the management of antenatal pelviectasis – are we there yet? malcolm a. lewis consultant...

The Management of antenatal pelviectasis – are we there yet?

Malcolm A. Lewis

Consultant Paediatric Nephrologist

RMCH

The Management of antenatal pelviectasis – are we there yet?

No

Thank you, Time for me to leg it!

The Management of antenatal pelviectasis – are we there yet?

Lies – damn lies – and statistics (?Disaeli)

Clinical trials, follow up studies, RCT’s, registry data

The Management of antenatal pelviectasis – are we there yet?

and the result of all this is….

we have become slaves to statistics

The Management of antenatal pelviectasis – are we there yet?

but what does this curve really mean?

The Management of antenatal pelviectasis – are we there yet?

but what does this curve really mean?

SHIT HAPPENS

The Management of antenatal pelviectasis – are we there yet?

Patient WH.• Antenatal scans left pelvic dilatation TPD 12

mm• Postnatal scans;-

9 mm

The Management of antenatal pelviectasis – are we there yet?

Patient WH.• Antenatal scans left pelvic dilatation TPD 12

mm• Follow up 09/06/2009 – age 13 months;-

5.7 mm

The Management of antenatal pelviectasis – are we there yet?

Patient WH.• Antenatal scans left pelvic dilatation TPD 12

mm• Follow up 22/06/2010 – age 24 months;-

37.3 mm

The Management of antenatal pelviectasis – are we there yet?

The Management of antenatal pelviectasis – are we there yet?

• Pathophysiology of antenatal renal tract dilatation

• Conditions associated with renal tract dilatation

• Investigation and follow up

The Management of antenatal pelviectasis – are we there yet?

Pathophysiology of antenatal renal tract dilatation

• Fetus is in a state of diuresis

• 7.5 ml/hr at 25 weeks gestation = 10 ml/kg/hr

• 10 ml/hr at 30 weeks gestation = 7.7 ml/kg/hr

• 27 ml/hr at 40 weeks gestation = 7.7 ml/kg/hr

• Postnatal urine production rate up to 2 - 6 ml/kg/hr

• Renal tract elastic so stretching possible

The Management of antenatal pelviectasis – are we there yet?

Conditions associated with renal tract dilatation

• Single kidney (agenesis, MCDK)

• Pelviectasis, pelvi-ureteric junction obstruction

• Hydro-ureter, vesico-ureteric junction obstruction

• Vesico-ureteric reflux

• Bladder outlet obstruction, posterior urethral valves

• Duplex systems with ureterocoele

The Management of antenatal pelviectasis – are we there yet?

The Management of antenatal pelviectasis – are we there yet?

The Management of antenatal pelviectasis – are we there yet?

The Management of antenatal pelviectasis – are we there yet?

The Management of antenatal pelviectasis – are we there yet?

The Management of antenatal pelviectasis – are we there yet?

The Management of antenatal pelviectasis – are we there yet?

The Management of antenatal pelviectasis – are we there yet?

Investigation and follow up • What exactly was seen antenatally?

7 mm 8.5 mm

The Management of antenatal pelviectasis – are we there yet?

Investigation and follow up • What exactly was seen antenatally?

The Management of antenatal pelviectasis – are we there yet?

Investigation and follow up • What exactly was seen antenatally?

The Management of antenatal pelviectasis – are we there yet?

Investigation and follow up • What exactly was seen antenatally?

The Management of antenatal pelviectasis – are we there yet?

Investigation and follow up • Isolated unilateral pelviectasis

– Is the contralateral kidney normal?

– What is the size of the renal pelvis (TPD)?

– Are the calyces dilated?

– Is the kidney big or small?

– Is there a ureter visible?

The Management of antenatal pelviectasis – are we there yet?

Investigation and follow up • Isolated unilateral pelviectasis

– Is the contralateral kidney normal?• If yes, chill, if no find the Jewish mother (or nephrologist)

– What is the size of the renal pelvis (TPD)?• <10 mm chill, >15 mm renogram, between follow

– Are the calyces dilated?• May mean obstruction or dysplasia, go to next question!

– Is the kidney big or small?• If big then more likely to be obstructed

– Is there a ureter visible?• If yes could be reflux or VUJO or combination

The Management of antenatal pelviectasis – are we there yet?

Investigation and follow up • Bilateral pelviectasis

– MCUG– and then…..

The Management of antenatal pelviectasis – are we there yet?

So when can we make a diagnosis?

The Management of antenatal pelviectasis – are we there yet?

So when can we make a diagnosis?

The Management of antenatal pelviectasis – are we there yet?

So what can we say about antenatal pelviectasis

Start worrying……………

details to follow

The Jewish mother’s telegram (? Text now)