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Abdominal pregnancy with complete ureteral obstruction: A case report
Volume 120 Number 2
Patient
Abdominal pregnancy with complete ureteral obstruction: A case report CLIFFORD A. LEVITT, JAMES M. INGRAM, Tampa, Florida A c A s E o F abdominal plete ureteral obstruction of the literature revealed
M.D. M.D.
pregnancy with comis reported. A review no other report of this
problem. The management of the acute anuric state and subsequent surgical treatment are presented, and the possible mechanism of this association is discussed. J. H. was a 23-year-old black woman, gravida 3, para 2, who was first seen in the emergency room on Feb. 28, 1972, complaining of right lower quadrant pain, nausea, vomiting, and a 12 pound weight loss over a two-month period. Her last normal menstrual period had begun on Oct. 11, 1971. Three days of spotting occurred on NOV. I2 to 15, 1971. She had been treated for a urinary tract infection three weeks prior to her visit to the emergency room. Pelvic examination revealed a uterus compatible in size with 16 weeks’ gestation. There was tenderness and guarding in the right lower quadrant, but no mass was palpated in either adnexal region. Laboratory data showed a hemoglobin of 10.6 Gm., white cell count of 13,500, and a catheterized urine which contained 35 to 40 white blood cells per high-power field and many bacteria. The Gravindex test was positive. After admission for observation, a placental scan demonstrated the placenta to be in the right posterolateral portion of the true pelvis. Over the next seven days her pain and urinary infection subsided, and she was discharged with antibiotic therapy. Four days after discharge, she returned to the clinic complaining of recurrent right lower quadrant pain, anorexia, swelling of her feet, and diminished output of urine. The patient was afebrile, lethargic, and incapable of answering questions clearly. The abdomen was slightly distended and there was abdominal tenderness which was most marked in the right lower quadrant. Pitting edema of the lower extremities was present. A marked change in the pelvic examination from her previous admission was noted. The contour of the uterus could not be identified, and both adnexal regions contained a soft, tender, immobile mass which was not separable from the cervix. No fetal tones could be detected with the Doptone. An admission diagnosis of possible abdominal Presented by invitation at the Thirty-sixth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Miami Beach, Florida, January 27-30, 1974. Reprint requests: Dr. Clifford A. Levitt, 10320 N. 56th St., Tampa, Florida 33617.
presentations
203
pregnancy, with either dehydration or partial ureteral obstruction, was made. On admission the hemoglobin was 7.5 Gm., the white cell count was 10,500, and the blood urea nitrogen (BUN) was 110 mg. per 100 ml. All other blood chemistry values were essentially normal. During the first 24 hours following admission, the total urinary output from a Foley catheter was 50 C.C. During the second 24 hours, the patient was anuric. Intake of 2,500 C.C. per 24 hours was maintained. The patient was observed closely for signs of intraperitoneal bleeding. A scout film of the abdomen revealed a fetal skeleton estimated to be of 16 weeks’ gestation, displaced to the left, and partially in the true pelvis. The entire soft tissue shadow was compatible with a uterus and pregnancy of 16 to 18 weeks’ gestation. An infusion pyelogram demonstrated a marked bilateral hydronephrosis and hydroureter, with complete obstruction of both ureters at the pelvic brim. Forty-eight hours after admission, bilateral No. 6F ureteral catheters were inserted without difficulty under cystoscopy. There was an immediate return of urine, under increased pressure, from both catheters. Retrograde pyelography at this time confirmed the presence of bilateral hydronephrosis and hydroureter. There was a prompt diuresis of 9 L. of urine over the next 16 hours. Twenty-four hours after insertion of the catheters the BUN was 34 mg. per 100 ml. and 48 hours after insertion the BUN had decreased to 5 mg. per 100 ml. During the next five days, with the catheters in place, the patient continued in a postobstructive diuresis. Urinary output was replaced for the first three days with equal volumes of 5 per cent dextrose in 0.5N saline and other electrolytes were supplemented as required. The anemia was corrected with the administration of 3 U. of packed red blood cells. The nephrology consultant team advised postponement of surgery, with careful observation for signs of internal bleeding, until the acute diuretic phase was over, and until both electrolyte balance and hematocrit values were stabilized. On the seventh hospital day, celiotomy revealed an abdominal pregnancy of approximately 16 weeks’ gestation, with the amniotic sac and fetus displaced to the left side of the pelvis. The placenta was implanted in the cul-de-sac and upon the posterior surface of the vagina, cervix, lower uterine fundus, and right broad ligament. The peritoneum overlying both ureters was covered either by the placenta or by an old hematoma of a partial abruptio placentae. The volume of the organized hematoma was equal in size to that of the placenta. During the removal of the fetus and exploration of the pelvis, this previously abrupted site was again separated, with an immediate blood loss of 1,500 C.C. Approximately 50 per cent of the placenta was removed, along with the fundus of the uterus and the right adnexa. A supracervical hysterectomy was elected because it would have been necessary to dissect directly into
204
Patient
presentations
the placental implantation site in order to remove the cervix. Blood loss during surgery was estimated at 3,000 C.C. and the same volume of blood was replaced by transfusion. The autolyzed fetus measured 14 cm. in sitting height and weighed 115 grams. The placental tissue and organized clot weighed a total of 480 grams. Postoperatively the urinary output was satisfactory, and the ureteral catheters were removed on the third postoperative day. Retrograde pyelograms at the time of removal showed a normal left pelvocalyceal system and ureter but there was ptosis and hydrnnephrosis remaining on the right. All BUN values were normal following the operation. Except for a moderate adynamic ileus, the patient had an uneventful postoperative course and was discharged on the eighth postoperative day. During the next six weeks, she received methotrexate, 10 mg. daily for five days, at two-week intervals. Serum gonadotropin levels were followed weekly by radioimmunoassay. The first three were above pituitary levels but by six weeks after surgery the gonadotropins were well within pituitary levels (less than 20 M.I.U. per mil vs. the Second International Reference Preparation for HMG). Six weeks after sllrgery, there was a definite fullness, but no fixation or tenderness in the cul-de-sac. The patient was lost to follow-up at this time. Although the literature on both dominal pregnancy is extensive,l-:j tient with symptomatic ondary to either of
tubal only
and one
ureteral obstruction these conditions has
abpasecbeen
reported. Hovadhanakul, Eachempati, and Cavanagh,’ in 1971, found partial obstruction of the right ureter associated with a chronic intraligamentous ectopic pregnancy. In this patient, a dilated right ovarian vein was found to compress the ureter. However, these workers considered that the ovarian vein syndrome was a srcondary ohstrllction mrntous
effect and M‘;~s the mass romhined
that the primary pressure of the with periureteral
rause of intraligafibrosis.
