International Urology and Nephrology 12 (2), pp. 113--117 (1980)

Ultrasonographic Diagnosis in a Case of Fetal Hydronephrosis B. SZ6KE, A. VIT~Z, J. TdTI-I Departments of Obstetrics and Gynecology, Pediatry, and Urology, Council Hospital, Dunafijv~iros, Hungary (Received July 30, 1978)

A case of fetal hydronephrosis diagnosed by ultrasonography in the 32rid week of pregnancy is reported. The finding was confirmed by urography performed in the neonatal period. Early neonatal therapeutic intervention has been made possible by the prenatal detection of the abnormality.

Detection of malformations or developmental defects during fetal life was not possible until recently, partly because of the well-known radiation hazards. The use of diagnostic ultrasound - a non-invasive and entirely harmless procedure - has, however, brought a decisive change in this respect. The method, first applied in obstetrics in 1958, has become a routine procedure since that time by providing reliable information on the size of the fetus, the site of the placenta, multiple pregnancies, etc. It also detects certain congenital anomalies, in the first place hydrocephalus, anencephaly, fetal abdominal tumours, ascites, as well as hydramnion which is often associated with abnormalities of this kind [4, 5, 7, 8 ]. While some of these abnormalities, for instance anencephaly, are accessible to the method in the early stage of pregnancy, thus enabling action to be taken, some others are unidentifiable until a more advanced stage of pregnancy. The first case of hydrocephalus detected in utero by ultrasonography was reported by Donald in 1968 [1]. Garrett and his associates were the first to describe a case of fetal polycystic kidney diagnosed by this method [2]. Since that time numerous reports have been published [3, 6, 9, 10] on the successful use of diagnostic ultrasound for detection of various fetal malformations in utero. Case report The patient was a 24-year-old third gravida. Her first pregnancy terminated in the delivery of a healthy fetus, the second in a stillbirth in the 5th month. Her family history was unremarkable. The present pregnancy had been uneventful until the 32nd week. From this time on, her abdomen seemed to increase abnormally in size and she became anemic. She was referred from the prenatal clinic to ultrasonography because of suspicion of twin pregnancy. International Urology and Nephrology 12, 1980

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Sz6ke et al. : Ultrasonooraphy in fetal hydronephrosis

Ultrasonography was performed according to the practice well known from the literature, using a two-dimensional Combison-apparatus with a transducer of 1 MHz. On the longitudinal scan the biparietal diameter was consistent with the time of pregnancy, whereas the abdominal diameter was found larger than expected. In the fetal abdomen a well demarcated, sharply outlined, round, echo-free zone could be clearly discerned. On the cross-sectional scan the cystic structure, 9 x 8 x 6 cm in size, was brought out still more clearly. A polyhydramnion was demonstrable in both planes (Figs 1 and 2). After the detection of this fetal mal-

Fig. 1. The longitudinal scan shows a large round echo-free zone in the fetal abdomen

Fig. 2. Cross-sectional scan. The left side of the fetal abdominal cavity is occupied for the greatest part by a cystous structure. On the right side polyhydramnion is seen International Urology and Nephrology 12, 1980

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formation the mother was checked weekly also by ultrasonography, and uterine volume was measured on each occasion. In the course of follow-up normal development of the fetus and a slight enlargement of the fetal cystic structure were noted. Vaginal parturition in the 40th week of pregnancy, in the presence of a neonatologist, was uneventful. The newborn weighed 3600 g, in agreement with previous ultrasonographic estimation, and had an Apgar-score of 10-10. Her body length was 51 cm, circumference of the head 36 cm and biparietal diameter 9.6 cm. The percentile was 75-90/40 weeks. The general condition of the baby was satisfactory, but the broad, bulging abdomen was conspicuous. A well-demarcated elastic mass of smooth surface occupying the right lower quadrant of the abdomen was felt. Bowel sounds over the abdomen were abundant. Physical examination revealed no other abnormality. In the further course she was kept at the infant-unit. She fed normally without vomiting, the stools were normal. Ultrasonography revealed a large cystous structure involving the right kidney. Laboratory investigations. Hgb 17.0 g/100 mt; haematocrit 40 per cent; platelet count 240,000/cu.mm; leukocyte count 10,400/cu.mm. Urinalysis: negative; Se-CN 18 rag/100 ml; Se-creatinine 0.5 rag/100 ml. The urinary cultures yielded E. coll. The plain film of the abdomen showed displacement of both the large and the small intestines to the left side. The right side was occupied by a homogeneous density revealing no details indicative of a tumour. lnfusion urography. At the right side there was no excretion, in contrast to the left side, where excretion was normalinintensity and timing. The entire pelveocalyceal system was distended. The ureter was found to take its origin at the posterior side of the renal pelvis and to form a curve medially. There was contrast medium in the bladder (Fig. 3). Pyelography thus revealed a diffuse dilatation of the left pelveocalyceal system in the absence of any excretion at the right side. From the third week onward the infant was developing normally. Nevigramon (nalidixic acid) was administered because of bacteriuria revealed by sensitivity tests. On the 40th day of life she was transferred for surgery to the Department of Urology, Heim Pill Children's Hospital, Budapest. On exposure of the right kidney from right lumbotomy, distension of the renal pelvis to the size of an apple was found. It had the appearance of a taut fish-bladder topped by the renal substrate of cystous consistency. At the pyeloureteraljunction the ureter showed an oblique origin. After aspiration of the contents measuring approximately 70 ml in volume, the remaining renal parenchyma was scarcely thicker than the pelvic wall. The hilar structures and the ureter were International Urology and Nephrology 12, 1980

