In Utero PUV Management

So the goals of diagnosing and taking care of a fetus that has been found to have postferal valves or bladder outlet obstruction, the first thing is to confirm the diagnosis, and that's where we will do the fetal MRI. And I think the most important intervention that we do is the extensive counseling of the family by a multidisciplinary team. So we have neonatologists, we have fetal surgeons, we have Doctor Clay from nephrology, uh, pediatric urology, social worker, everyone there at the same time to present to the family what our findings are during the testing and what we are predicting is going on with their baby, what steps can we take to intervene during the pregnancy if it's safe for the baby and the mother, and what are we going to do in terms of having a birth plan in place. Once we feel that um the family has a good understanding and if there is potential for reversing some of the injury, we might recommend an intervention during the pregnancy and uh early on, we can try a feetoscopic, looking in the womb with a telescope and getting into the baby's bladder with a telescope and then using a laser to go ahead and dissolve those valves. If we don't think that's an appropriate intervention, then we will put a shunt, which is basically a tube that goes from the baby's bladder into the space around the baby in the womb, allows urine to drain out, and that allows the amniotic space to be repopulated with the fluid, potentially allows for the lungs to be safe. Uh, unfortunately, the results with the shunts have not been very good for the kidneys, so the kidney damage unfortunately is still ongoing at that point. Here at Cincinnati, we've also developed a very um extensive program where when there is no kidney function in the fetus, we will under certain circumstances replace the fluid around the baby with uh um a biological solution to mimic what's happening during pregnancy, allow the lungs to continue to develop, and then know that that baby is going to require dialysis as soon as they're born. Again, going back to the most important thing though is the education so that we can provide a support for the family, help them understand what's going on with their baby, and help them decide what is the right step for them to take, whether it's intervention or no intervention and proceed with comfort care. Um, there are no wrong choices that the family makes. It's whatever is best for them and what they feel is best for their child. So it is really important to have a birth plan in place, um, that if you're in this scenario that you have to be planning to deliver in an area that has in a hospital that has a very high functioning NICU that can provide all of the expected, uh, and expertise that the baby's gonna require. So this is just an image showing um the postretal valve in the upper right hand corner of the screen and then uh the shunt where you can see that red plastic tube coming out of the baby's bladder and that allows for the urine that's obstructed to drain from the bladder as I mentioned, it does serve purpose in being able to protect the lungs, but unfortunately does not do as good a job as we would have hoped in protecting the bladder and the kidneys. And when we are able to look in with a telescope and visualize the valves, we can actually. Uh, dissolve them with a laser.