Case Report
Intrapartum Spontaneous Ureteral Rupture Deepa M. Narasimhulu, MD, Neha M. Egbert, MD, and Silverman Matthew, MD BACKGROUND: Although spontaneous rupture of the renal pelvis during pregnancy has been reported, albeit rarely, spontaneous ureteral rupture is extremely rare. CASE: We present the case of a 22-year-old nulliparous woman with spontaneous ureteral rupture after vaginal delivery diagnosed on contrast-enhanced computed tomography scan. Ureteroscopy revealed a rupture of her right midureter and a JJ stent was successfully placed. CONCLUSION: This case compels us to consider spontaneous ureteral rupture in the differential diagnosis for postpartum abdominal pain when common causes have been ruled out. We report this case to inform clinicians of this rare complication so that diagnosis is not delayed. Diagnosis can be made with contrast-enhanced computed tomography scan and cystoscopy, and ureteral stenting is a reasonable option for management. (Obstet Gynecol 2015;126:610–2) DOI: 10.1097/AOG.0000000000000788
U
reteral injury may be spontaneous or traumatic. Traumatic injury can occur in patients undergoing gynecologic surgery with risk factors such as prior pelvic surgery, endometriosis, pelvic inflammatory disease, and malignancy. Traumatic injury to the ureter in the obstetric patient is less common and can occur at the time of cesarean delivery, cesarean hysterectomy for placenta previa or placenta percreta, and if there are extensive lacerations at the time of vaginal delivery extending into the upper vagina and the vaginal fornix. Nontraumatic or spontaneous ureteral rupture is a rare occurrence and has been previously described in the literature but is usually seen at From the Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York. Corresponding author: Deepa M. Narasimhulu, 967 48th Street, Brooklyn, NY 11219; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/15
610
VOL. 126, NO. 3, SEPTEMBER 2015
Teaching Points 1. This case compels us to consider spontaneous ureteral rupture as a differential for abdominal pain in the postpartum period when other common causes have been ruled out. 2. Awareness of this potential complication will reduce delay in diagnosis and facilitate timely management and therefore reduce the chances of infectious sequelae.
the fornix and upper ureter.1 We describe a 22-yearold nulliparous woman who developed rupture of her right midureter after a vaginal delivery and presented with right lower abdominal pain. Diagnosis was made on contrast-enhanced computed tomography (CT), which showed contrast extravasation from the right ureter.
CASE A 22-year-old nulliparous woman without any significant medical or surgical history presented in early labor at term. The labor course was uneventful, and she delivered a healthy female neonate weighing 3,495 g with Apgar scores of 9 and 9. The third stage was complicated by postpartum hemorrhage as a result of uterine atony, with an estimated blood loss of 700 mL. Methergine was administered, and manual exploration of the uterus was performed to evaluate for retained placental tissue. Twelve hours after the birth, the patient developed right lower quadrant abdominal pain. The abdominal examination was unremarkable, and she was managed symptomatically. The next day, the patient had right flank pain radiating to the right groin. She was afebrile without any nausea or vomiting and denied urinary symptoms; lochia was normal. Laboratory testing revealed an elevated leukocyte count of 17,100/mm3 with increased neutrophils at 86%. Her hematocrit at that time was 28.6%, whereas her predelivery hematocrit was 32.7%. Examination at this point revealed costovertebral angle tenderness on the right side and a nontender abdomen. Urinalysis showed leukocyte esterase and hemoglobin, and urine culture was negative. Renal ultrasonogram was performed and did not show any abnormalities. Subsequently, the patient had a fever of 101.2˚F and repeat laboratory values revealed a lower leukocyte count of 10,900/mm3 and a decrease in hematocrit to 20.8%. The noncontrast CT showed a moderate amount of free fluid in the pelvis without any other abnormalities. In view of the decrease in hematocrit and free fluid in the pelvis, hemoperitoneum was suspected and two units of packed red
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
blood cells were transfused. The patient’s vital signs were stable, so a decision was made to perform a CT angiogram to see whether there was active bleeding; this study showed contrast extravasating from the right ureter (Figs. 1 and 2) and no active bleeding or hematoma. The decrease in hematocrit to 20.8% was probably the result of the acute blood loss resulting from postpartum hemorrhage, and the documented blood loss of 700 mL was probably an underestimation. Urology was consulted, and they performed cystoscopy and retrograde pyelogram, which also showed extravasation of contrast from the right ureter. Ureteroscopy revealed a complete ureteral transection at the level of the midureter on the right side, and a right JJ stent was successfully placed under ureteroscopic guidance. The patient’s symptoms resolved after stent placement. The stent was removed 6 weeks later under cystoscopic guidance, and the patient is currently asymptomatic.
