The authors present an overview of lower urinary tract obstruction (LUTO) in the fetus with a particular focus on the insult to the developing renal system. Diagnostic criteria along with the challenges in estimating long-term prognosis are reviewed. A proposed prenatal LUTO disease severity classification to guide management decisions with fetal intervention to maintain or salvage in utero and neonatal pulmonary and renal function is also discussed. Stage I LUTO (mild form) is characterized by normal amniotic fluid index after 18 weeks, normal kidney echogenicity, no renal cortical cysts, no evidence of renal dysplasia, and favorable urinary biochemistries when sampled between 18 and 30 weeks; prenatal surveillance is recommended. Stage II LUTO is characterized by oligohydramnios/anhydramnios, hyperechogenic kidneys but absent renal cortical cysts or apparent signs of renal dysplasia and favorable fetal urinary biochemistry; fetal vesicoamniotic shunting (VAS) or fetal cystoscopy is indicated to prevent pulmonary hypoplasia and renal failure. Stage III LUTO is oligohydramnios/anhydramnios, hyperechogenic kidneys with cortical cysts and renal dysplasia and unfavorable fetal urinary biochemistry after serial evaluation; fetal vesicoamniotic shunt may prevent severe pulmonary hypoplasia but not renal failure. Stage IV is characterized by intrauterine fetal renal failure, defined by anhydramnios and ultrasound (US) findings suggestive of severe renal dysplasia, and is associated with death in 24 h of life or end-stage renal disease (ESRD) within the first week of life; fetal vesicoamniotic shunt and fetal cystoscopy are not indicated.
Yolk-sac tumors account for about 20% of ovarian germ cell tumors and occur predominantly in women below 35 years of age. Modern evidence-based treatment strategies have ensured long term post-treatment survival, but with increased survival, attention has been turned to an urgent need for developing fertility sparing treatment strategies. In this report we describe the successful treatment of a young woman who was able to conceive and deliver two children, in spite of the loss of one ovary two years prior to being diagnosed with an ovarian yolk-sac tumor on the remaining ovary.
INTRODUCTION: Report on one institution's experience with diagnosis, management, and outcomes in vasa previa cases. METHODS: Retrospective study of all pregnancies referred to two tertiary hospitals from 2010 to 2016 for suspicion or high risk for vasa previa. Medical records and imaging were reviewed by multiple authors to confirm diagnosis and assess outcomes. RESULTS: 408 pregnant women were referred for evaluation of suspected vasa previa. 380 (93%) were not diagnosed with vasa previa after ultrasonography. Of the 28 confirmed cases, 20 (71%) and 8 (29%) were diagnosed as Type 1 and Type 2 vasa previa respectively. In 9 (32%) women, vasa previa resolved spontaneously after a mean 5.8 plus or minus 3.9 weeks. Unresolved cases were diagnosed on average at 25.9 plus or minus 5.2 weeks. Delivery occurred at 33.4 plus or minus 2.9 weeks on average. 13 (68%) neonates from unresolved vasa previa cases required NICU admission. Neonates had an average 5 minute Apgar score of 9. Only 1 fetus expired, but death was attributable to complications from a pericardial teratoma prior to delivery. One Type 2 case received antepartum laser obliteration of fetal vessels that successfully prolonged pregnancy. Average maternal blood loss was 860 plus or minus 56 cc with no ICU admissions or maternal deaths. CONCLUSION: In this large series, we display the continued improved maternal and neonatal outcomes in vasa previa. In equipped centers, physicians are able to successfully manage and deliver fetuses with careful antepartum attention. Furthermore, one case's treatment with laser ablation suggests a possible intervention in some presentations.
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