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Bañuelos Marco B, González R, Ludwikowski B, Lingnau A. Effectiveness of Prenatal Intervention on the Outcome of Diseases That Have a Postnatal Urological Impact. Front Pediatr 2019; 7:118. [PMID: 31001504 PMCID: PMC6454137 DOI: 10.3389/fped.2019.00118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/11/2019] [Indexed: 01/04/2023] Open
Abstract
We reviewed the literature addressing outcomes of fetal intervention of conditions that require post-natal urological management including lower urinary tract obstruction, hydrometrocolpos, congenital adrenal hyperplasia, and myelomeningocele. Despite several decades of fetal intervention for these conditions, benefits remain elusive in part because of the enormous difficulty of conducting prospective randomized studies. In this review, we reached the following conclusions: Prenatal intervention in lower urinary tract obstruction (LUTO) improves survival in the worst cases by improving pulmonary function and it may be advantageous for renal function, particularly in patients with adverse urine parameters.Prenatal treatment of female fetuses at risk of having congenital adrenal hyperplasia (CAH) reduces virilization. Non-invasive fetal DNA analysis allows earlier diagnosis, reducing the risk of treating with dexamethasone males and non-affected fetuses.Fetal treatment of myelomeningocele (MMC) is gaining momentum. Prospective studies including standardized urologic evaluation will determine if the encouraging results reported by some hold on the long term follow-up.
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Affiliation(s)
| | - Ricardo González
- Department of Urology, Charité Medical University of Berlin, Berlin, Germany
- Pediatric Surgery and Urology, Kinder- und Jugendkrankenhaus AUF DER BULT, Hanover, Germany
| | - Barbara Ludwikowski
- Pediatric Surgery and Urology, Kinder- und Jugendkrankenhaus AUF DER BULT, Hanover, Germany
| | - Anja Lingnau
- Department of Urology, Charité Medical University of Berlin, Berlin, Germany
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Thomas AN, McCullough LB, Chervenak FA, Placencia FX. Evidence-based, ethically justified counseling for fetal bilateral renal agenesis. J Perinat Med 2017; 45:585-594. [PMID: 28222038 PMCID: PMC5509412 DOI: 10.1515/jpm-2016-0367] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 12/28/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Not much data are available on the natural history of bilateral renal agenesis, as the medical community does not typically offer aggressive obstetric or neonatal care asbilateral renal agenesis has been accepted as a lethal condition. AIM To provide an evidence-based, ethically justified approach to counseling pregnant women about the obstetric management of bilateral renal agenesis. STUDY DESIGN A systematic literature search was performed using multiple databases. We deploy an ethical analysis of the results of the literature search on the basis of the professional responsibility model of obstetric ethics. RESULTS Eighteen articles met the inclusion criteria for review. With the exception of a single case study using serial amnioinfusion, there has been no other case of survival following dialysis and transplantation documented. Liveborn babies die during the neonatal period. Counseling pregnant women about management of pregnancies complicated by bilateral renal agenesis should be guided by beneficence-based judgment informed by evidence about outcomes. CONCLUSIONS Based on the ethical analysis of the results from this review, without experimental obstetric intervention, neonatal mortality rates will continue to be 100%. Serial amnioinfusion therefore should not be offered as treatment, but only as approved innovation or research.
