>> THE DIAGNOSIS OF LOWER URINARY TRACT OBSTRUCTION IS
TYPICALLY MADE AT THE TIME OF AN ULTRASOUND EVALUATION.
>> NORMAL PRENATAL ULTRASOUND SCREENING IS
GENERALLY DONE IN THE MID-SECOND TRIMESTER.
>> UNLIKE A TYPICAL ULTRASOUND WHERE YOU SEE
BLACK, WHICH IS FLUID AROUND THE BABY,
THERE WAS NO FLUID AROUND THE BABY.
ALL OF THE FLUID WAS IN HIS BLADDER AND IT WAS ENORMOUS.
>> CLEARLY, IF THERE IS SOMETHING ABNORMAL THAT'S
RECOGNIZED WITH RESPECT TO THE KIDNEYS OR THE BLADDER,
THE SOONER THAT WE CAN SEE THOSE FAMILIES AND THE
SOONER THAT WE CAN DO IMAGING OF THAT FETUS,
THE BETTER OFF WE THINK THAT WE ARE.
>> PRENATAL DIAGNOSIS AS WELL AS EVALUATION OF
FETUSES WITH LUTO REALLY REQUIRES A
MULTIDISCIPLINARY TEAM OF SPECIALISTS.
>> OUR TEAM, OF COURSE, HAS GREAT EXPERTISE WITH
THE MEDICAL ISSUES, BUT IT GOES WAY BEYOND THAT.
IT'S SORT OF, WE SPIN A HUGE SAFETY NET TO DEAL WITH ALL
THE NEEDS OF THE FAMILY.
>> THAT FAMILY RECEIVES SUPPORT NOT ONLY FROM
A MEDICAL PERSPECTIVE, BUT ALSO FROM A FAMILY
PERSPECTIVE.
>> WE WANT THE FAMILIES TO JUST BE CONCERNED WITH THE
MEDICAL ISSUES AND NOT ALL THE OTHER SUPPORT-RELATED
SORTS OF ISSUES.
>> THE GOAL IS TO PROVIDE FAMILIES WITH THE
INFORMATION THAT'S NEEDED FOR THAT PARTICULAR FAMILY
TO MAKE AN INFORMED DECISION ABOUT THEIR FETUS AND ABOUT
THEIR PREGNANCY, WHETHER THAT BE POTENTIAL IN UTERO
TREATMENT OR WHETHER THAT BE LETTING NATURE TAKE ITS COURSE.
>> WHEN THEY COME TO SEE US, WE DO A COMPREHENSIVE
DIAGNOSTIC EVALUATION.
>> THE KEY STEPS ARE TO CONFIRM THAT THE BABY IS A MALE.
>> A LOWER URINARY TRACT OBSTRUCTION IN THE CONTEXT
OF A FEMALE FETUS TYPICALLY REFLECTS A CLOACAL
ABNORMALITY, WHICH IS A MUCH MORE COMPLEX ANOMALY THAT
WILL ACTUALLY NOT BENEFIT FROM IN UTERO INTERVENTION.
>> IT'S IMPORTANT TO CONFIRM THAT THERE ARE NO OTHER
MAJOR BIRTH DEFECTS OR ABNORMALITIES THAT WOULD
ALTER THE SURVIVAL OR LONG-TERM OUTCOME OF THAT BABY.
>> SO FETAL CARRIER TYPING, EITHER THROUGH AN
AMNIOCENTESIS OR CVS, IS VERY IMPORTANT TO DOCUMENT NORMAL
FETAL CHROMOSOMES.
WE ALSO PERFORM AN ULTRASOUND AND AN
ECHOCARDIOGRAM.
>> TO ASSESS THE URINARY TRACT OBSTRUCTION AND TO
ALSO MAKE CERTAIN THAT THERE'S NOTHING ELSE WRONG.
>> WE NEED TO MAKE SURE THERE'S NO MAJOR CARDIAC
ANOMALIES OR OTHER ORGAN SYSTEMS INVOLVED,
BUT WE REALLY, REALLY HAVE TO LOOK AT THE URINARY TRACT
CAREFULLY.
WE HAVE TO LOOK AT WHAT DOES THE BLADDER LOOK LIKE.
IS IT SHOWING THE CHARACTERISTIC THICKENING
OF THE MUSCLE WALLS?
WE HAVE TO LOOK AT WHAT ARE THE URETERS DOING.
ARE THEY DILATED?
