# MMIHS — GCMD Library living collection

Updated: n/a · 2 episodes · 72 cited statements

## Episodes
### Foundations
- [Overview of Prenatal Diagnosis: Cincinnati Fetal Center](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743) — video · 40:34 · [machine version](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743.md)

### Diagnosis & Workup
- [Prenatal diagnosis of fetal lower urinary tract obstruction: Fetal...](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919) — video · 40:14 · [machine version](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=0) Prenatal Ultrasound Evaluation of LUTO (Ep 2)
- [6:51](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=411) Differential Diagnosis and Mimics (Ep 2)
- [17:24](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1044) Renal Function Assessment and Prognostic Criteria (Ep 2)
- [27:56](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1676) Vesico-Amniotic Shunting: Technique and Outcomes (Ep 2)
- [38:06](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2286) Cases Where Intervention Is Not Indicated (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=0) Introduction and Pathophysiology of LUTO (Ep 1)
- [5:00](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=300) Ultrasound Evaluation and Diagnostic Criteria (Ep 1)
- [11:40](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=700) Differential Diagnosis and Special Cases (Ep 1)
- [18:20](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1100) Renal Function Assessment and Serial Bladder Drainage (Ep 1)
- [23:20](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1400) Gestational Age Considerations and Q&A (Ep 1)
- [28:20](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1700) Vesicoamniotic Shunting Technique and Evidence (Ep 1)
- [35:00](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2100) Long-term Outcomes and Cases Not Suitable for Intervention (Ep 1)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "The three major causes of LUTO are urethral atresia (complete obstruction with no communication from bladder neck through urethra), posterior urethral valves (flap of tissue in proximal urethra), and mid-urethral hypoplasia (significant tapering and narrowing that becomes progressive obstruction as pelvic anatomy matures)." — Mark (clinical) [Ep 2 · 0:32](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=32)
- "Incomplete urethral obstruction leads to progressive oligohydramnios until anhydramnios, resulting in physical deformations (joint contractures, flattened ears, Potter phenotype), pulmonary hypoplasia from inability to expand chest, and severe hydronephrosis with progressive renal fibrocystic dysplasia and renal failure." — Mark (clinical) [Ep 2 · 1:30](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=90)
- "In sheep model, early mid-gestational reversal of urethral obstruction prevented progressive dysplastic changes to kidneys and preserved kidney function, giving rise to the concept of vesico-amniotic shunting." — Mark (clinical) [Ep 2 · 2:58](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=178)
- "Early shunting had highly variable outcomes and success rates." — Mark (clinical) [Ep 2 · 4:32](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=272)
- "A stepwise approach to identifying fetuses for shunt therapy includes: high-resolution ultrasound to assess anatomy and rule out associated anomalies (myelomeningocele, cardiac disease, genetic syndromes), karyotype confirmation to rule out chromosomal abnormalities, and renal function evaluation by serial bladder drainage." — Mark (guideline) [Ep 2 · 4:50](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=290)
- "Amnioinfusion is sometimes necessary to expand amniotic fluid space and restore fluid interface for better ultrasound resolution when initial evaluation is difficult." — Mark (clinical) [Ep 2 · 5:19](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=319)
- "Not an insignificant portion of LUTO cases have chromosomal abnormalities such as major trisomies or Klinefelter syndrome." — Mark (epidemiological) [Ep 2 · 5:36](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=336)
- "It is important to confirm male fetus because female fetuses with large bladder-like structures are usually cloacal abnormalities that do not benefit from shunting due to different pathophysiology." — Mark (clinical) [Ep 2 · 5:53](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=353)
- "Renal function evaluation involves draining the bladder completely on several occasions and analyzing sodium, chloride, calcium, osmolarity, total proteins, and beta-2-microglobulin as reflections of proximal tubular injury and possible glomerular injury." — Mark (guideline) [Ep 2 · 6:17](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=377)
- "Increased kidney echogenicity is evidence of compression of renal parenchyma rather than a poor prognostic sign per se; following serial bladder drainages and allowing kidneys to drain, re-expansion of parenchyma occurs with more normal echogenicity." — Mark (clinical) [Ep 2 · 8:10](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=490)