DISCUSSION Spontaneous ureteral rupture is a rare condition that occurs in the absence of recent instrumentation, surgery, or trauma. The pathogenic pathway underlying nontraumatic disruption of the urinary collecting system is an increased intraluminal pressure, which may be the result of calculi (most common, greater than 50%), iatrogenic or postirradiation strictures, tumor, retroperitoneal fibrosis, and connective tissue disorders.1,2 The most common site of spontaneous perforation in the urinary collecting system is the fornix followed by the upper ureter.1 Consequences of ureteral rupture include urinoma, abscess formation, urosepsis, and renal impairment. Physiologic hydronephrosis of pregnancy is a result of mechanical and hormonal influences and
Fig. 1. Computed tomography scan of the abdomen, coronal view, showing leakage of contrast (red arrow) from the right ureter (yellow arrow). Narasimhulu. Intrapartum Spontaneous Ureteral Rupture. Obstet Gynecol 2015.
VOL. 126, NO. 3, SEPTEMBER 2015
causes an increase in intraluminal pressure. It is more pronounced on the right side and does not extend beyond the pelvic brim.3 The unequal dilatation has been thought to result from a cushioning effect of the sigmoid colon on the left ureter and from greater right ureteral compression exerted by the dextrorotated uterus. Pyelonephritis and pain from overdistention are occasional manifestations of this physiologic phenomenon; however, rupture of the renal collecting system may rarely occur, especially with intraluminal pressures exceeding 20–75 mm Hg.1 Spontaneous rupture of the urinary tract in pregnancy has been reported mostly to occur in the second and third trimesters and involves the pelvicalyceal system.4–6 There is usually some underlying renal pathology in these cases.7 One report described a pregnant patient who developed spontaneous rupture of the renal pelvis after an intravenous fluid bolus.8 Patients often present with sudden onset of severe abdominal and flank pain associated with nausea and vomiting mimicking a ureteric colic. They may also present with an acute abdomen as a result of an infected urinoma or a retroperitoneal hematoma if there is associated injury to renal parenchyma.2 Because it is a rare occurrence, diagnosis remains a challenge and is usually apparent on contrast CT with delayed films and can be confirmed on retrograde pyelogram. The location of the rupture at the level of the midureter is unusual as is the likely intrapartum occurrence of the rupture. Our patient did not have any underlying renal pathology or other predisposing risk factors. Although our patient had manual uterine exploration, the likelihood of ureteral rupture resulting from manipulation at that time is remote, especially because there was no instrumentation and no uterine perforation. Also, the likelihood of an avulsive force injuring the ureter during the manual exploration is unlikely as a result of the location of the rupture at the midureter and the absence of retroperitoneal bleeding that would be expected from such an injury in a pregnant patient. Therefore, it is unlikely that the injury was iatrogenic. We hypothesize that the increased intraluminal pressure resulting from physiologic hydronephrosis of pregnancy in addition to rapid changes in intraabdominal pressure while pushing might have resulted in the ureteral rupture, whereas the intravenous fluid bolus that the patient received before the epidural might have contributed by increasing the urine flow and further increased the intraluminal pressure. The fact that the rupture occurred on the right side supports our hypothesis
Narasimhulu et al
Intrapartum Spontaneous Ureteral Rupture
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
611
Fig. 2. Computed tomography scan of the abdomen, sagittal view, showing leakage of contrast from the right ureter (yellow arrows) with the extravasated contrast tracking along the psoas muscle (red arrows). Narasimhulu. Intrapartum Spontaneous Ureteral Rupture. Obstet Gynecol 2015.
because physiologic hydronephrosis of pregnancy is more pronounced on the right side. The fact that our patient had a decrease in hematocrit with free fluid in the pelvis led to the diagnosis of intraabdominal bleeding as the most likely cause of the pain, because nephrolithiasis and appendicitis were ruled out on the initial noncontrast CT scan. Our patient also had a negative renal ultrasonogram, which may be related to the location of the ureteral injury at the midureter. Other reports of spontaneous rupture in pregnancy were at the renal pelvis, and hence perinephric fluid was seen on ultrasonogram in some of these patients. In patients in whom the diagnosis was delayed, especially in the older case reports, infection of the urinoma set in with perinephric abscess formation and nephrectomy became necessary. We report this case to make readers aware of this extremely rare but possible complication so that diagnosis is not unduly delayed.
