for determining oligo (Magann 2011)

Sonographic Assessment of AFV:Amniotic Fluid Index•In summary, although some reports suggest that an AFI

between 5.1 and 8.1 to 10.0 cm is associated with adverse outcomes, these results should be interpreted with caution ... Two ACOG practice bulletins have defined an AFI of greater than 5.0 cm as consistent with a normal amniotic fluid volume (Magann JUM 2011; 30:523)•The fetal urine production rate and amniotic fluid index are markedly increased by maternal rest in the left lateral decubitus position (Ulker JUM 2011; 30:481)•Maternal hydration with 2 L of water in a patient with a low AFV can increase the AFI by up to 31% (Kilpatrick Obstet Gynecol 1991; 78:1098–1102)

Sonographic Assessment of AFV:SDP > AFI

“The relationship between the fixed cutoffs of an AFI of 5 cm or less and a single deepest pocket of 2 cm or less for identifying adverse pregnancy outcomes is uncertain. The use of the single deepest pocket compared to the AFI to identify oligohydramnios in at-risk pregnancies seems to be a better choice because the use of the AFI leads to an increase in the diagnosis of oligohydramnios, resulting in more labor inductions and cesarean deliveries without any improvement in peripartum outcomes.”

Magann, JUM November

2011, 30:1573

Sonographic Assessment of AFV:SDP > AFI

Reddy et al, JUM May

2014, 33:745–757

•Width of pocket >= 1 cm•Exclude umbilical cord and fetal parts• Both the AFI and maximum vertical pocket correlate poorly with the actual amniotic fluid volume measured with dye dilution techniques•SDP preferred (simpler and fewer FP), esp. in twins

Sonographic Assessment of AFV:SDP > AFI•“In assessing oligohydramnios, the deepest vertical pocket

(<2 cm) is preferred over AFI (5 cm) because it results in fewer obstetric interventions without a significant difference in the perinatal outcome, and the single deepest pocket should be at least 1 cm wide.”

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Kidneys:Visualization and Size

•Kidneys seen as early as 14-16 weeks‣No good architecture until 16-18 weeks‣90% kidneys clearly seen by 20 weeks•Size‣4-5 VB’s‣Renal length in mm is ~ (age in weeks + 5)

Don’t Confuse Normal Medullary Pyramids with Hydro

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Harker AJR 1997

Beckwith–Wiedemann Syndrome

Bladder

•Usually seen after 13 weeks•Fills and empties every 30 minutes to one hour•Bladder produces 30ml/hour near term

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2VC in AF ≠ 2VC around Bladder

Gender Determination:Why?

•Careful!•Twins (Dizygosity)•Marker for successful amniocentesis c multiple gestations•R/O X-linked disorder•Ambiguous genitalia

Gender Determination: U/S•Documentation of testicles within scrotum provides 100%

reliability‣Normal descent not present until 28-34 weeks•Beware hypertrophied labia•Can’t see perineum for gender determination in 30% of

cases, and gender incorrectly assigned in 3% of cases even with adequate visualization of the perineum•“Whilst the accuracy of sonographic determination of fetal gender at 11-14 weeks is good, it still falls significantly short of invasive karyotyping tests.” (Whitlow 1999)•3D still not as good as 2D (Efrat 1999)

If not seen at 34-36 weeks, high probability of cryptorchidism.JUM 2002:21(1):15


•Goals•Normal Anatomy•Specific Anomalies‣Pretty much anything you have seen or

studied in the paediatric or adult populations may be seen here!•In Utero Therapy

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Urachal Cancer in an Adult Allantoic Duct Cyst with Patent Urachus

B

A


•Congenital abnormalities of the urinary tract account for 15% to 20% of all congenital disorders diagnosed prenatally•In cases of unilateral renal anomalies in the 2nd trimester, ~8% had additional unsuspected major anomalies•Keep looking!