- "Hydronephrosis pathophysiology: as collecting system (balloon) enlarges within kidney (sponge in fishbowl), it compresses parenchyma against serosa, impairing delicate vasculature and causing cell death, progressive fibrosis, and eventually cystic dysplasia." — Mark (clinical) [Ep 2 · 8:49](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=529)
- "Presence of cortical cysts indicates irreversibly damaged kidney not amenable to in utero therapy." — Mark (clinical) [Ep 2 · 10:18](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=618)
- "Patent urachus (tract from bladder dome to umbilical cord that reopens with high bladder pressure) is one etiology for LUTO with normal amniotic fluid volume." — Mark (clinical) [Ep 2 · 12:41](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=761)
- "Megacystis-microcolon-hypoperistalsis syndrome is a neurologic defect in bladder and ureteral muscles preventing contraction and emptying; these patients have massively distended bladder with normal amniotic fluid, thin bladder walls after drainage, and extremely poor survival (most do not survive more than a few years)." — Mark (clinical) [Ep 2 · 14:47](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=887)
- "The first urine specimen from bladder tap is not predictive or reliable because it is exposed to degradation products and osmotic gradients that change electrolyte composition; serial taps (second at 2 days, third at 4 days) sample urine from ureters/intrarenal collecting system and then freshly produced urine, which have much higher predictive value." — Mark (clinical) [Ep 2 · 19:05](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1145)
- "Prognostic urinary electrolyte cutoff thresholds (sodium <100, chloride <90, osmolarity <210, calcium <8, beta-2-microglobulin <6, total protein <40 mg/dL) predict potential for survival with successful shunt placement; values above these indicate significant renal injury." — Mark (guideline) [Ep 2 · 18:00](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1080)
- "All prognostic urinary electrolyte cutoff thresholds were based on urine analyzed between 18 to 22 weeks gestation; they cannot be used before 18 weeks or after 22 weeks without adjustment for gestational age." — Mark (guideline) [Ep 2 · 26:18](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1578)
- "Bladder morphology after drainage can suggest etiology: symmetric thick-walled bladder with difficult keyhole suggests urethral atresia; elongated bladder with more proximal thickening suggests posterior urethral valves; snowman appearance (head-chest-body shape) suggests mid-urethral hypoplasia/prune belly variant with smooth muscle deficiency in bladder dome." — Mark (clinical) [Ep 2 · 21:19](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1279)
- "In mid-urethral hypoplasia cases, histology shows abnormal smooth muscle from proximal ureters to renal pelvis and severe abnormalities in bladder dome smooth muscle development." — Mark (clinical) [Ep 2 · 25:13](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1513)
- "The Paris group (Francis Muller, Humberto Nicolini) emphasized importance of using gestational-age-specific cutoffs for urinary electrolytes." (guideline) [Ep 2 · 25:53](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1553)
- "Primary goal of fetal bladder shunting is to prevent pulmonary hypoplasia secondary to oligohydramnios; secondary goals are preservation of renal function and bladder function." (guideline) [Ep 2 · 28:41](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1721)
- "Vesico-amniotic shunt is a double-tailed silastic pigtail catheter (Rocket or Harrison shunt) with coils in different directions; flat end outside baby's abdomen prevents baby from grabbing and pulling it out, other end inside bladder." (clinical) [Ep 2 · 29:08](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1748)
- "Shunt placement is outpatient procedure with IV remifentanyl/propofol, local anesthetic, antibiotic, indomethacin, and possibly nifedipine; mother goes home couple hours later." (clinical) [Ep 2 · 29:43](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1783)
- "Amnioinfusion before shunt placement is critical because without good fluid volume around fetus, external end of shunt cannot be deposited properly (most difficult part of procedure)." (clinical) [Ep 2 · 30:06](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1806)
- "Shunt should ideally be inserted inferior to bladder because higher placement risks holes in shunt ending up in peritoneal cavity as bladder deflates, causing fetal urinary ascites." (clinical) [Ep 2 · 31:05](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1865)
- "Birmingham group meta-analysis showed in good-prognosis cases (by urinary electrolytes), there appeared to be some benefit to drainage; in poor-prognosis cases, drainage appeared to have even better result." (clinical) [Ep 2 · 31:37](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1897)