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SzSke et al.: Ultrasonography in fetal hydronephrosis

Fig. 3. Excretion urography. Pyelectasia on the left side, no excretion on the right side dealt with according to current practice. Six days after operation the sutures were removed. The surgical wound had healed by first intention. (The intervention was performed by Dr. J. Tdth, at the Department of Pediatric Urology of Helm Pal Children's Hospital.) Morphological study (Dr. Gorficz). The surgical specimen was made up of a hydronephros with a renal parenchymal rim of 1 - 2 mm breadth. Hydronephrosis had been caused by an oblique origin of the ureter with narrowing of the pelveoureteral junction. Onthe sections the renal capsule was increased in thickness, the cortical area and the renal parenchyma were narrow. Several glomerular and tubular elements were found, some of them of saccular distension. Increase in fibrous tissue was associated with sporadic round-cell infiltrations and diffuse tubular dilatation. Surgical repair of pyelectasia of the left side is considered at some later time. The infant has been under our observation since discharge. No pyuria has been found, the renal functions are normal. Somatic and mental development are satisfactory.

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Discussion Ultrasonography, which has been gaining g r o u n d as a routine procedure, has opened up new vistas in prenatal diagnostics. It detects certain malformations in early intrauterine life, thus enabling interruption o f pregnancy in due time. Even in case o f anomalies which elude detection until later stages o f pregn a n c y it m a y be instrumental in the identification o f abnormalities being accessible to surgical therapy in the early neonatal period. Previous knowledge o f the necessity for neonatal surgery improves the chances o f these interventions which m a y be life-saving in m a n y cases. U l t r a s o n o g r a p h y being free f r o m any h a z a r d is reproducible as often as necessary. As a simple and reliable procedure it also lends itself to follow-up studies.

References 1. Donald, I. : Ultrasonic in obstetrics. Brit. Med. Bull., 24, 71 (1968). 2. Garrett, W. J., Grunwald, G., Robinson, D. E.: Prenatal diagnosis of foetal polycystic kidney by ultrasound. Aust. N. J. Obstet. Gynec., 10, 7 (1970). 3. Kratochwil, A., Sch6n, R., Wiltschke, H.: Echographische Diagnose eines fetalan Abdominaltumors. Maximal geftillte Harnblase als Folge einer posterioren Urethralklappe. Geburtsh. u. Frauenheilk., 32, 506 (1972). 4. Kurjak, A.: The antenatal diagnosis of fetal malformations and abnormalities by ultrasound. Ultrasonic in Medicine, Excerpta Med., 1975, p. 304. 5. Lee, T. G., Blake, S. : Prenatal fetal abdominal ultrasonography and diagnosis. Radiology, 124, 475 (1977). 6. Okulski, T. A. : The prenatal diagnosis of lower urinary tract obstruction using B scan. J. Clin. Ultrasound, 5, 268 (1977). 7. Perlam, M., Potashnik, I., Wise, S. : Hydramnion and fetal renal anomalies. Amer. J. Obstet. Gynec., 125, 966 (1976). 8. Sabbagha, R. E., Depp, R. : Sonar, a tool for the detection of fetal congenital anomalies. Clin. Obstet. Gynec., 20, 279 (1977). 9. Santos-Ramos, R., Duenhoelter, J. H.: Diagnosis of congenital fetal abnormalities by sonography. Obstet. Gynec., 45, 279 (1975). 10. Tart6, S., Szab6, G., T6th, M. : A k6zponti idegrendszer fejl6d6si rendelleness6geinek felismer6se ultrahang vizsg~ilat segits6g6vel. Magy. N6"orv. L., 38, 563 (1975).

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International Urology and Nephrology 12, 1980