612
Narasimhulu et al
REFERENCES 1. Pampana E, Altobelli S, Morini M, Ricci A, D’Onofrio S, Simonetti G. Spontaneous ureteral rupture diagnosis and treatment. Case Rep Radiol 2013;2013:851859. 2. Izumoto H, Matsui H, Hayashi H, Kondo R, Teramoto S. Spontaneous renal rupture in pregnancy. Arch Surg 1989;124:389. 3. Schulman A, Herlinger H. Urinary tract dilatation in pregnancy. Br J Radiol 1975;48:638–45. 4. Wolff JM, Jung PK, Adam G, Jakse G. Non-traumatic rupture of the urinary tract during pregnancy. Br J Urol 1995;76:645–8. 5. Satoh S, Okuma A, Fujita Y, Tamaka M, Nakano H. Spontaneous rupture of the renal pelvis during pregnancy: a case report and review of the literature. Am J Perinatol 2002;19:189–95. 6. Sidra LM, Keriakos R, Shayeb AG, Kumar N, Najia S. Rupture renal pelvicalyceal system during pregnancy. J Obstet Gynaecol 2005;25:61–3. 7. Eaton A, Martin PC. Ruptured ureter in pregnancy—a unique case? Br J Urol 1981;53:78–9. 8. Huang E, Sayegh R, Craigo S, Chelmow D. Rupture of the renal pelvis associated with intravenous fluid bolus. J Matern Fetal Neonatal Med 2002;11:345–6.
Intrapartum Spontaneous Ureteral Rupture
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Intrapartum Spontaneous Ureteral Rupture Deepa M. Narasimhulu, MD, Neha M. Egbert, MD, and Silverman Matthew, MD BACKGROUND: Although spontaneous rupture of the renal pelvis during pregnancy has been reported, albeit rarely, spontaneous ureteral rupture is extremely rare. CASE: We present the case of a 22-year-old nulliparous woman with spontaneous ureteral rupture after vaginal delivery diagnosed on contrast-enhanced computed tomography scan. Ureteroscopy revealed a rupture of her right midureter and a JJ stent was successfully placed. CONCLUSION: This case compels us to consider spontaneous ureteral rupture in the differential diagnosis for postpartum abdominal pain when common causes have been ruled out. We report this case to inform clinicians of this rare complication so that diagnosis is not delayed. Diagnosis can be made with contrast-enhanced computed tomography scan and cystoscopy, and ureteral stenting is a reasonable option for management. (Obstet Gynecol 2015;126:610–2) DOI: 10.1097/AOG.0000000000000788
U
reteral injury may be spontaneous or traumatic. Traumatic injury can occur in patients undergoing gynecologic surgery with risk factors such as prior pelvic surgery, endometriosis, pelvic inflammatory disease, and malignancy. Traumatic injury to the ureter in the obstetric patient is less common and can occur at the time of cesarean delivery, cesarean hysterectomy for placenta previa or placenta percreta, and if there are extensive lacerations at the time of vaginal delivery extending into the upper vagina and the vaginal fornix. Nontraumatic or spontaneous ureteral rupture is a rare occurrence and has been previously described in the literature but is usually seen at From the Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York. Corresponding author: Deepa M. Narasimhulu, 967 48th Street, Brooklyn, NY 11219; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/15
610
VOL. 126, NO. 3, SEPTEMBER 2015
Teaching Points 1. This case compels us to consider spontaneous ureteral rupture as a differential for abdominal pain in the postpartum period when other common causes have been ruled out. 2. Awareness of this potential complication will reduce delay in diagnosis and facilitate timely management and therefore reduce the chances of infectious sequelae.
the fornix and upper ureter.1 We describe a 22-yearold nulliparous woman who developed rupture of her right midureter after a vaginal delivery and presented with right lower abdominal pain. Diagnosis was made on contrast-enhanced computed tomography (CT), which showed contrast extravasation from the right ureter.
