Obstetrica }i Ginecologia LXV (2017) 177-180 Case Report

BILATERAL HYDRONEPHROSIS – A CASE WITH AN

UNFAVORABLE OUTCOME
Gashi Astrit M.1, Ismajli Jakup 2, Gjocaj Curr3, Gojnovci Xhevdet4, RafunaNaser5,
Nuraj Petrit6

1 Department of Obstetrics and Gynecology, University Clinical Centre of Kosovo, Pristine

2 Emergency Department in Obstetrics and Gynecology Clinic, University Clinical Centre of
Kosovo, Pristine
3 Director of the Hospital and University Clinical Service of Kosovo
4 Neonatology Clinic, University Clinical Centre of Kosovo, Pristine
5 Pregnancy Pathology Department in Obstetrics and Gynecology Clinic, University Clinical
Centre of Kosovo, Pristine
6 Urology Clinic, University Clinical Centre of Kosovo, Pristine

Abstract

Hydronephrosis is characterized by dilatation of the collecting system of the kidney. Fetal hydronephrosis
is usually the expression of an obstruction of the urinary tract and, less frequently, of a nonobstructive pathology. In
our case, we have to do with bilateral hydronephrosis. This can be due to bilateral vesico-ureteric reflux and
urethral obstruction, which is usually associated with evident ureteral dilation. Review of the literature suggests
that in the first two years of life occurs spontaneous regression in approximately 40%–50% of cases and need for
surgery in 20%–30% of cases, according to the grade of hydronephrosis present during the prenatal period. The
cases with bilateral hydronephrosis associated with oligohydramnios, have unfavorable prognosis. We present a
case, with an iatrogenic preterm birth, because of congenital abnormalities of the kidney and urinary tract, but with
unfavorable outcome (death of the baby), from neonatal complications as prematurity and manifestation of Infant
respiratory distress syndrome (IRDS). Despite the adequate management with the timely diagnosis and therapy, the
baby died within a few hours.

Introduction

Hydronephrosis is characterized by dilatation the grade of hydronephrosis present during the

