Prenatal Ultrasound Diagnosis and Conservative Management of Fetal Lower Urinary Tract Obstruction with Bilateral Hydroureteronephrosis and Severe Oligohydramnios at 23 Weeks of Gestation: A Case Report

Jackson Mandala Putra; Abarham Martadiansyah; Nuswil Bernolian

doi:10.70716/mohr.v4i3.603

Authors

Jackson Mandala Putra Department of Obstetrics and Gynecology, Faculty of Medicine, Sriwijaya University, Palembang, Indonesia.
Abarham Martadiansyah Department of Obstetrics and Gynecology, Faculty of Medicine, Sriwijaya University, Palembang, Indonesia.
Nuswil Bernolian Department of Obstetrics and Gynecology, Faculty of Medicine, Sriwijaya University, Palembang, Indonesia.

DOI:

https://doi.org/10.70716/mohr.v4i3.603

Keywords:

Lower urinary tract obstruction, Megacystis, Hydroureteronephrosis, Oligohydramnios, Prenatal ultrasonography

Abstract

Fetal lower urinary tract obstruction (LUTO) is a rare group of congenital anomalies characterized by megacystis, bilateral hydroureteronephrosis, and, in severe forms, oligohydramnios that predisposes to pulmonary hypoplasia and renal dysplasia. This report described a 37-year-old multigravida (G3P2A0) referred at 23 weeks of gestation with intermittent abdominal pain and a suspected fetal anomaly. Serial fetal ultrasonography demonstrated bilateral hydronephrosis and hydroureter, a distended, thick-walled bladder with a keyhole sign suggestive of LUTO, and severe oligohydramnios (deepest vertical pocket 0.59 cm). Maternal renal function and infection screening were unremarkable. After multidisciplinary counseling regarding the guarded prognosis and the local unavailability of fetal therapy, expectant management was undertaken, comprising tocolysis with nifedipine, antenatal corticosteroids, maternal rehydration, and planned amnioinfusion with serial ultrasound surveillance. The patient stabilized and was discharged for close follow-up. This case underscored the central role of prenatal ultrasonography in early recognition of LUTO and the importance of severity-based, multidisciplinary counseling. When severe oligohydramnios presents in the second trimester, the prognosis is guarded, and standardized staging and timely referral to a fetal-therapy center are essential to optimize perinatal outcomes

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References

Anderson, T., Oseji, O., Yancey, J., & Bogojevic, A. (2023). Prenatal diagnosis of LUTO: Case report and review of the literature. International Journal of Pregnancy & Child Birth, 9(5), 145-146. https://doi.org/10.15406/ipcb.2023.09.00293

Becker, A., & Baum, M. (2006). Obstructive uropathy. Early Human Development, 82(1), 15–22. https://doi.org/10.1016/j.earlhumdev.2005.11.002

Capone, V., Persico, N., Berrettini, A., Decramer, S., De Marco, E. A., De Palma, D., … Montini, G. (2022). Definition, diagnosis and management of fetal lower urinary tract obstruction: Consensus of the ERKNet CAKUT-Obstructive Uropathy Work Group. Nature Reviews Urology, 19(5), 295–303. https://doi.org/10.1038/s41585-022-00563-8

Farrugia, M. K. (2016). Fetal bladder outlet obstruction: Embryopathology, in utero intervention and outcome. Journal of Pediatric Urology, 12(5), 296–303. https://doi.org/10.1016/j.jpurol.2016.05.047

Fontanella, F., Duin, L., Adama van Scheltema, P. N., Cohen-Overbeek, T. E., Pajkrt, E., Bekker, M., … Bilardo, C. M. (2017). Fetal megacystis: Prediction of spontaneous resolution and outcome. Ultrasound in Obstetrics & Gynecology, 50(4), 458–463. https://doi.org/10.1002/uog.17422

Friedman, P., & Ogunyemi, D. (2018). Oligohydramnios. In Obstetric imaging: Fetal diagnosis and care (2nd ed., pp. 511–515). Elsevier.

Gagnier, J. J., Kienle, G., Altman, D. G., Moher, D., Sox, H., & Riley, D. (2014). The CARE guidelines: Consensus-based clinical case report guideline development. Journal of Clinical Epidemiology, 67(1), 46–51. https://doi.org/10.1016/j.jclinepi.2013.08.003

Haeri, S. (2015). Fetal lower urinary tract obstruction (LUTO): A practical review for providers. Maternal Health, Neonatology and Perinatology, 1, 26. https://doi.org/10.1186/s40748-015-0026-1

Hodges, S. J., Werle, D., McLorie, G., & Atala, A. (2010). Megaureter. The Scientific World Journal, 10, 603–612. https://doi.org/10.1100/tsw.2010.54

Hofmeyr, G. J., & Lawrie, T. A. (2012). Amnioinfusion for potential or suspected umbilical cord compression in labor. Cochrane Database of Systematic Reviews, (1), CD000013. https://doi.org/10.1002/14651858.CD000013.pub2

