eMedicine Specialties > Pediatrics: Surgery > Urology

Antenatal Hydronephrosis: Treatment & Medication

Author: Dennis B Liu, MD, Assistant Professor of Urology and Pediatrics, University of Toledo College of Medicine
Coauthor(s): John D Edmondson, MD, Consulting Staff, Virginia Urology Center
Contributor Information and Disclosures

Updated: Dec 11, 2008

Treatment

Medical Care

  • To date, no medical interventions are indicated for the treatment of antenatal hydronephrosis. However, medical therapy is indicated in fetuses with oligohydramnios and the resultant pulmonary hypoplasia. Pulmonary hypoplasia is the precursor for bronchopulmonary dysplasia that develops in the neonate and is the major cause of mortality in this patient population. Surfactant is needed to decrease surface tension at the air-liquid interface of the alveoli, and glucocorticoids administered to the mother in the prenatal period have been shown to stimulate production of surfactant-associated proteins and enhance lung maturation.33
  • Randomized trials have concluded that antenatal corticosteroids, administered between 48 hours and 7 days before preterm delivery, decrease the incidence of respiratory distress syndrome and death.34,35 However, short-term adverse effects include hypertension, hyperglycemia, infections, intestinal perforations, GI bleeding, inhibition of somatic growth, and hypertrophic cardiomyopathy.36,37,38 Long-term adverse effects may include impairment of somatic, lung, and brain growth.33 Risks and benefits must be carefully weighed in each patient.

Surgical Care

  • Intervention for a fetus with antenatal hydronephrosis is controversial for various reasons. First, obtaining an accurate diagnosis with current technology is difficult. Second, the natural history of each disease process causing antenatal hydronephrosis is variable and has not been fully elucidated. Finally, the lack of data regarding the success and complications of intervention has impeded progress in defining specific indications for treatment.
  • The main considerations in evaluating a fetus with antenatal hydronephrosis are gestational age, laterality of the lesion, the presence of unfavorable prognostic factors, volume of amniotic fluid, and overall fetal well-being.
  • Lesions detected early in fetal development may have a significant impact on renal and pulmonary development. Laterality of the lesion is significant, with bilateral lesions being more predictive of poor outcome. The presence of unfavorable prognostic factors, such as renal cortical cysts and echogenic parenchyma on prenatal ultrasonography, elevated levels of urinary electrolytes on vesicocentesis, and reduced lung volume or thoracic circumference, should also be considered.39 The presence of oligohydramnios is the most significant indicator of poor fetal outcome, and intervention should not be considered in its absence. In the presence of multiple fetal anomalies or chromosomal anomalies predictive of poor outcome, parents may elect to terminate the pregnancy.
  • A management strategy has been developed based on initial and serial prenatal ultrasonographic findings.23 Significant unilateral hydronephrosis does not require prenatal intervention; however, it should be evaluated in the postnatal period with follow-up renal ultrasonography (if needed), voiding cystourethrography, and diuretic renography.
  • Bilateral hydronephrosis without bladder distension is more significant and should be monitored prenatally with serial ultrasonographic examinations to monitor for bladder distension and development of oligohydramnios. Postnatal evaluation should be performed as above. A fetus that presents with bilateral hydronephrosis and a distended bladder should raise serious concern for an obstructive process, such as urethral atresia or urethral valves.
  • If oligohydramnios is not present, serial examinations are adequate with definite postnatal evaluation as described above. In the presence of oligohydramnios, evaluation for the presence of unfavorable prognostic factors with karyotype analysis and vesicocentesis is warranted. Referral to a tertiary care center should also be a consideration. Fetuses with findings consistent with a poor outcome are generally not good candidates for prenatal intervention.
  • Treating a potentially obstructive process in the presence of oligohydramnios by diversion of urine into the amniotic space would seemingly allow normal renal and lung development. Relief of the obstructed flow of urine should optimize eventual renal function, and restoration of normal levels of amniotic fluid should prevent the development of pulmonary hypoplasia. However, experimentally and in clinical situations, this is not entirely true. Sufficient evidence indicates that restoring amniotic fluid volume is beneficial for lung development and preventing pulmonary hypoplasia; however, little evidence indicates that renal function is improved with this intervention. Experimental models and autopsy evaluations have demonstrated that irreversible dysplasia is often present by the time hydronephrosis is detected.23 Intervention should only be considered in fetuses with oligohydramnios and a significant chance of recovery of renal function based on renal prognostic factors.
  • Prenatal intervention is limited by technical considerations and lack of adequate comparison between the varying modalities with regard to patient selection and outcome measures, especially whether fetal intervention improves postnatal outcomes. Numerous advances have been made in refining current modalities; however, no prospective randomized trials are currently underway that compare outcomes of the various interventions.
  • The first successful in utero decompression was achieved with open fetal surgery by creating bilateral cutaneous ureterostomies in a 21-week fetus.40 Although the intervention was successful, the neonate did not survive because of pulmonary complications.
  • Open vesicostomies have also been attempted; however, these open interventions have been abandoned in favor of percutaneous shunt procedures. An eloquent description can be found in a review by Freedman et al.4 They describe several advances in technique that have allowed more success than in initial attempts, such as use of amnioinfusion to enhance fetal visualization, use of fetal paralysis, routine use of antibiotics, and increased appreciation of proper catheter placement. They also describe specific outcome measures that are needed for appropriate evaluation of the effects of fetal intervention, including gross survival, postnatal survival, shunted survival, and nadir creatinine at 1 year. Laparoscopy has also been described but have been associated with high rates of complications.41
  • Fetal cystoscopic ablation of posterior urethral valves has been described with varying success.42 The fetoscope is passed percutaneously through a cannula into the fetal bladder, and ablation of the valves is achieved with laser coagulation. Other less invasive techniques have been developed to help prevent oligohydramnios-induced pulmonary hypoplasia. As previously mentioned, serial transabdominal amnioinfusion is helpful in placement of percutaneous shunts. It may also have a therapeutic role in the reduction of pulmonary hypoplasia.43 This intervention could be useful in fetuses with oligohydramnios associated with antenatal hydronephrosis.