Clinton et al, JUM March 2016, 35(3) 561-564


•Goals•Normal Anatomy•Specific Anomalies‣Kidneys•In Utero Therapy

Hydronephrosis

•UPJ >> UVJ > Ureterocele•1/330 infants, M:F=4.5:1, major nonrenal malformations in 9.5%•Surgical correction between 6-12 months has good outcome•Delayed diagnosis too common: <25%/55% detected by age 1 and 5•Multiple measurements proposed‣AP diameter, AP ratio, transverse ratio,

circumference ratio, renal thickness, caliectasis

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Hydronephrosis•Best method is AP diameter of renal pelvis•>= 4 mm before 33 weeks and >= 7 mm after 33 weeks‣ 100% sensitivity, FP = 42%/21% (Corteville 1991)•Reproducibility: 70% both normal and abnormal over 2 hour

period using 5 mm (Persutte 1998)•Maternal hydration may cause fetal pyelectasis (Robinson 1998, Babcook 1998)•Minimize parental anxiety for mild pyelectasis (Harding 1999, Kent 2000, Feldman 2001)

•Mild renal pyelectasis >= 4 mm AP diameter•In 0.6%–4.5% of fetuses in the second trimester•Perform follow-up U/S at 32 weeks to rule out persistent pyelectasis•If >= 7 mm at 32-weeks, obtain postnatal follow-up‣Assess kidneys postnatally only after waiting 48-72 hours! (and

other sources say at least 3 days and ideally 1 week)

Hydronpehrosis: What to Do?

Reddy et al, JUM May

2014, 33:745–757

•Significantly more complicated system, using 28 weeks rather than 32 weeks as the cut-off, and requiring assessment of multiple other factors in addition to AP diameter of the renal pelvis

Hydronpehrosis: What to Do?

Nguyen et al, J Ped Urol Dec 2014, 10(6):982-

988

Ureteropelvic Junction Obstruction

•Most common congenital malformation of the urinary tract•Most common cause of neonatal and fetal hydronephrosis•Unilateral in 70%

Ureteropelvic Junction Obstruction:Sonography

•Hydronephrosis with variable caliectasis•Vast majority demonstrate nonprogressive mild to moderate pyelocaliectasis•Prognosis depends on opposite kidney, AFV, and presence of any other anomalies•Up to 25% fetuses with UPJ demonstrate polyhydramnios‣ Impaired renal concentrating ability with increased

renal output

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UPJ UPJ

UPJ UPJ

Fetal Pyelectasis and Trisomy-21

•Lots of initial enthusiasm‣ Like most markers, enthusiasm has waned with time•Pyelectasis in 17-25% of fetuses with Trisomy 21 vs.

2-3% in controls‣ >=4mm before 33 weeks and >=7mm after 33 weeks•Sensitivity = 17%•PPV (1 in 90) compares favorably to other currently

accepted screening tools for T-21 (advanced maternal age, low MSAFP, and BPD/FL)

Obstet Gynecol 1990;76:58-60

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Conclusion:Isolated Pyelectasis and T-21

•Association between Down syndrome and pyelectasis exists, but the association with isolated pyelectasis is more problematic •Risk-benefit ratio suggests that amniocentesis should be reserved for cases with other risk factors‣Maternal age‣ Abnormal “quad screen” (low MSAFP, high E3 …)‣Other U/S markers (NSF, limbs, EIF, FEB, …)‣ LR ~ 1.5 (JUM May 2014, 33:745–757)• “Moot point” with advance of NIPT/NIPD

Renal Agenesis

•Bilateral RA occurs 2/10000 births; 2.5:1 Male:Female‣Death from pulmonary hypoplasia‣ Potter’s facies‣ 14% CV anomalies, 40% MS anomalies•Unilateral RA occurs 4-20 times more commonly; Male

= Female‣Frequently associated with additional GU

malformations, usually not life-threatening

Renal Agenesis: Sonography•One of the most difficult malformations to confirm

(anhydramnios)‣Non-visualization of bladder more important than

renal “visualization”‣Adrenals assume a reniform shape•Instillation of 100-150 cc of isotonic fluid proposed‣ PROM‣Anhydramnios of any cause has a poor prognosis•Spontaneous filling and emptying of bladder excludes

this diagnosis (bladder seen p 13 weeks)

Renal Agenesis: “Clues”•“Lying Down” adrenal‣Can also be seen in

crossed fused ectopia and pelvic kidney•Doppler to assess renal

arteries‣Easier said than done

Unilateral Renal Agenesis

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Unilateral Renal Agenesis Unilateral Renal Agenesis