CASE A 22-year-old nulliparous woman without any significant medical or surgical history presented in early labor at term. The labor course was uneventful, and she delivered a healthy female neonate weighing 3,495 g with Apgar scores of 9 and 9. The third stage was complicated by postpartum hemorrhage as a result of uterine atony, with an estimated blood loss of 700 mL. Methergine was administered, and manual exploration of the uterus was performed to evaluate for retained placental tissue. Twelve hours after the birth, the patient developed right lower quadrant abdominal pain. The abdominal examination was unremarkable, and she was managed symptomatically. The next day, the patient had right flank pain radiating to the right groin. She was afebrile without any nausea or vomiting and denied urinary symptoms; lochia was normal. Laboratory testing revealed an elevated leukocyte count of 17,100/mm3 with increased neutrophils at 86%. Her hematocrit at that time was 28.6%, whereas her predelivery hematocrit was 32.7%. Examination at this point revealed costovertebral angle tenderness on the right side and a nontender abdomen. Urinalysis showed leukocyte esterase and hemoglobin, and urine culture was negative. Renal ultrasonogram was performed and did not show any abnormalities. Subsequently, the patient had a fever of 101.2˚F and repeat laboratory values revealed a lower leukocyte count of 10,900/mm3 and a decrease in hematocrit to 20.8%. The noncontrast CT showed a moderate amount of free fluid in the pelvis without any other abnormalities. In view of the decrease in hematocrit and free fluid in the pelvis, hemoperitoneum was suspected and two units of packed red
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
blood cells were transfused. The patient’s vital signs were stable, so a decision was made to perform a CT angiogram to see whether there was active bleeding; this study showed contrast extravasating from the right ureter (Figs. 1 and 2) and no active bleeding or hematoma. The decrease in hematocrit to 20.8% was probably the result of the acute blood loss resulting from postpartum hemorrhage, and the documented blood loss of 700 mL was probably an underestimation. Urology was consulted, and they performed cystoscopy and retrograde pyelogram, which also showed extravasation of contrast from the right ureter. Ureteroscopy revealed a complete ureteral transection at the level of the midureter on the right side, and a right JJ stent was successfully placed under ureteroscopic guidance. The patient’s symptoms resolved after stent placement. The stent was removed 6 weeks later under cystoscopic guidance, and the patient is currently asymptomatic.
DISCUSSION Spontaneous ureteral rupture is a rare condition that occurs in the absence of recent instrumentation, surgery, or trauma. The pathogenic pathway underlying nontraumatic disruption of the urinary collecting system is an increased intraluminal pressure, which may be the result of calculi (most common, greater than 50%), iatrogenic or postirradiation strictures, tumor, retroperitoneal fibrosis, and connective tissue disorders.1,2 The most common site of spontaneous perforation in the urinary collecting system is the fornix followed by the upper ureter.1 Consequences of ureteral rupture include urinoma, abscess formation, urosepsis, and renal impairment. Physiologic hydronephrosis of pregnancy is a result of mechanical and hormonal influences and
Fig. 1. Computed tomography scan of the abdomen, coronal view, showing leakage of contrast (red arrow) from the right ureter (yellow arrow). Narasimhulu. Intrapartum Spontaneous Ureteral Rupture. Obstet Gynecol 2015.