- "PLUTO trial was only randomized trial of bladder shunting; babies randomized when physician was uncertain whether to shunt; karyotype and urinalysis were not mandatory, amniotic fluid volume not used as prognostic evaluator." (clinical) [Ep 2 · 32:27](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1947)
- "PLUTO trial designed to collect 150 patients over 4 years but only 31 patients randomized; trial stopped early due to poor recruitment (only 20% of planned patients)." (epidemiological) [Ep 2 · 33:41](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2021)
- "PLUTO trial showed approximately 3-fold increase in survival in shunted fetuses compared to conservative management, but numbers very small and benefit unproven (confidence intervals crossed unity, results not significant)." (clinical) [Ep 2 · 33:55](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2035)
- "All 12 deaths in PLUTO trial were from pulmonary hypoplasia; improved survival inferred to be related to decrease in lung hypoplasia." (clinical) [Ep 2 · 34:36](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2076)
- "Only 7 of 12 live-born shunted babies in PLUTO trial were alive at age 2, and only 2 of shunted survivors had normal renal function; all 3 conservatively managed survivors had significant renal impairment." (epidemiological) [Ep 2 · 34:47](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2087)
- "Six studies reporting long-term outcomes of shunted babies show consistent results: approximately 40-50% have normal renal function, approximately one-third require dialysis or transplant." (epidemiological) [Ep 2 · 36:06](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2166)
- "In Canadian population, when parents review outcome studies, many opt for termination of pregnancy rather than shunting." (epidemiological) [Ep 2 · 37:13](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2233)
- "Some LUTO cases can resolve spontaneously, either by baby peeing and filling amniotic sac, spontaneous bladder decompression resulting in asymmetric hydronephrosis or urinary ascites, or development of perinephric urinoma." (clinical) [Ep 2 · 37:23](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2243)
- "Bladder rupture usually occurs after drainage (not spontaneously) and always resolves after a few days." (clinical) [Ep 2 · 38:06](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2286)
- "Megacystis-microcolon-hypoperistalsis syndrome and cloacal dysgenesis are cases where intervention by shunting is not indicated; clues include female fetus and normal amniotic fluid volume." (guideline) [Ep 2 · 38:26](https://library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2306)
- "The three major causes of LUTO are urethral atresia (complete obstruction with no communication from bladder neck through urethra), posterior urethral valves (flap of tissue in proximal urethra), and mid-urethral hypoplasia (significant tapering and narrowing that becomes progressive obstruction as pelvic anatomy matures)" — Mark (clinical) [Ep 1 · 0:44](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=44)
- "Complete urethral obstruction leads to progressive oligohydramnios until anhydramnios, physical deformations (joint contractures, ear flattening, Potter's phenotype), pulmonary hypoplasia due to inability to expand and contract chest, and severe hydronephrosis with progressive renal fibrocystic dysplasia resulting in renal failure after birth" — Mark (clinical) [Ep 1 · 1:41](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=101)
- "In sheep models, early mid-gestational reversal of obstruction prevented progressive dysplastic changes to kidneys and preserved kidney function, giving rise to the concept of in utero shunting" — Mark (clinical) [Ep 1 · 3:10](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=190)
- "A stepwise approach to identifying fetuses for shunt therapy involves: (1) high-resolution ultrasound to evaluate anatomy and rule out associated anomalies like myelomeningocele or cardiac disease, (2) karyotype confirmation to rule out chromosomal abnormalities, and (3) renal function evaluation by serial bladder drainage" — Mark (clinical) [Ep 1 · 4:44](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=284)
- "Amnioinfusions can be performed to expand the amniotic fluid space and restore fluid interface for better high-resolution ultrasound imaging when evaluation is difficult" — Mark (clinical) [Ep 1 · 5:31](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=331)
- "It is important to confirm male fetus because female fetuses with large bladder-like structures are usually cloacal abnormalities that do not benefit from shunting due to completely different pathophysiology" — Mark (clinical) [Ep 1 · 6:04](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=364)
- "The keyhole sign is the dilated proximal urethra down to the level of obstruction, characteristic of posterior urethral valves" — Mark (clinical) [Ep 1 · 7:42](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=462)