Johnson, M. P., Bukowski, T. P., Reitleman, C., Isada, N. B., Pryde, P. G., & Evans, M. I. (1994). In utero surgical treatment of fetal obstructive uropathy: A new comprehensive approach to identify appropriate candidates for vesicoamniotic shunt therapy. American Journal of Obstetrics and Gynecology, 170(6), 1770–1779. https://doi.org/10.1016/s0002-9378(94)70353-1

Kurtz, M. P. (2023). Prenatal diagnoses and intervention. Urologic Clinics of North America, 50(3), 351-359. https://doi.org/10.1016/j.ucl.2023.04.006

Koch, A., Sananès, N., & Weingertner, A.-S. (2023). Uropatías obstructivas bajas. EMC - Pediatría, 58(3), 1-4. https://doi.org/10.1016/S1245-1789(23)47986-3

Morris, R. K., Malin, G. L., Quinlan-Jones, E., Middleton, L. J., Hemming, K., Burke, D., … Kilby, M. D. (2013). Percutaneous vesicoamniotic shunting versus conservative management for fetal lower urinary tract obstruction (PLUTO): A randomised trial. The Lancet, 382(9903), 1496–1506. https://doi.org/10.1016/S0140-6736(13)60992-7

Muñoz, H. (2022). EP20.13: A case report: Urinoma amniotic shunt and other option for LUTO treatment. Ultrasound in Obstetrics & Gynecology, 60(S1), 248-249. https://doi.org/10.1002/uog.25517

Munoz, J. L., Tounsi, S., Buskmiller, C., Sanz Cortes, M., Donepudi, R. V., Belfort, M. A., & Nassr, A. A. (2024). Outcomes of fetal lower urinary tract obstruction based on timing of oligohydramnios onset. Prenatal Diagnosis, 44(2), 131-137. https://doi.org/10.1002/pd.6493

Mustafa, H. J., Khalil, A., Johnson, S., Gordijn, S. J., Ganzevoort, W., Melling, C., … Nassr, A. A. (2024). Fetal lower urinary tract obstruction: International Delphi consensus on management and core outcome set. Ultrasound in Obstetrics & Gynecology, 64(5), 635–650. https://doi.org/10.1002/uog.27684

Nassr, A. A., Shazly, S. A. M., Abdelmagied, A. M., Araujo Júnior, E., Tonni, G., Kilby, M. D., & Ruano, R. (2017). Effectiveness of vesicoamniotic shunt in fetuses with congenital lower urinary tract obstruction: An updated systematic review and meta-analysis. Ultrasound in Obstetrics & Gynecology, 49(6), 696–703. https://doi.org/10.1002/uog.15988

Nguyen, H. T., Benson, C. B., Bromley, B., Campbell, J. B., Chow, J., Coleman, B., … Mevorach, R. (2014). Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system). Journal of Pediatric Urology, 10(6), 982–998. https://doi.org/10.1016/j.jpurol.2014.10.002

Paraboschi, I., Pierucci, U. M., Peycelon, M., Pelizzo, G., & Ruano, R. (2024). Indications and outcomes of fetal cystoscopy for lower urinary tract obstruction: A comprehensive review. Prenatal Diagnosis, 44(13), 1539–1549. https://doi.org/10.1002/pd.6709

Ruano, R., Sananes, N., Sangi-Haghpeykar, H., Hernandez-Ruano, S., Moog, R., Becmeur, F., … Favre, R. (2015). Fetal intervention for severe lower urinary tract obstruction: A multicenter case-control study comparing fetal cystoscopy with vesicoamniotic shunting. Ultrasound in Obstetrics & Gynecology, 45(4), 452–458. https://doi.org/10.1002/uog.14652

Sananes, N., Favre, R., Koh, C. J., Zaloszyc, A., Braun, M. C., Roth, D. R., … Ruano, R. (2015). Urological fistulas after fetal cystoscopic laser ablation of posterior urethral valves: Surgical technical aspects. Ultrasound in Obstetrics & Gynecology, 45(2), 183–189. https://doi.org/10.1002/uog.13379

Shannon, K. J., VanLoh, S., Espinoza, J., Sanz-Cortes, M., Donepudi, R., Shamshirsaz, A. A., Koh, C. J., Roth, D. R., Braun, M. C., Angelo, J., Belfort, M. A., & Nassr, A. A. (2022). Pathological and sonographic review of early isolated severe lower urinary tract obstruction and implications for prenatal treatment. Ultrasound in Obstetrics & Gynecology, 59(2), 124-130. https://doi.org/10.1002/uog.23718

Smith-Harrison, L. I., Hougen, H. Y., Timberlake, M. D., & Corbett, S. T. (2015). Current applications of in utero intervention for lower urinary tract obstruction. Journal of Pediatric Urology, 11(6), 341–347. https://doi.org/10.1016/j.jpurol.2015.07.012

Yamacake, K. G. R., & Nguyen, H. T. (2013). Current management of antenatal hydronephrosis. Pediatric Nephrology, 28(2), 237–243. https://doi.org/10.1007/s00467-012-2240-7