Unilateral Renal Agenesis

Unilateral Renal Agenesis, Isolated

Rt Lt

D = 6.1 cm

Unilateral Renal Agenesis, T-18

Bilateral Renal Agenesis:Don’t Get Fooled by Adrenals

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Bilateral Renal Agenesis Bilateral Renal Agenesis(vs. Normal Variant Two Renal Arteries)

Bilateral Renal Agenesis, 2 Cases:Compare with ARPCKD Later in Talk

Crossed Fused Ectopia

•1/7000 births•May mimic unilateral renal agenesis•Ectopic kidney is large and usually bilobed

Crossed Fused Ectopia Crossed Fused Ectopia

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Pelvic Kidney

•1/1200 births•May mimic unilateral renal agenesis

Pelvic Kidney

Duplex Anomalies

•Duplicated collecting systems and ureters‣ + 2:1 Female:Male•Exception to male predominance rule in GU

system‣40% bilateral•Simple and ectopic ureteroceles‣Ureteroceles are bilateral in 15% of cases•Classical appearance is asymmetric hydronephrosis of

the upper pole

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KU

BB

Sepulveda JUM 22(8) 2003

Cystic Renal Disease

•Majority‣MCDK‣Obstructive uropathy resulting in renal

dysplasia•Minority‣PCKD (AR >> AD)‣Syndromes‣? Maternal Substance Use

Isolated Renal Cyst Multicystic Dysplastic Kidney (Potter Type II): Clinical

•Most common neonatal renal mass•Most likely cause of congenital cystic renal dysplasia•Male:female = 2:1, 80% on left•? association c IDM

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•Classically, excellent prognosis if opposite kidney is normal‣May rarely have renin dependent hypertension‣ Even when apparently sonographically isolated, close

follow-up and amniocentesis may be indicated (3% T-21). Renal/genital-urinary tract abnormalities were diagnosed subsequently in 33% and non-renal abnormalities in 16% of cases (7% CHD). (Aubertin 2002)‣ 40% contralateral renal abnormalities•May be associated with many other nonrenal structural and

chromosomal abnormalities

Multicystic Dysplastic Kidney (Potter Type II): Clinical

MCDK: Embryology

•Consequence of in utero obstruction‣Classic form: early

obstruction, before 8-10 weeks•Atresia of ureteric bud

system prevents the metanephric blastema from inducing formation of nephrons

Offer fetal MRI autopsy PRN

MCDK

Courtesy Dave Nyberg

MCDK:Sonographic Appearance

•Paraspinal mass with macroscopic cysts, “Bunch of grapes”•Cysts are noncommunicating, randomly situated, variable size and shape•No normal renal parenchyma visualized•May see spontaneous involution or significant interval changes secondary to minimal residual urine formation

MCDK:Sonographic Appearance

•Differential Diagnosis: UPJ‣Cysts communicate‣Largest “cyst” (renal pelvis) is located medially‣Kidney has reniform morphology•Always check contralateral kidney, bladder, and

for presence of nonrenal malformations

MCDK, Unilateral

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MCDK, Unilateral MCDK, Unilateral

MCDK, Unilateral in Pelvic Kidney MCDK:40% Contralateral Abnormalities•20% contralateral MCDK‣Functionally anephric•10% contralateral agenesis•10% contralateral hydronephrosis, usually from

UPJ

Bilateral MCDK MCDK, Bilateral

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•20% contralateral MCDK•10% contralateral agenesis‣Functionally anephric•10% contralateral hydronephrosis, usually from

UPJ

MCDK:40% Contralateral Abnormalities

MCDK + Unilateral RA

•20% contralateral MCDK•10% contralateral agenesis•10% contralateral hydronephrosis, usually from UPJ

MCDK:40% Contralateral Abnormalities

MCDK + UPJ

Cystic Renal Dysplasia(Potter Type IV)

•Obstructive uropathy‣Early obstruction results in renal dysplasia‣ Late obstruction results in hydronephrosis•Cortical cysts in the setting of obstructive uropathy

indicate dysplasia•Increased renal echogenicity usually but not always implies dysplasia•Sonographically normal kidneys may exhibit severe dysplastic change at birth