>> IF YOU BEGIN TO SEE THAT THE KIDNEYS LOOK,
ON ULTRASOUND, WHITER OR BRIGHTER THAN IS NORMAL,
THAT TENDS TO SUGGEST THAT THERE MAY BE UNDERLYING
ABNORMALITIES.
>> THE KEY THING WE LOOK FOR ARE THE PRESENCE OF CYSTS ON
THE OUTER PART OF THE KIDNEY BECAUSE A PRESENCE OF CYSTS
INEVITABLY MEANS THAT THERE'S IRREVERSIBLE DAMAGE
IN THE KIDNEY AND THERE IS NO WAY TO SALVAGE THAT KIDNEY.
>> LASTLY, WE NEED TO STUDY THE RENAL FUNCTION BY SERIAL
URINE SAMPLINGS.
>> A BLADDER TAP, USUALLY SERIAL BLADDER TAPS,
TWO, THREE TIMES OVER DAYS TO ASSESS THE FETAL URINARY
COMPOSITION.
>> WE CAN TAKE THAT URINE AND SEND IT TO THE
LABORATORY AND LOOK AT DIFFERENT ELECTROLYTES AND
PROTEIN MARKERS.
THE MORE STUFF THAT'S IN THE URINE,
THE WORSE THE FUNCTION OF THE KIDNEYS.
>> IN SOME CASES, THE KIDNEYS ARE ALREADY
DESTROYED AND THERE'S NOTHING WE CAN DO ABOUT IT.
>> BUT WHAT WE LEARNED OVER THE LAST DECADES IS THAT YOU
REALLY HAVE TO DRAIN THE BLADDER MORE THAN ONCE
BECAUSE THE FIRST TIME YOU DRAIN THE URINE FROM THE
BLADDER, THAT REPRESENTS URINE THAT MAY HAVE BEEN
THERE FOR DAYS OR WEEKS AND IS REALLY,
DOESN'T REFLECT THE ABILITY OF THE KIDNEY TO FUNCTION.
AND SO IF YOU GET RID OF THAT FIRST AMOUNT OF URINE
AND ALSO LOOK TO SEE HOW RAPIDLY THE BLADDER WOULD
REFILL WITH URINE, THAT POTENTIALLY COULD TELL YOU
THAT THE KIDNEYS WERE ACTUALLY WORKING OK,
AND IF THERE WAS SERIAL IMPROVEMENT IN THE
ELECTROLYTES THAT WOULD TEND TO BE A GOOD PROGNOSTIC FACTOR.
>> IN ORDER TO BE ELIGIBLE FOR THE SHUNT PROCEDURE,
THERE STILL HAD TO BE GOOD REMAINING KIDNEY FUNCTION
AT THAT TIME.
>> THE RESULTS OF THE ULTRASOUND,
THE CONFIRMATION OF NORMAL CARRIER TYPE,
AND THE RESULTS OF THE URINE TESTING WILL REALLY
DETERMINE WHETHER OR NOT THAT BABY HAS A CHANCE OF
BENEFITTING FROM INTERVENTION OR WHETHER
INTERVENTION WON'T HELP.
>> THERE ARE SOME CASES WHERE WE SIMPLY CAN'T HELP,
WHERE THE DAMAGE HAS ALREADY BEEN DONE,
WHERE WE'RE TOO LATE TO DO ANYTHING ABOUT IT.
>> AND IN THOSE CASES, FAMILIES MIGHT CHOOSE TO
TAKE THE PREGNANCY TO TERM WITH POTENTIAL PALLIATIVE
CARE OR FAMILIES MIGHT CHOOSE TO END THE PREGNANCY.
>> THE FAMILY HAS THE INFORMATION THAT THEY NEED.
THEY HAVE THE COUNSELING THEY NEED.
THEY HAVE THE SUPPORT THAT THEY NEED.
THEY KNOW THAT THEY HAVE DONE EVERYTHING POSSIBLE TO
TRY AND GIVE THAT BABY THE BEST POSSIBLE CHANCE.
>> FAMILIES LOOK TO US, LOOK TO OUR MEDICAL TEAM AND TO
OUR EXPERTISE AT THE CENTER FOR FETAL DIAGNOSIS AND
TREATMENT TO BE ABLE TO GUIDE THEM IN TERMS OF WHAT
THIS ANOMALY MEANS FOR THEIR FETUS.
WHETHER OR NOT THERE ARE OPTIONS FOR PRENATAL
TREATMENT AND WHAT THE RISKS AND BENEFITS OF THOSE
OPTIONS ARE.