NICU Case Study (TAR)

Maternal History

UVA Nursing Seminar III GNUR 6626 Sydney Stryker RN, BSN, C-ELBW, RNC-NIC, RNC-LRN, N-NNIC

Differencial Diagnosis

Admission

Problem List

PubMed

Clinical Course

Labs

Hydronephrosis

Sources

Question 1

Question 2

Physical Exam

Hydronephrosis Case Study

Hydronephrosis in newborns often presents with no outward symptoms. This is because the blockage or reflux may be mild and not cause significant impairment to kidney function. However, in some cases, there can be some physical signs or symptoms that indicate a more serious condition. Here's a list of some clinical characteristics of hydronephrosis in a newborn:

• Abdominal swelling: This can be a sign of a severe blockage in the urinary tract that is causing urine to back up into the kidneys.
• Urinary tract infection (UTI): Newborns with hydronephrosis may be more susceptible to UTIs, which can cause fever, poor feeding, vomiting, and lethargy.
• Mass in the abdomen: In some cases, a hydronephrotic kidney can be felt as a mass in the abdomen during a physical examination.

Clinical Characteristics

• RFP

• CBC

• BC

Age: 11 days at PMA 37w1d

Lab Trends

• Prenatal US
• Obstruction --> Oligohydraminos --> lung development
• Voiding Cystourethrogram (VCUG): uses x-rays to show how urine flows through the bladder and urethra
• Radionuclide Scan: creates images of the urinary tract as a radioactive substance passes through

Diagnosis/Testing

Admission

• SVD
• 35w4d
• Cord clamping was delayed for 60 seconds
• Clear Fluid
• APGAR 8 and 9 at 1 and 5 minutes
• Resuscitation included: Stimulation and bulb suction
• Admitted to the NICU for further workup for hydronephrosis and possible posterior valves
• Admission Measurements

FEN

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FEN

Current Problem List

• Premature infant of 35 weeks gestaion
• Hydronephrosis, bilateral s/p cutaneous-vesicostomy
• Posterior urethral valves (PUV)
• Newborn affected by oligohydraminios
• LGA Infant
• Posterior urethral valve determined by voiding cystourethrography (VCUG)
• Pulmonary artery stenosis of peripheral branch
• E. coli UTI

Yalçınkaya, F., & Özçakar, Z. B. (2020). Management of antenatal hydronephrosis. Pediatric nephrology (Berlin, Germany), 35(12), 2231–2239. https://doi.org/10.1007/s00467-019-04420-6

Key summary points

• Antenatal hydronephrosis is the most frequently detected abnormality by prenatal US and its outcome depends on the underlying etiology.

• There is still no consensus for the evaluation and management of patients with AHN.

• Mild isolated AHN represents up to 80% of the cases and generally regarded as a self-limited condition.

• Conservative approach with careful close follow up for patients with asymptomatic VUR and UPJO is generally recommended in recent years.

Management of Antenatal Hydronephrosis

• Ureteropelvic junction (UPJ) obstruction: This occurs when there is a blockage at the point where the ureter meets the renal pelvis. It can be due to intrinsic narrowing or extrinsic compression.
• Vesicoureteral reflux (VUR): In VUR, urine flows backward from the bladder into the ureters and sometimes up to the kidneys, which can lead to dilation of the renal pelvis and ureters.
• Posterior urethral valves (PUV): PUV is a condition where flaps of tissue in the urethra obstruct urine flow, leading to bladder outlet obstruction and subsequent hydronephrosis.
• Megaureter: This is an abnormal dilation of the ureter, which can be congenital or acquired. It may result from abnormal peristalsis or a functional obstruction.
• Multicystic dysplastic kidney (MCDK): This congenital condition involves abnormal development of the kidney, leading to the formation of multiple cysts and non-functional renal tissue. Hydronephrosis can occur due to the dilation of cysts.
• Duplex kidney: In this condition, there is a duplicated collecting system, leading to two ureters draining a single kidney or each draining a separate portion of the kidney. Obstruction in one or both of the ureters can cause hydronephrosis.
• Prune belly syndrome: This rare congenital disorder involves underdeveloped abdominal muscles, urinary tract abnormalities, and often, bilateral hydronephrosis.
• Neurogenic bladder: Conditions such as spinal cord abnormalities or spinal dysraphism can lead to neurogenic bladder dysfunction, causing urinary retention and subsequent hydronephrosis.

Differencial Diagnosis

Nguyen HT, Benson CB, Bromley B, et al. Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system). Journal of Pediatric Urology. 2014;10(6):982–998. [Al-Salem AH. Chapter 2: Hydronephrosis in infants and children. In: An Illustrated Guide to Pediatric Urology. Cham, Switzerland: Springer International Publishing, 2017. 43–69. Baskin LS. Overview of fetal hydronephrosis. UpToDate website. www.uptodate.com/contents/overview-of-fetal-hydronephrosis External link. Updated December 20, 2018. Accessed January 15, 2019 Yalçınkaya F, Özçakar ZB. Management of antenatal hydronephrosis. Pediatr Nephrol. 2020 Dec;35(12):2231-2239. doi: 10.1007/s00467-019-04420-6. Epub 2019 Dec 6. PMID: 31811536.

Pertient Systems

• FEN
• Urology/Nephrology
• Respiratory
• Cardiovascular
• Infecious Disease
• Pain and Sedation

• Prophylactic Antibiotics
• Foley for strict I&Os
• Wait and See
• Surgical Mangement:
• Vesicostomy: small opening, or stoma, is created in the bladder wall to provide an alternative route for urine drainage.
• Typically performed in cases where there is severe bladder outlet obstruction, such as posterior urethral valves (PUV).

Management

What is hydronephrosis in newborns?Hydronephrosis in newborns is enlargement, or dilation, of the renal pelvis—the basin in the central part of the kidney where urine collects. Hydronephrosis can occur in one or both kidneys. This condition is often diagnosed before birth during a prenatal ultrasound. In some cases, hydronephrosis is mild and goes away on its own without treatment. In other cases, hydronephrosis may be a sign of a blockage in the urinary tract or reflux—or back up—of urine from the bladder to the kidney that needs treatment. Males are about twice as likely as females to have hydronephrosis. In 1 or 2 out of every 100 pregnancies, the fetus is diagnosed with hydronephrosis. In about half of these cases, the hydronephrosis goes away by the time the infant is born.

• History of emeis and inability to tolerate feeds, likely dysomotility complicated by uremia.
• No malrotation noted on 3/10 upper GI. Now tolerating feeds with slow advance, no recent emesis.
• PICC TPN/IL +Carnitine TF 150ml/kg/day
• MHM/DHM 45ml/kg/day PO/NG
• Continue decrease protien at 2gm/kg per nephrology due to elvated BUN

FEN

Maternal History

32 y.o. G4P1112

• Prenatal US dignosed hydronephrosis and possible PUV
• Oligohydraminos

• Prenatal Labs
• Betamethasone x2

Physical Exam

By Systems

• Nuero
• HEENT
• Neck
• Chest
• CV
• Abdomen
• Back
• GU
• Extremities
• Skin