of the collecting system of the kidney. Fetal prenatal period. The cases with bilateral
hydronephrosis is usually the expression of an hydronephrosis associated with oligohydramnios,
obstruction of the urinary tract and, less frequently, have unfavorable prognosis.
of a nonobstructive pathology. In our case, we have Ther e are numerous causes of
to do with bilateral hydronephrosis. This can be due hydronephrosis such as;
to bilateral vesico-ureteric reflux and urethral · Uretero-pelvic junction (UPJ) obstruction
obstruction, which is usually associated with evident (unilateral or bilateral)
ureteral dilation. Review of the literature suggests · Vesico-ureteric junction obstruction
that in the first two years of life occurs spontaneous · Megaureter (with or without reflux)
regression in approximately 40%–50% of cases and (unilateral or bilateral)
need for surgery in 20%–30% of cases, according to · Cloacal dysgenesis
CORESPONDENCE: Astrit M. Gashi, email:astritgashi772@gmail.com
Obstetrica }i Ginecologia 177
KEY WORDS: Bilateral hydronephrosis; iatrogenic; preterm birth; Caesarian delivery;
neonatal complications; unfavorable outcome
 Bilateral hydronephrosis – a case with an unfavorable outcome
· Complicated duplex kidney (unilateral or
bilateral)
· Bladder and urethral obstruction (e.g.,
posterior urethral valves)
· Vesico-ureteric reflux (VUR) (unilateral or
bilateral
· Megacystis micr ocolon intestinal
hypoperistalsis syndrome
· Hydrometrocolpos
· Abdomino-pelvic masses
Hydronephrosis with or without dilation of
the ureters accounts for approximately 50% of all
prenatally detected renal abnormalities [1]., Its
incidence is 1–5 per 500 newborns. The sex of the
fetus is male.
For the ultrasound evaluation of a fetus with
abnormal dilatation of the urinary tract must take into
consideration various parameters:
· The time of beginning,
· The severity of the obstruction,
· The level and degree of dilation,
· The unilateral or bilateral,
· The nature of the damage,
· The volume of amniotic fluid, and
· Association with other congenital
malformations (these relate mainly to the contralateral
kidney and are represented by multicystic kidney,
ectopia, and renal agenesis, but also with extra-renal
anomalies include CHD, skeletal dysplasias, and spine
anomalies).
However, the functional damage caused by
the obstruction usually leads to a progressive dilation
of the pelvis, the calices, and the ureters. In severe
and early obstruction, the consistently increased
intraluminal pressure upstream of the obstruction
results in an irreversible loss of nephrons due to
ischemic damage.
The likelihood of a postnatal pathology
increases with the degree of renal pelvis dilatation:
· Mild (12%–14%), with the increase of the
anteroposterior diameter of the pelvis about 4 to 7
mm in the second trimester and 7 to 9 mm in the third
trimester.
· Moderate (45%), with the increase of the
anteroposterior diameter of the pelvis about 7 to 10
178 Obstetrica }i Ginecologia
mm in the second trimester and 9 to 15 mm in the
third trimester.
· Severe renal pelvis dilatation (90%), with
the increase of the anteroposterior diameter of the
pelvis > 10 mm in the second trimester and > 15 mm
in the third trimester [2].
The Society for Fetal Urology has developing
a grading system for the hydronephrosis, which is
used for children, but is often applied also for prenatal
diagnosis [3].
This grading system have IV grade:
· Grade I - when the dilatation is confined to
the renal pelvis,
· Grade II- when calyces are visible and a
moderate dilatation of pelvis and calyces is present
but confined within the renal borde,
· Gr ade III- when have a significant
dilatation of the pelvis and calyces is associated with
normal renal parenchymal thickness,
· Grade IV- when the renal pelvis is so dilated
as to cause cortical thinning.
Case Presentation
A 36-year-old woman pregnant, G2 P1,
presented at 27 weeks of gestation after two previous
visits elsewhere, as an outpatient in a gynecological
clinic. During an ultrasound examination was
discovered fetal hydronephrosis in both kidneys or
bilateral hydronephrosis. Also, ureteral dilation and
bladder overdistension was present (Figure 1, 2). We
evaluated that the cause was urethral obstruction.
Specifically, we are dealing with posterior urethral
valves (Figure 3). The anteroposterior diameter of
the pelvis on a transverse view of the abdomen was
6 mm. The amniotic fluid index (AFI) was 4 cm, so,
of easily reduced. Fetal Biometry responds to the
27th week of gestation, so, had not intrauterine growth
restriction (IUGR). Following identification of urinary
tract dilation, a detailed anatomic scan was performed
to exclude the presence of associated extra-renal
anomalies. The patient had made the amniocentesis
in the 19th week of gestation, that resulting in a normal
karyotype. The sex of the fetus was male. All routine
laboratory tests such as: complete blood count, urine
 Astrit M. Gashi