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Affiliation(s)
- Alana N. Thomas
- Corresponding author: Alana N. Thomas MD, Baylor college
of Medicine, Texas Children's Hospital, Department of Pediatrics,
Section of Neonatology, 6621 Fannin St, WT-6104, Houston, TX 77030, USA, Tel.:
+ (832) 826-1380, Fax: + (832) 825-1386,
| | - Laurence B. McCullough
- Center for Medical Ethics and Health Policy, Baylor College of
Medicine, Houston, TX, USA; and Department of Obstetrics and Gynecology,
Weill Medical College of Cornell University, New York, NY, USA
| | - Frank A. Chervenak
- Department of Obstetrics and Gynecology, Weill Medical College of
Cornell University, New York, NY, USA
| | - Frank X. Placencia
- Department of Pediatrics, Section of Neonatology, Baylor College of
Medicine, Texas Children's Hospital, Houston, TX, USA
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Maternal treatment with dexamethasone during gestation alters sexual development markers in the F1 and F2 male offspring of Wistar rats. J Dev Orig Health Dis 2016; 8:101-112. [DOI: 10.1017/s2040174416000453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Maternal treatment with dexamethasone (Dex) in threatening preterm delivery alters activities at the hypothalamic–pituitary–adrenal axis in the offspring. This alteration may interfere with reproductive function. The impact of gestational Dex exposure on male reproductive function of the offspring was investigated. A total of 25 pregnant rats randomly assigned to five groups (n=5) were treated with normal saline (control), Dex (100 μg/kg/day sc) during gestation days (GD) 1–7, 8–14, 15–21 and 1–21, respectively. Birth weight, anogenital distance (AGD), pubertal age, sperm parameters, hormonal profile and histopathology of testis and epididymis were determined in the F1 and F2 offspring. Results showed a significant increase (P<0.05) in pubertal age, serum corticosterone and gonadotropin-releasing hormone (GnRH) levels in the male offspring of DexGD 15–21 and 1–21 groups and a significant decrease (P<0.05) in serum testosterone, luteinizing hormone, birth weight and AGD at birth in the male F1 offspring. In the F2 offspring, there was a significant reduction (P<0.05) in serum corticosterone, testosterone, follicle-stimulating hormone and GnRH when compared with the control. Dex treatment at GD 15–21 and 1–21 significantly reduced (P<0.05) sperm motility and normal morphology in the F1 and F2 offspring. Maternal Dex treatment in rats during late gestation may disrupt sexual development markers in the F1 and F2 male offspring.
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Jeje SO, Akindele OO, Balogun ME, Raji Y. Maternal treatment with dexamethasone during lactation delays male puberty and disrupts reproductive functions via hypothalamic-pituitary-gonadal axis alterations. ACTA ACUST UNITED AC 2016; 23:43-9. [PMID: 26774541 DOI: 10.1016/j.pathophys.2015.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 12/25/2015] [Accepted: 12/26/2015] [Indexed: 01/09/2023]
Abstract
The effects of maternal treatment with dexamethasone during lactation on pubertal timing, serum hormonal profile and sperm indices in the male offspring were assessed. Twenty lactating dams were divided into 4 groups (n=5). Group 1 was administered subcutaneously 0.02ml/100g/day normal saline at lactation days 1-21. Groups 2-4 were administered subcutaneously 100μg/kg/day dexamethasone (Dex) at lactation days 1-7, 1-14, and 1-21 respectively. Results showed that there was significant reduction in serum testosterone in the DexLD 1-7 (p<0.05), DexLD 1-14 (p<0.01) and DexLD 1-21 (p<0.001) relative to control. In addition there was a significant reduction in serum FSH and LH in the DexLD 1-7 (p<0.01), DexLD 1-14 (p<0.001) and DexLD 1-21 (p<0.001) when compared with the control. Treatment with dexamethasone during lactation significantly increased the days of preputial separation in the DexLD 1-7 (p<0.05), DexLD 1-14 (p<0.05) and DexLD 1-21 (p<0.001) relative to control. Maternal treatment with dexamethasone throughout lactation period also significantly reduced sperm counts (p<0.001), motility (p<0.01) and increased percentage abnormal sperm (p<0.001) in the offspring when compared with the control. In conclusion, maternal treatment with dexamethasone during lactation may induce delayed puberty and disrupt reproductive functions by altering activities at hypothalamic-pituitary-gonadal axis in the male offspring.