Consultations

Consultations are indicated as directed by the initial evaluation but may include the following:

  • Neonatologist
  • Pediatrician
  • Pediatric urologist
  • Pediatric nephrologist
  • Pediatric cardiologist
  • Pediatric cardiac surgeon
  • Pediatric surgeon
  • Pediatric orthopedic surgeon
  • Pediatric neurosurgeon

Medication

Glucocorticoids

These agents elicit anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.


Betamethasone (Celestone Soluspan)

Prenatal betamethasone is administered to pregnant women according to the recommendations by a National Institutes of Health (NIH) Consensus Conference Panel for all pregnancies at 24-34 weeks' gestation at risk of preterm delivery, preterm premature rupture of membranes (PROM) at 30-32 weeks' gestation, and in complicated pregnancies with anticipated delivery at <34 weeks' gestation. Reduces neonatal mortality rates, respiratory distress syndrome (RDS), and intraventricular hemorrhage (IVH).

Adult

12 mg IM qd for 2 doses (repeated courses optional but associated with significant adverse effects)

Pediatric

Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; betamethasone decreases effect of salicylates and vaccines used for immunization

PROM <29 weeks' gestation; diabetes mellitus; gestational diabetes mellitus; severe preeclampsia

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Multiple courses of antenatal betamethasone produce higher frequency of early-onset neonatal sepsis, chorioamnionitis, endometritis, and neonatal death; case reports of transient hypertrophic cardiomyopathy and cushingoid syndrome in neonates

Surfactants

Exogenous surfactant can be helpful in treatment of airspace disease (eg, RDS). Following inhaled administration, surface tension is reduced and alveoli are stabilized, thus decreasing the work of breathing and increasing lung compliance.


Beractant (Survanta)

A semisynthetic bovine lung extract containing phospholipids, fatty acids, and surfactant-associated proteins B (7 mcg/mL) and C (203 mcg/mL).

Adult

Pediatric

100 mg/kg (ie, 4 mL/kg) intratracheally divided in 4 aliquots administered at least 6 h apart

Pregnancy
Precautions

Must be warmed to room temperature; administer only under carefully supervised conditions because of risk of acute airway obstruction


Calfactant (Infasurf)

A natural calf lung extract containing phospholipids, fatty acids, and surfactant-associated proteins B (260 mcg/mL) and C (390 mcg/mL).

Adult

Pediatric

3 mL/kg intratracheally; may repeat q6-12h; not to exceed 3-4 doses

Pregnancy
Precautions

Administer only under carefully supervised conditions because of risk of acute airway obstruction

More on Antenatal Hydronephrosis

Overview: Antenatal Hydronephrosis
Differential Diagnoses & Workup: Antenatal Hydronephrosis
Treatment & Medication: Antenatal Hydronephrosis
Follow-up: Antenatal Hydronephrosis
References
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Further Reading

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Keywords

antenatal hydronephrosis, congenital hydronephrosis, fetal hydronephrosis, urinary tract, ultrasonography, ultrasound, oligohydramnios, pyelonephritis, symptomatic flank pain, abdominal pain, renal calculi, hypertension, renal failure, pulmonary hypoplasia, nonrefluxing nonobstructed megaureter, prune belly syndrome, isolated antenatal hydronephrosis, IAHN

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Contributor Information and Disclosures

Author

Dennis B Liu, MD, Assistant Professor of Urology and Pediatrics, University of Toledo College of Medicine
Dennis B Liu, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Urological Association, Ohio Urological Society, Society for Fetal Urology, and Society for Pediatric Urology
Disclosure: Nothing to disclose.

Coauthor(s)

John D Edmondson, MD, Consulting Staff, Virginia Urology Center
John D Edmondson, MD is a member of the following medical societies: American College of Surgeons, American Urological Association, and Endourological Society
Disclosure: Nothing to disclose.

Medical Editor

Martin David Bomalaski, MD, FAAP, Pediatric Urologist, Alpine Urology
Martin David Bomalaski, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and American Urological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Harry P Koo, MD, Chairman of Urology Division and Director of Pediatric Urology, Virginia Commonwealth University; Professor of Surgery, VCU School of Medicine, Medical College of Virginia; Director of Urology, Children's Hospital of Richmond
Harry P Koo, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and American Urological Association
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Marc Cendron, MD, Associate Professor of Surgery, Harvard School of Medicine; Consulting Staff, Department of Urological Surgery, Children's Hospital Boston
Marc Cendron, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, European Society for Paediatric Urology, Johns Hopkins Medical and Surgical Association, New Hampshire Medical Society, Society for Fetal Urology, and Society for Pediatric Urology
Disclosure: Nothing to disclose.

 
 
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