VOL. 126, NO. 3, SEPTEMBER 2015
causes an increase in intraluminal pressure. It is more pronounced on the right side and does not extend beyond the pelvic brim.3 The unequal dilatation has been thought to result from a cushioning effect of the sigmoid colon on the left ureter and from greater right ureteral compression exerted by the dextrorotated uterus. Pyelonephritis and pain from overdistention are occasional manifestations of this physiologic phenomenon; however, rupture of the renal collecting system may rarely occur, especially with intraluminal pressures exceeding 20–75 mm Hg.1 Spontaneous rupture of the urinary tract in pregnancy has been reported mostly to occur in the second and third trimesters and involves the pelvicalyceal system.4–6 There is usually some underlying renal pathology in these cases.7 One report described a pregnant patient who developed spontaneous rupture of the renal pelvis after an intravenous fluid bolus.8 Patients often present with sudden onset of severe abdominal and flank pain associated with nausea and vomiting mimicking a ureteric colic. They may also present with an acute abdomen as a result of an infected urinoma or a retroperitoneal hematoma if there is associated injury to renal parenchyma.2 Because it is a rare occurrence, diagnosis remains a challenge and is usually apparent on contrast CT with delayed films and can be confirmed on retrograde pyelogram. The location of the rupture at the level of the midureter is unusual as is the likely intrapartum occurrence of the rupture. Our patient did not have any underlying renal pathology or other predisposing risk factors. Although our patient had manual uterine exploration, the likelihood of ureteral rupture resulting from manipulation at that time is remote, especially because there was no instrumentation and no uterine perforation. Also, the likelihood of an avulsive force injuring the ureter during the manual exploration is unlikely as a result of the location of the rupture at the midureter and the absence of retroperitoneal bleeding that would be expected from such an injury in a pregnant patient. Therefore, it is unlikely that the injury was iatrogenic. We hypothesize that the increased intraluminal pressure resulting from physiologic hydronephrosis of pregnancy in addition to rapid changes in intraabdominal pressure while pushing might have resulted in the ureteral rupture, whereas the intravenous fluid bolus that the patient received before the epidural might have contributed by increasing the urine flow and further increased the intraluminal pressure. The fact that the rupture occurred on the right side supports our hypothesis
Narasimhulu et al
Intrapartum Spontaneous Ureteral Rupture
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
611
Fig. 2. Computed tomography scan of the abdomen, sagittal view, showing leakage of contrast from the right ureter (yellow arrows) with the extravasated contrast tracking along the psoas muscle (red arrows). Narasimhulu. Intrapartum Spontaneous Ureteral Rupture. Obstet Gynecol 2015.
because physiologic hydronephrosis of pregnancy is more pronounced on the right side. The fact that our patient had a decrease in hematocrit with free fluid in the pelvis led to the diagnosis of intraabdominal bleeding as the most likely cause of the pain, because nephrolithiasis and appendicitis were ruled out on the initial noncontrast CT scan. Our patient also had a negative renal ultrasonogram, which may be related to the location of the ureteral injury at the midureter. Other reports of spontaneous rupture in pregnancy were at the renal pelvis, and hence perinephric fluid was seen on ultrasonogram in some of these patients. In patients in whom the diagnosis was delayed, especially in the older case reports, infection of the urinoma set in with perinephric abscess formation and nephrectomy became necessary. We report this case to make readers aware of this extremely rare but possible complication so that diagnosis is not unduly delayed.
612
Narasimhulu et al
REFERENCES 1. Pampana E, Altobelli S, Morini M, Ricci A, D’Onofrio S, Simonetti G. Spontaneous ureteral rupture diagnosis and treatment. Case Rep Radiol 2013;2013:851859. 2. Izumoto H, Matsui H, Hayashi H, Kondo R, Teramoto S. Spontaneous renal rupture in pregnancy. Arch Surg 1989;124:389. 3. Schulman A, Herlinger H. Urinary tract dilatation in pregnancy. Br J Radiol 1975;48:638–45. 4. Wolff JM, Jung PK, Adam G, Jakse G. Non-traumatic rupture of the urinary tract during pregnancy. Br J Urol 1995;76:645–8. 5. Satoh S, Okuma A, Fujita Y, Tamaka M, Nakano H. Spontaneous rupture of the renal pelvis during pregnancy: a case report and review of the literature. Am J Perinatol 2002;19:189–95. 6. Sidra LM, Keriakos R, Shayeb AG, Kumar N, Najia S. Rupture renal pelvicalyceal system during pregnancy. J Obstet Gynaecol 2005;25:61–3. 7. Eaton A, Martin PC. Ruptured ureter in pregnancy—a unique case? Br J Urol 1981;53:78–9. 8. Huang E, Sayegh R, Craigo S, Chelmow D. Rupture of the renal pelvis associated with intravenous fluid bolus. J Matern Fetal Neonatal Med 2002;11:345–6.
Intrapartum Spontaneous Ureteral Rupture
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