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Courtesy Dave Nyberg

Cystic Renal Dysplasia not MCDK Two More Cases of Postobstructive Cystic Dysplasia

UPJ Turning into Cystic Renal Dysplasia Cystic Renal Disease



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AR PCKD: Clinical

•AKA Potter type I or Infantile PCKD•1 in 50,000 newborns•Remember hepatic involvement‣Inverse relationship between degree of hepatic

and renal disease‣Renal manifestations predominate in prenatal

form•Death from pulmonary hypoplasia

AR PCKD: Ultrasound

•Large echogenic kidneys bilaterally, usually without macroscopic cysts‣New technology may allow cyst visualization, at

least postnatally (Stein-Wexler 2003)•Oligohydramnios, non-visualization of bladder•Diagnosis may be made by 16-18 weeks•Normal sono before 3rd trimester does not exclude diagnosis

AR PCKD

Prenatal D = 5.4 cm Postnatal

AR PCKD

AR PCKD AR PCKD

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AR PCKD AR PCKD

AR PCKD

Offer fetal autopsy PRN

AD PCKD

•AKA Potter type III or Adult PCKD (rare in utero)•Cystic echogenic kidneys with normal AFV and positive FH‣May have late presentation c normal mid trimester

appearance‣May have asymmetric involvement‣May mimic AR PCKD (only 50% had detectable

cysts)‣Scan mom (and dad)!•Accurate prenatal DNA test available p CVS

AD PCKD: Prognosis

•7 cases detected in utero or shortly after birth (Pretorius 1987)•1 TOP, 1 neonatal death•4/5 normal renal function•3/5 normal BP at 4 years of age

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AD PCKD AD PCKD

Syndromes Associated With Renal Cysts

•Trisomy 13 or 18•Meckel-Gruber (AR)‣MCDK, encephalocele, postaxial polydactyly•Jeune, Zellweger, ...

Meckel-Gruber Syndrome Meckel-Gruber Syndrome

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Cystic Renal Disease



Maternal Cocaine Use

•AKA fetal renal hamartoma, leiomyomatous hamartoma, congenital Wilms tumor•Most common solid renal mass prenatally•Other fetal renal neoplasms are very rare•Association with polyhydramnios•Postnatal nephrectomy usually curative

Mesoblastic Nephroma

January 2012 RadioGraphics, 32, 99-103

Mesoblastic Nephroma

Mesoblastic Nephroma Mesoblastic Nephroma

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Mesoblastic Nephroma Mesoblastic Nephroma

Mesoblastic Nephroma Megaureter

•Dilated ureter‣Obstruction (UVJ, ureterocele)‣Reflux‣Neither•Coexisting GU anomalies frequently present•Distinguish ureter (from bowel)‣Touches spine, originates from renal pelvis,

extends into a retrovesicular position

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Megacystis

•First trimester•After the first trimester

•A longitudinal bladder diameter of >=7 mm at the 10–14 week scan•1/1500 pregnancies, ~14/1 M:F

Megacystis in the 1st Trimester

Nicolaides UOG 2003; 21: 338–341, 145 fetuses

Megacystis in the 1st Trimester•7-15 mm‣25% aneuploidy‣If euploid, 90% resolve•10% potential progression to severe

obstructive uropathy•> 15 mm‣Risk of aneuploidy falls to 10% (similar to

trends with many other anomalies)‣If euploid invariably associated with severe

obstructive uropathy and renal dysplasia

Megacystis in the 1st Trimester•Aneuploidy‣T13 > T 18 >> T21•6X increased risk for T18 and T13 given

maternal age, EGA, and NT•Expected T21 not different from observed‣Megacystis associated with increased NT‣Circulating cell-free DNA from maternal blood

will hopefully obviate this discussion!