Figure 1 Coronal scan of a hydronephrotic fetal kidney in
a 27-week fetus, showing dilation of the pelvis, the calyces
are visible but not significantly dilated.
Figure 3 Posterior urethral valves. In a 27+3 weeks fetus,
a significant dilatation of the bladder and of the proximal
part of the urethra (arrow) is clearly seen.
analysis, and biochemical laboratory tests were
normal. Four years ago, the patient had a vaginal
delivery, who gave birth to a healthy male child.
During a careful inspection, hirsutism was noticed,
which the patient had been in for a long time with
this problem. This disorder had not caused any
problems with infertility. The patient was thoroughly
informed about the fetal diagnosis and received
adequate counseling for the delivery modus and
surgical intervention in the fetus immediately after
the birth. In consultation with the pediatric surgeon,
surgical correction was postponed until birth.
After corticosteroid regimens and
confirmation to lung maturity, and acceptable renal
function, preterm delivery with early ex utero surgery
is taken into consideration. After the end of the 30th
week of pregnancy, due to the fetal diagnosis
previously determined and the anhydramnios, with
the informed consent of both parents, are deciding to
Figure 2 Hydronephrosis and dilation of the ureter are
present
end a pregnancy with Caesarean section. On
17.07.2017, at 8:45 AM, the baby of the male sex is
born, with body weight 1700 grams, and Apgar score
was; 7 in the first minute, 8 in the fifth minute.
Because of the prematurity and
manifestation of the signs of Infant respiratory distress
syndrome (IRDS), the baby is transferred to the
Neonatal Intensive Care Unit. Initially, placed in nasal
CPAP masks, Blood is collected for laboratory
analysis and abdominal ultrasound is made. Results:
Complete blood count (CBC): Red blood cell count
(RBC): 3.87 million/mm3. Hemoglobin (Hgb): 13.8
g/dL. Hematocrit (Hct): 43.1 %.White blood cell
count (WBC): 16.4/mm3, Platelet count (Plt):229 /
mm3. Neutrophils: 42.2%, Lymphocytes: 51.4%,
Monocytes: 1.0%. Blood glucose: 4,2mmol/L. Arterial
Blood Gas: pH (acidity):7.07, pCO2 (partial pressure
of carbon dioxide): 99 torr., pO2 (partial pressure of
oxygen): 32 torr., Base excess (the loss of buffer
base to neutralize acid): ± 4.7 mEq/L.
The abdominal ultrasound reconfirms bilateral
hydronephrosis. Also,ureteral dilation and bladder
overdistension. The chest radiograph confirms
respiratory distress syndrome (RDS). The treatment
started according to the protocol with fluid, antibiotic
therapy, and surfactant administration. Even despite
therapy, the condition is constantly worsening the baby
is intubated and passes on mechanical ventilation. The
baby’s condition continues to worsen even further
until cardiac arrest, even despite reanimation
measures, the baby died. Ultrasound images showing
several different degrees of hydronephrosis;
Obstetrica }i Ginecologia 179
 Bilateral hydronephrosis – a case with an unfavorable outcome
Discussions
Ultrasound monitoring of fetuses with urinary
obstruction, has allowed the definition of some general
diagnostic criteria and algorithms for pre- and
postnatal management of such patients. But there
are still limitations in the diagnostic and therapeutic
approach e.g. is the inability of the sonographic
examination to fully define the extent and severity of
parenchymal damage and to forecast its outcome at
the time of initial diagnosis. To relieve prenatal urinary
tract obstruction, in some selected cases can be
performed the technical feasibility of in utero vesico-
amniotic shunting. While research for sensitive
biochemical markers (such as the value of serum
creatinine) that might accurately reflect the (residual)
fetal renal function have been unsuccessful for many
reasons. Management should therefore be limited to
serial ultrasound follow-up in utero and during the
first year after birth, associated with postnatal
biochemical evaluation of renal function. Review of
the literature suggests that in the first two years of
life occurs spontaneous regression in approximately
40%–50% of cases and need for surgery in 20%–
30% of cases, according to the grade of the
hydronephrosis present during the prenatal period
[4,5].
Conclusions
We present a case, with an iatrogenic
preterm birth, because of congenital abnormalities of
the kidney and urinary tract, but with unfavorable
180 Obstetrica }i Ginecologia
outcome (death of the baby), fr om neonatal
complications as prematurity and manifestation of
Infant respiratory distress syndrome (IRDS). Despite
the adequate management with the timely diagnosis
and therapy, the baby died within a few hours.
Conflict of Interests
All the authors not have any conflict of
interests.
Acknowledgments
We acknowledge the contribution of the
medical staff from the two units of the Hospital and
University Clinical Service of Kosovo, for their
assistance.
References
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