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Affiliation(s)
- S O Jeje
- Laboratory for Reproductive Physiology and Developmental Programming, Department of Physiology, University of Ibadan, Ibadan, Nigeria; Department of Human Physiology, Cross River University of Technology, Okuku Campus, Cross River State, Nigeria.
| | - O O Akindele
- Laboratory for Reproductive Physiology and Developmental Programming, Department of Physiology, University of Ibadan, Ibadan, Nigeria
| | - M E Balogun
- Department of Physiology, Faculty of Medicine, College of Health Sciences, Ebonyi State University, Abakaliki, Nigeria
| | - Y Raji
- Laboratory for Reproductive Physiology and Developmental Programming, Department of Physiology, University of Ibadan, Ibadan, Nigeria
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Abstract
This article summarizes the most recent literature regarding congenital lower urinary tract obstruction in the fetus and newborn. Lower urinary tract obstruction is a heterogeneous group of rare diagnoses that have significant potential for in utero mortality and long-term morbidity in survivors. The diagnosis and management of the most common causes are reviewed. In addition, the current state of prenatal intervention for congenital lower urinary tract obstruction is discussed.
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Affiliation(s)
- Douglass B Clayton
- Division of Pediatric Urologic Surgery, Department of Urologic Surgery, Monroe Carrel Jr. Children's Hospital, 2200 Children's Way, 4102 DOT, Nashville, TN 37232, USA.
| | - John W Brock
- Division of Pediatric Urologic Surgery, Department of Urologic Surgery, Monroe Carrel Jr. Children's Hospital, 2200 Children's Way, 4102 DOT, Nashville, TN 37232, USA
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Swetz KM, Burkle CM, Berge KH, Lanier WL. Ten common questions (and their answers) on medical futility. Mayo Clin Proc 2014; 89:943-59. [PMID: 24726213 DOI: 10.1016/j.mayocp.2014.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 02/07/2014] [Accepted: 02/12/2014] [Indexed: 12/25/2022]
Abstract
The term medical futility is frequently used when discussing complex clinical scenarios and throughout the medical, legal, and ethics literature. However, we propose that health care professionals and others often use this term inaccurately and imprecisely, without fully appreciating the powerful, often visceral, response that the term can evoke. This article introduces and answers 10 common questions regarding medical futility in an effort to define, clarify, and explore the implications of the term. We discuss multiple domains related to futility, including the biological, ethical, legal, societal, and financial considerations that have a bearing on definitions and actions. Finally, we encourage empathetic communication among clinicians, patients, and families and emphasize how dialogue that seeks an understanding of multiple points of view is critically important in preventing or attenuating conflict among the involved parties.
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Affiliation(s)
- Keith M Swetz
- Department of Medicine, Section of Palliative Medicine and Biomedical Ethics Program, Mayo Clinic, Rochester, MN.
| | | | - Keith H Berge
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
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Kilby MD, Morris RK. Fetal therapy for the treatment of congenital bladder neck obstruction. Nat Rev Urol 2014; 11:412-9. [DOI: 10.1038/nrurol.2014.132] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Singh RR, Cuffe JSM, Moritz KM. Short- and long-term effects of exposure to natural and synthetic glucocorticoids during development. Clin Exp Pharmacol Physiol 2013; 39:979-89. [PMID: 22971052 DOI: 10.1111/1440-1681.12009] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
1.Glucocorticoids (GCs) are necessary for fetal development, but clinical and experimental studies suggest that excess exposure may be detrimental to health in both the short and longer term. 2.Exposure of the fetus to synthetic GCs can occur if the mother has a medical condition requiring GC therapy (e.g. asthma) or if she threatens to deliver her baby prematurely. Synthetic GCs can readily cross the placenta and treatment is beneficial, at least in the short term, for maternal health and fetal survival. 3.Maternal stress during pregnancy can raise endogenous levels of the natural GC cortisol. A significant proportion of the cortisol is inactivated by the placental 'GC barrier'. However, exposure to severe stress during pregnancy can result in increased risk of miscarriage, low birth weight and behavioural deficits in children. 4.Animal studies have shown that excess exposure to both synthetic and natural GCs can alter normal organ development, including that of the heart, brain and kidney. The nature and severity of the organ impairment is dependent upon the timing of exposure and, in some cases, the type of GC used and the sex of the fetus. 5.In animal models, exposure to elevated GCs during pregnancy has been associated with adult-onset diseases, including elevated blood pressure, impaired cardiac and vascular function and altered metabolic function.
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Affiliation(s)
- Reetu R Singh
- School of Biomedical Sciences, The University of Queensland, St Lucia, Qld., Australia
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