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Distal Urinary Tract Obstruction and Megacystis

•Obstruction distal to UVJ usually secondary to posterior urethral valves‣Almost exclusively male‣Other GU anomalies in 25%‣Other structural and chromosomal

abnormalities•DDx: Urethral stricture or agenesis, persistent cloaca with urethral stricture or stenosis, MCMCIH

Posterior Urethral Valves:Sonographic Findings

•Bladder‣ Dilatation of the urinary bladder and proximal urethra‣ “Keyhole” appearance to bladder•??? utility: “seen only in 51% of fetuses confirmed to have

[PUV] and was seen in 37% who did not have [PUV] (Obstet & Gynecol June 2018)

‣ Bladder wall thickening visible after shunt or spontaneous decompression•Kidneys‣ Only 40% have pelvicaliectasis or ureterectasis‣ Renal involvement may be asymmetric‣ Renal cortical cysts implies dysplasia

Posterior Urethral Valves:Sonographic Findings

•Amniotic Fluid‣Only 50% have oligohydramnios‣Normal AFV has good prognosis•Urine ascites or perinephric urinoma•Determine gender

Posterior Urethral Valves

Posterior Urethral Valves Posterior Urethral Valves

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Posterior Urethral Valves Posterior Urethral Valves, Spontaneous Rupture

July 22nd 4 days later

Another Case of Bladder Rupture

Posterior Urethral Valves

B

B

Urachal Remnants

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Megacystis Microcolon Intestinal Hypoperistalsis Syndrome

•Mainly female with normal or increased AFV•Enlarged non-obstructed bladder•Shortened and dilated proximal SB•Malrotated microcolon•Absent or ineffective peristalsis

Courtesy Harris Finberg

Megacystis Microcolon Intestinal Hypoperistalsis Syndrome

MCMCIH #2

Megacystis

Poly

XX

Fetal Hydroceles•Fairly common finding

in 3rd trimester•Small, stable collections are normal•Fluid accumulates within processus vaginalis during testicular descent

Hypospadias•Urethral meatus

opens on ventral shaft•Associated with chordee, resulting in angulation (“bent”) of corpora cavernosa•Make diagnosis with caution...

Ambiguous Genitalia•Trisomy 18

(Edward syndrome)•Again, don’t overcall‣May be difficult

diagnosis‣Parental anxiety‣Starts major

multispecialty workup

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Fetal Ovarian Cysts

•Common: autopsy studies demonstrate 30% prevalence•Most are small and simple•Most resolve within a few months after birth•? prenatal aspiration of large (>4cm) cysts to prevent torsion, but vast majority suggest that watchful waiting is all that is required (Heling 2002)

See Kennedy et al, Radiographics, 2015

B

SC

Fetal Ovarian Cysts

Torsion:postnatally without flow

B

C

Fetal Ovarian Cysts

Proven torsion #2 (composite courtesy of Anne Kennedy):33 week follow-up growth incidental finding

Proven torsion #3: Note peripheral follicles and lack of flowProven torsion #3:

Note hemorrhage: bright on T1 and T2

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In Utero Therapy

•Congenital Hydronephrosis‣Urethral obstruction

between 18 and 32 weeks may benefit from in utero decompression‣Assess oligo, renal dysplasia,

fetal urine electrolytes and hourly urine output‣Shunt or vesicostomy•Instillation of AF (Diagnostic not therapeutic)

Vesicocentesis

PUV Treated with Catheter

In Utero Therapy

•Therapeutic instillation of AF•“We report a case of bilateral renal agenesis treated with serial amnioinfusion in which the newborn survived the newborn period and was able to undergo peritoneal dialysis as a bridge to planned renal transplantation.”•Subsequent editorial: “Ethical Considerations Concerning Amnioinfusions for Treating Fetal Bilateral Renal Agenesis”• Obstet Gynecol 2014;0:1–3 & 2018;131:130-134•“Maternal–fetal interventions for anhydramnios in the

context of severe fetal kidney anomalies are still not considered accepted standard clinical practice”• Obstet Gynecol 2018 June

“Amnioinfusion Compared With No Intervention in Women With Second-Trimester Rupture of Membranes: A Randomized Controlled Trial”

•Therapeutic instillation of AF•“[N]ationwide, multicenter, open-label, randomized controlled trial, the PPROM: Expectant Management versus Induction of Labor-III (PPROMEXIL-III) trial, in women with singleton pregnancies and preterm prelabor rupture of membranes at 16 0/7 to 24 0/7 weeks of gestation with oligohydramnios (single deepest pocket less than 20 mm).”•“CONCLUSION: In women with second-trimester preterm prelabor rupture of membranes and oligohydramnios, we found no reduction in perinatal mortality after amnioinfusion.”• Obstet Gynecol January 2019: 133(1);129–136



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Goals

•Always document bladder, kidneys, and AF volume•Questions to be answered‣Is oligohydramnios present?‣Is the urinary tract dilated?‣Is renal size/shape/echogenicity abnormal?‣Are renal cysts present?‣Are associated anomalies present?

