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ISSN: 1476-7058 (print), 1476-4954 (electronic)

J Matern Fetal Neonatal Med, Early Online: 1–5


! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.996125

ORIGINAL ARTICLE

The diagnostic value of routine antenatal ultrasound in screening


for congenital uropathies
Anne M. de Grauw1,2, Herman T. den Dekker1,3,4, Amerik C. de Mol1, and Sabina Rombout-de Weerd5
1
Department of Pediatrics, Albert Schweitzer Hospital Dordrecht, The Netherlands, 2Department of Pediatrics, Leiden University Medical Centre
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Leiden, The Netherlands, 3Department of Pediatrics, Division of Respiratory Medicine, Erasmus MC – Sophia Children’s Hospital Rotterdam,
The Netherlands, 4Department of Epidemiology, Erasmus MC Sophia – Children’s Hospital Rotterdam, The Netherlands, and 5Department of
Gynaecology, Albert Schweitzer Hospital Dordrecht, The Netherlands

Abstract Keywords
Background: Antenatal hydronephrosis (ANH) is characteristic for congenital obstructive Counseling, hydronephrosis, prenatal
abnormalities of the urinary tract (COAUT). COAUT is the most common cause of urinary diagnosis, ultrasonography,
tract infections (UTI’s) in newborns. The prognosis of mild to moderate ANH is unclear. The aim urinary tract infections
of this study was to determine the diagnostic value of antenatal ultrasound screening for ANH
in order to inform patients correctly. History
Methods: A retrospective cohort study over the period 2009–2011, evaluating all structural
ultrasounds and proven cases of ANH. Also, evaluation of all patients diagnosed with UTIs Received 24 October 2014
Revised 20 November 2014
For personal use only.

caused by COAUT in the same period.


Results: About 7003 children underwent antenatal screening. Of them, 0.7% (n ¼ 47) were Accepted 4 December 2014
diagnosed with ANH. In the same period, 257 children without ANH had a proven UTI. Of them, Published online 26 December 2014
4.3% (n ¼ 11) were diagnosed with COAUT, which was not found during antenatal screening.
The predictive value of the antenatal ultrasound was higher in the third trimester than the
second trimester (sensitivity 0.97 versus 0.62, respectively).
Conclusion: Antenatal ultrasound screening is a reliable method in diagnosing ANH. Third
trimester scanning is more specific for diagnosing ANH than second trimester scanning.
Our findings allow collaborating gynecologists and pediatricians to inform patients more
accurately in the future after the antenatal detection of COAUT.

Introduction This often (41–88%) concerns a transient stage of ANH,


without clinical consequences [9].
Urinary tract infections (UTI’s), including cystitis and
The underlying causes of ANH range from ureteropelvic
pyelonephritis, are among the most common bacterial infec-
junction stenosis to posterior urethral valves. Early diagnosis
tions in childhood [1]. Besides preventing urosepsis, main
and proper postnatal investigation of these abnormalities
goal of treatment is prevention of recurrence of UTI’s and
potentially reduces morbidity [4]. It is unclear whether this
long-term complications including renal scarring, hyperten-
early treatment does also benefit renal function in children
sion, and impaired renal function [2,3]. Congenital obstruc-
with only mild or moderate ANH.
tive abnormalities of the urinary tract (COAUT) increase the
The natural history of ANH varies widely, although most
risk of UTI’s [4,5]. Antenatal hydronephrosis (ANH) is an
cases resolve spontaneously [9]. Some cases, however, mostly
early sign of COAUT. The reported incidence in all
caused by posterior urethral valves, can be life threatening and
pregnancies varies between 1 and 5% [6–9]. Up to 88.5% of
require close monitoring or even intra-uterine intervention.
COAUT is currently diagnosed by antenatal ultrasound
Urinary obstruction results in renal dysplasia and renal failure,
screening [10]. Approximately 50% of all anomalies detected
and pulmonary development might be influenced by the
by antenatal ultrasound comprise ANH, with the highest
decreased amount of amniotic fluid. Currently, interventions
prevalence (2.5–5%) in the second trimester of pregnancy.
are reserved for fetuses with posterior urethral valves and
oligohydramnios, or fetuses with solitary kidney and severe
ANH and oligohydramnios. Intervention is only recommended
in the second and the third trimester and is associated with
Address for correspondence: Anne M. de Grauw, Department of
Pediatrics, Albert Schweitzer Hospital Dordrecht, The Netherlands. significant morbidity and mortality [11,12]. This causes
Tel: +31 6 50964347. E-mail: A.M.de_Grauw@LUMC.nl uncertainty for physicians in counseling parents on their
2 A. M. de Grauw et al. J Matern Fetal Neonatal Med, Early Online: 1–5