- "Increased echogenicity of kidneys is evidence of compression of renal parenchyma rather than a poor prognostic sign per se; following bladder drainage and allowing kidneys to drain, re-expansion of parenchyma occurs with more normal echogenicity" — Mark (clinical) [Ep 1 · 8:21](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=501)
- "The pathophysiology of hydronephrosis involves the collecting system (like a balloon) expanding within the kidney (like a sponge in a glass fishbowl), compressing parenchyma against the serosa, impairing delicate vasculature, resulting in cell death, progressive fibrosis, and eventually cystic dysplasia" — Mark (clinical) [Ep 1 · 9:01](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=541)
- "The presence of discrete cortical cysts indicates irreversible kidney damage and is not amenable to any in utero therapy due to severity of underlying injury" — Mark (clinical) [Ep 1 · 10:29](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=629)
- "Patent urachus (a tract from bladder dome to umbilical cord insertion that normally closes early in embryonic development) can reopen with early obstruction and high bladder pressure, draining urine into amniotic fluid space, explaining obstructive uropathy with normal amniotic fluid volume" — Mark (clinical) [Ep 1 · 12:53](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=773)
- "Megacystis-microcolon-hypoperistalsis syndrome is a neurologic defect in bladder and ureteral muscles preventing bladder contraction and emptying, more common in females but seen in males, with extremely poor survival (most do not survive more than a few years)" — Mark (clinical) [Ep 1 · 14:58](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=898)
- "In megacystis-microcolon-hypoperistalsis syndrome, after bladder drainage the entire bladder remains very thin-walled because it does not develop hyperplasia or thickening typically seen in complete obstruction, and amniotic fluid flows into amniotic cavity through a completely patent urethra" — Mark (clinical) [Ep 1 · 15:34](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=934)
- "Karyotype analysis can be obtained through amniocentesis (if possible), chorionic villus sampling, vesicocentesis (with FISH technology to screen and confirm male karyotype and rule out major aneuploidies), or cordocentesis for fetal blood" — Mark (clinical) [Ep 1 · 16:49](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1009)
- "Favorable prognostic urinary values for potential survival with shunt placement are: sodium <100 mEq/L, chloride <90 mEq/L, osmolarity <210 mOsm, calcium <8 mg/dL, beta-2 microglobulin <6 mg/L, and total protein <40 mg/dL" — Mark (clinical) [Ep 1 · 18:12](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1092)
- "Autopsy studies confirmed that fetuses with urinary values above the cutoff thresholds (not much higher) showed significant fibrotic injury to kidneys, while those with values below thresholds showed very little or very early changes potentially salvageable with in utero therapy" — Mark (clinical) [Ep 1 · 18:35](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1115)
- "Serial bladder drainage (first tap, second tap 2 days later, third tap 2 days after that) is necessary because the first urine specimen is not predictive or reliable; the third or fourth values have much higher predictive value for detecting significant underlying injury as they represent freshly produced urine" — Mark (clinical) [Ep 1 · 19:27](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1167)
- "Improving urinary electrolyte values across serial taps (e.g., sodium initially poor but dropping with second and third taps) indicates an excellent candidate for shunting with reasonably good prognosis, while worsening values indicate ongoing irreversible damage that shunting won't benefit" — Mark (clinical) [Ep 1 · 20:29](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1229)
- "After bladder drainage, urethral atresia cases show symmetric, very thick, universal bladder wall thickening with a typical keyhole; posterior urethral valve cases show elongated bladder shape with more proximal than distal thickening; mid-urethral hypoplasia (prune belly/triad) cases show a 'snowman appearance' with typical hypertrophy in lower bladder but significant smooth muscle deficiency in upper bladder" — Mark (clinical) [Ep 1 · 21:31](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1291)
- "All urinary electrolyte cutoff thresholds are based on urine analyzed between 18 to 22 weeks of gestation; these cutoffs cannot be used before 18 weeks or after 22 weeks without adjustment" — Mark (clinical) [Ep 1 · 26:30](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1590)
- "Urinary electrolyte cutoff values change with gestational age due to maturation and increasing kidney function; at 17 weeks the cutoff would be higher, and at 24-26 weeks the cutoffs would be much lower" — Mark (clinical) [Ep 1 · 27:00](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1620)