Thank You!

• Dave Nyberg: “Diagnostic Imaging of Fetal Anomalies”•Anne Kennedy: AMIRSYS images & gorgeous fetal ovarian torsion•Harris Finberg: MCMCIH from Dave’s Book• Don Milburn: early “Radar”•Sierra Club: old Desktop calendars

Sexy

SAM #1A useful rule of thumb for fetal renal length is:

(1) The length of the fetal kidney in mm is the EGA in weeks.

(2) The length of the fetal kidney in mm is the EGA in weeks + 5.

(3) The length of the fetal kidney is two-three vertebral bodies.

(4) The length of the fetal kidney is equivalent to the BPD.(5) The length of the fetal kidney is equivalent to the femur

length.

SAM #1A useful rule of thumb for fetal renal length is:

(1) The length of the fetal kidney in mm is the EGA in weeks.

(2) The length of the fetal kidney in mm is the EGA in weeks + 5.

(3) The length of the fetal kidney is two-three vertebral bodies.

(4) The length of the fetal kidney is equivalent to the BPD.(5) The length of the fetal kidney is equivalent to the femur

length.

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SAM #1 Learning PointA useful rule of thumb for fetal renal length is:

Charts are often not easily accessible to the general sonologist, so a reasonably accurate and easily remembered heuristic is very usefulLength in weeks + 5, with one SD ~5 mm

SAM #2The contralateral kidney in multicystic kidney

disease (MCDK) is abnormal in approximately what percentage of cases?

(1) <5(2) 10(3) 40(4) 70(5) 100

SAM #2The contralateral kidney in multicystic kidney


(1) <5(2) 10(3) 40(4) 70(5) 100

SAM #2 Learning PointThe contralateral kidney in multicystic kidney


Don’t get “satisfaction of search” or “happy eye”

SAM #3Approximately how many cysts are generally

sonographically identified in each kidney in fetuses with ARPCKD?

(1) None(2) 1-5(3) 5-10(4) 10-20(5) >20

SAM #3Approximately how many cysts are generally


(1) None(2) 1-5(3) 5-10(4) 10-20(5) >20

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SAM #3 Learning PointApproximately how many cysts are generally


None: the name of this process is misleading; the “cysts” present are generally beneath the limit of ultrasound resolution

SAM #4The most common solid renal mass seen in utero is:

(1) AML (angiomyolipoma)(2) MN (mesoblastic nephroma)(3) CFE Crossed Fused Ectopia)(4) Wilms (5) RCC (Renal Cell Carcinoma)

SAM #4The most common solid renal mass seen in utero is:

(1) AML (angiomyolipoma)(2) MN (mesoblastic nephroma)(3) CFE Crossed Fused Ectopia)(4) Wilms (5) RCC (Renal Cell Carcinoma)

SAM #4 Learning PointThe most common solid renal mass seen in utero is:

Differential for solid renal masses in utero is entirely different than that in adults

SAM #5Although not etched in stone, the most commonly

accepted normal values for semiquantitative estimates of normal amniotic fluid volume using the

maximum vertical pocket method are

(1) > 2 and < 8 cm(2) > 1 cm and < 10 cm(3) > 10 cm and < 20 cm(4) > 3 cm and < 15 cm(5) > 4 cm and < 8 cm

SAM #5Although not etched in stone, the most commonly



(1) > 2 and < 8 cm(2) > 1 cm and < 10 cm(3) > 10 cm and < 20 cm(4) > 3 cm and < 15 cm(5) > 4 cm and < 8 cm

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SAM #5 Learning PointAlthough not etched in stone, the most commonly



2-8 for SDP/MVPFor AFI, >10 and <20 is essentially always normal

Thomas C. Winter, MD Director of Abdominal Imaging ••Goals...

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