child with ANH. The aim of this study was to determine the charts. Antenatal ultrasounds were registered using
diagnostic value of antenatal ultrasound screening for ANH, as Astraiaß [13] and our Obstetric en Gynaecological databases.
well as the outcome during childhood, in a large Dutch Ultrasounds were performed by trained gynaecologists or
teaching hospital. sonographers. In case of congenital abnormalities of the renal
tract, the Astraiaß chart was labeled. We evaluated all charts
Patients and methods for ANH diagnoses by routine structural ultrasound in the
In this retrospective cohort study, all children who were born second trimester. The DBC registration (Dutch financial
between 1 January 2009 and 31 December 2011 in our registration system for all medical diagnoses and procedures)
hospital were included for evaluation. All children who were was checked for pediatric renal and urinary tract ultrasounds
born in the same period and diagnosed with UTI’s caused by performed during the study period to control for any missing
(COAUT) were included for evaluation as well (postnatal data in the Astraiaß registration.
diagnosed group).
The Albert Schweitzer Hospital (ASZ) is a 537-bed Postnatal follow-up
university-affiliated teaching hospital in the Netherlands. By protocol, all children diagnosed with ANH were attended
Approximately 3000 clinical deliveries are performed each by a pediatrician directly after birth, and prophylactic therapy
year at the ASZ, which makes this hospital a main represen-
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(Amoxicillin/Clavulanic acid 40/5 mg/kg/d) was started.


tative clinical birth center in the Netherlands. This study was Patients underwent an ultrasound of the urinary tract and
approved by the hospital medical ethical committee. kidneys in their first week of life, but not earlier than 4 days
In the Netherlands, all pregnant women are offered a after birth, since relative dehydration during the first days
routine structural fetal ultrasound between approximately 18 might mask underlying abnormalities of the urinary tract [14].
and 22 weeks of gestational age. The Dutch national Postnatal ultrasounds of the urinary tract were performed by
guidelines of structural fetal ultrasound indicate that during specialized radiologists. Their findings were divided into (1)
the 20 weeks ultrasound at least the following items should be normal and (2) abnormal, which was based on multiple
reviewed: visualization of both kidneys, density of the renal criteria (sizes and dimensions, as well as structural aspects).
parenchyma, and diameter of the renal pelvis. If ANH is An abnormal postnatal ultrasound was considered as golden
detected, an extensive ultrasound including evaluation for standard for diagnosing COAUT.
lower urinary tract obstruction, renal dysplasia, and extrarenal Based on the outcome of this postnatal ultrasonography,
For personal use only.

structural malformations is performed. This evaluation will individual follow-up took place and further imaging was
then be repeated in the third trimester. In case of congenital performed. This included voiding cystourethrogram (VCUG),
abnormalities such as ANH, patients are referred to an mercaptoacetyltriglycine (MAG-3 scan), and/or a Di-Mercapto
obstetrician for further evaluation and follow-up. In case of Succinic Acid (DMSA) scintigraphy. Further therapeutic
persistent ANH in the third trimester, mothers will deliver in a or prophylactic treatment was considered by a pediatric
clinical setting (instead of a home delivery with a midwife). In nephrologist.
case of bilateral urinary tract anomalies or additional
anomalies (other than the urinary tract), patients are referred Postnatal-diagnosed anomalies of the urinary tract
to a university medical center for delivery and follow-up.
Routinely, all children who were diagnosed with UTI in the
Exclusion first years of life were offered abdominal ultrasound for
COAUT. The hospitals DBC system was checked for any
Patients were excluded when meeting one or more of the diagnosis of UTI’s including pyelonephritis, and/or renal
following exclusion criteria: (1) proven syndromal disorder, ultrasounds during the study period. All charts were inde-
(2) multiple congenital anomalies (not restricted to the renal pendently evaluated for COAUT by two observers.
and urogenital tract), (3) UTI’s based on abnormalities of the
external genitalia (e.g. phimosis and hypospadia), (4) patients
referred to university medical centers during pregnancy, and Analysis
(5) patients born with only one functional kidney. Differences between antenatal and postnatal ultrasounds, and
the antenatal and postnatal diagnosed groups, were tested with
Definitions the 2-test for dichotomous variables and the Student t-test for
ANH was defined as an anterioposterior diameter (APD) of continuous variables. Results are expressed as means and
the renal pelvis 45 mm before a gestational age of 24 weeks, corresponding 95% confidence intervals (CI’s). Results with a
and/or 410 mm at a gestational age 430 weeks. UTI’s were p value 50.05 were considered statistically significant. All
defined as by bacterial culture proven infections of the urinary statistical analyses were performed using SPSS 21.0 (SPSS
tract. In case of voiding urine, a bacterial culture should show Inc, Chicago, IL).
4105 bacteria after 48 h of incubation should show 4103
bacteria. In case of catheter urine, a bacterial culture should Results
show 4103 bacteria. During the study period, structural ultrasounds were performed
in 7003 mothers in their second trimester of pregnancy. In 47
Data extraction
cases (0.7%) ANH was diagnosed (Table 1). Of these cases,
Patient characteristics were collected using the hospitals 66% was male. Four children (9%) with ANH had a
electronic patient’s registration system and the paper patient normal renal anatomy, and seven (15%) had only a mild,
DOI: 10.3109/14767058.2014.996125 A multidisciplinary evaluation 3
Table 1. Overview of the antenatal and postnatal diagnosed groups with COAUT.