- "The primary goal of fetal bladder shunting is to prevent pulmonary hypoplasia secondary to oligohydramnios; secondary goals are preservation of renal function and bladder function" (clinical) [Ep 1 · 28:52](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1732)
- "Vesicoamniotic shunting uses a double-tailed silastic pigtail catheter (Rocket shunt) with coils in different directions so the flat end outside the baby's abdomen cannot be grabbed and pulled out, and the other end is inside the bladder" (clinical) [Ep 1 · 29:27](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1767)
- "Shunt placement is done as an outpatient procedure with IV remifentanyl and if necessary propofol, local anesthetic, antibiotic, indomethacin, and possibly nifedipine, with mother going home a couple hours later" (clinical) [Ep 1 · 29:54](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1794)
- "Amnioinfusion before shunt placement is the most important step because without good fluid volume around the fetus, the external end of the shunt (the trickiest part) cannot be deposited properly" (clinical) [Ep 1 · 30:18](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1818)
- "Shunt should ideally be inserted inferior to the bladder because the higher the placement, the greater the risk that when the bladder deflates, some shunt holes will be in the peritoneal cavity, potentially causing fetal urinary ascites" (clinical) [Ep 1 · 31:16](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1876)
- "The Birmingham group's meta-analysis showed that in cases with good prognosis from urinary electrolytes, there appeared to be some benefit to drainage, and in the poor prognosis group, drainage appeared to have an even better result" (epidemiological) [Ep 1 · 31:48](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1908)
- "The PLUTO trial randomized patients only when the physician was uncertain whether to shunt; if they knew whether shunting worked, patients were not randomized; karyotype and urinalysis were not mandatory, and amniotic fluid volume was not used as a prognostic evaluator" (clinical) [Ep 1 · 32:59](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1979)
- "The PLUTO trial was designed to collect 150 patients over 4 years but only 31 patients were randomized by the end, representing only 20% of planned recruitment" (epidemiological) [Ep 1 · 33:53](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2033)
- "In the PLUTO trial, shunted fetuses showed about a 3-fold increase in survival compared to those not shunted, but numbers were very small and the benefit is unproven; all 12 deaths were from pulmonary hypoplasia" (epidemiological) [Ep 1 · 34:33](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2073)
- "In the PLUTO trial, only 7 of 12 live-born shunted babies were alive at age 2, and only 2 of the shunted survivors had normal renal function; all 3 conservatively managed survivors had significant renal impairment" (epidemiological) [Ep 1 · 34:59](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2099)
- "Difficulties in fetal therapy trials include: conditions are rare, many go undetected prenatally, many parents choose termination when faced with outcome realities, delay in accepting new therapy reflects clinician and patient bias based on small heterogeneous observational studies, and loss of clinical equipoise" (opinion) [Ep 1 · 35:18](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2118)
- "Long-term outcome data from 6 studies show consistent results: among shunted fetuses with good electrolytes (the best of the best), only 40-50% have normal renal function and approximately one-third require dialysis or transplant" (epidemiological) [Ep 1 · 36:17](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2177)
- "Some LUTO cases can resolve spontaneously, either by the baby starting to void and refill its bladder naturally, or by spontaneous bladder decompression resulting in asymmetrical hydronephrosis or urinary ascites" (clinical) [Ep 1 · 37:40](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2260)
- "Bladder rupture usually occurs after bladder drainage rather than spontaneously, and always resolves after a few days" (clinical) [Ep 1 · 38:17](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2297)
- "Megacystis-microcolon-hypoperistalsis syndrome and cloacal dysgenesis are cases where there is no role whatsoever for shunting intervention" (clinical) [Ep 1 · 38:38](https://library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2318)

## Changelog
- Aug 29: Collection generated from campaign corpus: 2 items, 1 dossiers, summaries for 4 audience(s)
- Aug 29: Collection reviewed and published
- Aug 29: Collection generated from campaign corpus: 2 items, 1 dossiers, summaries for 1 audience(s)
- Aug 29: Collection generated from campaign corpus: 2 items, 1 dossiers, summaries for 3 audience(s)

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