Posterior Urethral Valves
Making diagnosis in a newborn is not an easy business especially when symptoms are non-specific. The normal culprits are neonatal sepsis. But what happens when things are a bit off and you cannot just say it is "neonatal sepsis"?
(Borrowed from Pinterest)
Bouncing baby boy is born preterm at 35 weeks. No significant event in the antenatal period. Mother's ANC profile was unremarkable: a 32 year old, para 2+ 1 then, with no co-morbidities. No obstetric ultrasound done in the pregnancy period. Events resulting to premature labor not clear. Fetal distress not reported.
At birth baby scores 6/1, 7/5 and 8/10. BVM resuscitation done. Baby taken to nursery with a diagnosis of mild birth asphyxia. Placenta found to be normal. No signs of prematurity from examination of neonate, finstrom score of > 38.
In nursery baby does well. No other events to support birth asphyxia. Baby weaned off oxygen after 24 hours, breastfeeding well. On day 3, some abdominal distention noted. Mother reports baby has not been passing stool but has been passing urine, baby had however passed meconium. On examination, abdomen is distended and soft. Bowel sounds are present. Decision made to insert a flatus tube. Some stool is passed but abdominal distention still present. Aspirate from feeding tube contains milk. Vital parameters remain normal. NEC is ruled out. Thoughts focus on increasing gut motility by giving erythromycin, keeping flatus tube and normal saline enema. No improvement in symptoms. Baby now is irritable.
Blood is taken for Complete Blood Count and urea, electrolytes and creatinine on day 6 of life. CBC is essentially normal but there is serious derangement in UECS, with urea of 32.50, Creatinine of 673, Potassium of 10.9 and sodium of 112.0. Re-examination of abdomen is done, consistency of abdomen found to be different with hard mass felt in lower abdomen while rest of abdomen essentially soft and bowel sound present. A urethral catheter inserted to check whether it is urine retention. 80 cc of urine drained. Abdominal distention slightly subsides. Ascites!
(Borrowed from link.springer.com)
Efforts focus on establishing the cause of urine outlet obstruction and correcting the AKI. At this point an impression of posterior urethral valves is made. Baby is taken for an ultrasound scan which confirms the posterior urethral valves plus, significant thickening of bladder wall with key hole sign positive, grade 4 hydronephrosis.
Urethral catheter maintained to help in
passing urine. UECS improve remarkably as below. The abdominal distention resolved.
Date
|
Urea
|
Creatinine
|
Na
|
K
|
27/01/19
|
32.5
|
673.0
|
112.0
|
10.9
|
29/01/19
|
31.70
|
365.0
|
134.0
|
5.9
|
30/01/19
|
12.4
|
209.0
|
139.0
|
6.6
|
3/02/19
|
11.3
|
108
|
141.0
|
5.5
|
Baby was referred to the national hospital for primary valve ablation.