Antenatal Postnatal
diagnosed diagnosed
(N ¼ 47) (N ¼ 11) p valueô
Diagnosis N (%) N (%)
UPJ-stenosis 14 (29.8) 2 (18.2) 0.44
Uretral valves 2 (4.3) 1 (9.1) 0.67
Primary obstructive mega-ureter 5 (10.6) 4 (36.4) 0.03
Multicystic dysplastic kidney 10 (21.3) – NA
Double collecting system 2 (4.3) 3 (27.3) 0.01
Unsignificant pelvic dilatation 7 (14.9) – NA
Sub-pelvic stenosis 1 (2.1) – NA
Extrarenalpyelum 1 (2.1) 1 (9.1) 0.26
Solitary kidney 1 (2.1) – NA
No congenital anomalies 4 (8.5) – NA
Vesico-ureteral reflux (%) 8 (17.0) 9 (81.8) 50.001
Complications* 9 (19.1) 11 (100)** NA
Surgical correction 11 (23.4) 3 (27.3) 0.79
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NA, not applicable. ôCalculated with the 2-test for dichotomous variables/Student t-test for
continuous variables.
*Recurrent UTI’s/pyelonephritis.
**By definition diagnosed with UTI’s/pyelonephritis.

Table 2. Postnatal follow-up of ANH. follow-up was done with MCUG, MAG3, and DMSA-
scanning. Ultimately, six patients (12.8%) developed severe
Ultrasound N ¼ 47
renal damage and scarring, as detected by DMSA. VUR was
Age in days (mean, range) 6.0 (1–45) registered in eight patients (17.0%).
Affected side In the same period, 4.3% (n ¼ 11; 73% male) with an
Left 19 (40.4)
For personal use only.

Right 15 (31.9) UTI was diagnosed with structural anomalies of the urogeni-
Both 13 (27.7) tal tract, which had not been found by antenatal screening.
Renal parenchyma Children in the postnatal diagnosed group were significantly
Normal 33 (70.2)
more often diagnosed having VUR compared with the
Cystic 7 (14.9)
Abnormal 2 (4.3) antenatal diagnosed group (17% versus 82%, p value50.001).
Not reported 5 (10.6) Primary obstructive mega-ureters and renal double sys-
Dilatation in millimeters (mean) tems were also more often diagnosed after presenting
Left 18.7
Right 13.4
with UTI compared with antenatal diagnosed abnormalities
(Table 1).
MCUG N ¼ 41
Age in months (mean, range) 1.1 (1 d–4.5 months)
VUR 8 (19.5) Diagnostic value
MAG3 N ¼ 20 If ANH was diagnosed in the second trimester, there was a
Age in months (mean, range) 3.7 (1–24) positive predictive value of 0.80 and a negative predictive
PUJ (%) 6 (30.0) value of 0.99 for postnatal diagnosed obstructive abnormal-
POM (%) 3 (15.0) ities of the urinary tract. The sensitivity and the specificity for
DMSA N ¼ 11 an abnormal postnatal ultrasound scan were 0.62 and 0.99,
respectively.
Age in months (mean, range) 7.1 (0.5–48)
Scarring (%) 6 (54.5) ANH diagnosed in the third trimester provided a positive
predictive value of 0.85 and a negative predictive value of
0.99 for postnatal diagnosed abnormalities of the urinary
tract. The sensitivity and the specificity for an abnormal
clinical non-significant dilatation of the pyelum at postnatal postnatal ultrasound scan were high (0.97 and 0.99,
ultrasound. None of these cases had a renal pelvis diameter respectively) (Table 3).
55 mm at ultrasound in the third trimester of the pregnancy.
However, ANH in the third trimester of pregnancy (gestational
Outcome
age 430 weeks) is defined as an anterio-posterior diameter of
the renal pelvis 410 mm. Using this definition, 63% still had Nineteen percent (n ¼ 9) of the patients in the ANH group
AHN at time of measurement in the third trimester. Postnatal developed at least one UTI during the study period. About
ultrasound was performed according to the protocol in the first 23% (n ¼ 11) of patients with ANH needed surgical interven-
days after delivery (Table 2). Thirty-three patients (70.2%) did tion, compared with 27% (n ¼ 3) in the postnatal diagnosed
not have any damage of the renal parenchym, whereas seven group (p value: 0.79). None of the patients suffered from
patients had cystic malformations. Further investigation and severe renal failure.
4 A. M. de Grauw et al. J Matern Fetal Neonatal Med, Early Online: 1–5

Table 3. Diagnostic values of second and third trimester for a cohort of 234 neonates with ANH over a follow-up
ultrasound screening.
period up to 13 years. 182 children were managed conserva-
Second
tively and 137 were found to have stable or even improved
trimester Third trimester renal function.
ultrasound ultrasound Our results demonstrate that a third trimester ultrasound is
Positive predictive value 0.80 0.85 more specific for diagnosing antenatal uropathy than a second
Negative predictive value 0.99 0.99 trimester screening. Ismaili et al. [14] demonstrated the same
Sensitivity 0.62 0.97 higher specificity in third trimester scanning in a Belgian
Specificity 0.99 0.99
population. Our study findings should be taken into account
in the possible future implementation of a structural third
trimester scan for all pregnancies, which is by this time no
routine in the Netherlands.
Discussion
The vast majority of ANH resolves spontaneously without
Our results demonstrate that antenatal ultrasound is a reliable intervention or complications; however, its presentation can
method in diagnosing ANH. Third trimester ultrasound be worrisome for counseling physicians and parents. Even
is more sensitive for ANH than second trimester scanning. more, our follow-up period is too short to draw conclusions on
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The single most used parameter for diagnosing ANH is the late effects like hypertension.
APD of the renal pelvis. It has been demonstrated that the Given this fact, it is important to realize that hydrone-
APD is an objective parameter with small intra-observer and phrosis represents a spectrum, and it is very important to
inter-observer variation [15,16]. APD is influenced by several differentiate in future studies which cases of ANH present the
factors, including gestational age, gender, and the degree of greatest risk for developing postnatal pathology and require
bladder distention. Our study design was only differentiated follow-up and potential intrauterine intervention.
on gestational age. In the current literature, there is
no consensus on what should be considered an optimal Conclusion
APD-threshold for ANH [17]. We used the definition by
Our results demonstrate that antenatal ultrasound is a reliable
Lee et al. [18].
method in diagnosing ANH. Third trimester scanning is more
Mild dilatation of the pelvis is considered a benign
specific for diagnosing ANH than second trimester scanning.
For personal use only.

condition. In our population, 24% of cases of ANH were


Routinely performed third trimester ultrasound scan with
either not confirmed by postnatal radiology or only mildly
specific assessment of the fetal kidneys could, therefore,
dilated without clinical consequences. A systematic review by
improve the detection rate of congenital uropathy. Our
Passerotti et al. [19] reported an average spontaneous
evaluation makes it possible to inform patients more accur-
resolvement of ANH in 62% of patients. This difference
ately in the future after the antenatal detection of COAUT.
might be explained by the diagnostic criteria of ANH we used.
We used a cut-off value of 45 and 410 mm (second and third
trimesters, respectively), whereas many articles define44 mm Declaration of interest
in the second trimester, and47 mm in the third trimester as cut- The authors report that they have no conflicts of interest.
off values.
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