The snmp dual mcc-hanisnl of obstruction was present in thiq patient. The pressure of the fixcad combined mass of tho fetus, amniotic sac, and placenta contril)uted to the obstruction. ever. the inflammatory response of urctcral tissue to placental implantation the hematoma of partial abruptio probably played an equal or greater A review of the literature by both and ourselves revealed no other report
Howperiand to placentae role. Cavanagh of this the
problrm. Hobvcver. considering the frequency with which the placenta is implanted upon the posterior broad ligament and pelvic peritoneum it seetns rrasonable to assume that varying degrees of ureteral obstruction, secondary to abdominal pregnanry, occur fairly often. Only in the rare patient in whom the obstruction was symptomatic has the urinary tract been investigated. In addition, the frequently acute and lifethreatening nature of the problem precludes urinary trart study. In our patient, complete urinary obstruction was the dominant presenting symptom, and it posed a greater immediate threat than the abdominal pregnanry itself. Surgical management of the abdominal pregnancy was carried out only after mechanical relief of the obstruction, diuresis, resolution of acute azotemia, and correction of anemia by transfusions were accomplished.
REFERENCES
1. Crawford, J. D., and Ward, J. V.: Obstet. Gynecol. 10: 549, 1957. 2. Cross, J. B., Lester, W. M., and McCain, J. R.: AM. J. OBSTET. GYNECOL. 62: 303, 1951. 3. Ware, H. H.: AM. J. OBSTET. GYNECOL. 55: 561, 1948. 4. Hovadhanakul, P., Eachempati, U., and Cavanagh. D.: 4111. J. OBSTET. GYNECOL. 110: 311. 1971.
Patient
Abdominal pregnancy with complete ureteral obstruction: A case report CLIFFORD A. LEVITT, JAMES M. INGRAM, Tampa, Florida A c A s E o F abdominal plete ureteral obstruction of the literature revealed
M.D. M.D.
pregnancy with comis reported. A review no other report of this
problem. The management of the acute anuric state and subsequent surgical treatment are presented, and the possible mechanism of this association is discussed. J. H. was a 23-year-old black woman, gravida 3, para 2, who was first seen in the emergency room on Feb. 28, 1972, complaining of right lower quadrant pain, nausea, vomiting, and a 12 pound weight loss over a two-month period. Her last normal menstrual period had begun on Oct. 11, 1971. Three days of spotting occurred on NOV. I2 to 15, 1971. She had been treated for a urinary tract infection three weeks prior to her visit to the emergency room. Pelvic examination revealed a uterus compatible in size with 16 weeks’ gestation. There was tenderness and guarding in the right lower quadrant, but no mass was palpated in either adnexal region. Laboratory data showed a hemoglobin of 10.6 Gm., white cell count of 13,500, and a catheterized urine which contained 35 to 40 white blood cells per high-power field and many bacteria. The Gravindex test was positive. After admission for observation, a placental scan demonstrated the placenta to be in the right posterolateral portion of the true pelvis. Over the next seven days her pain and urinary infection subsided, and she was discharged with antibiotic therapy. Four days after discharge, she returned to the clinic complaining of recurrent right lower quadrant pain, anorexia, swelling of her feet, and diminished output of urine. The patient was afebrile, lethargic, and incapable of answering questions clearly. The abdomen was slightly distended and there was abdominal tenderness which was most marked in the right lower quadrant. Pitting edema of the lower extremities was present. A marked change in the pelvic examination from her previous admission was noted. The contour of the uterus could not be identified, and both adnexal regions contained a soft, tender, immobile mass which was not separable from the cervix. No fetal tones could be detected with the Doptone. An admission diagnosis of possible abdominal Presented by invitation at the Thirty-sixth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Miami Beach, Florida, January 27-30, 1974. Reprint requests: Dr. Clifford A. Levitt, 10320 N. 56th St., Tampa, Florida 33617.
presentations
203
pregnancy, with either dehydration or partial ureteral obstruction, was made. On admission the hemoglobin was 7.5 Gm., the white cell count was 10,500, and the blood urea nitrogen (BUN) was 110 mg. per 100 ml. All other blood chemistry values were essentially normal. During the first 24 hours following admission, the total urinary output from a Foley catheter was 50 C.C. During the second 24 hours, the patient was anuric. Intake of 2,500 C.C. per 24 hours was maintained. The patient was observed closely for signs of intraperitoneal bleeding. A scout film of the abdomen revealed a fetal skeleton estimated to be of 16 weeks’ gestation, displaced to the left, and partially in the true pelvis. The entire soft tissue shadow was compatible with a uterus and pregnancy of 16 to 18 weeks’ gestation. An infusion pyelogram demonstrated a marked bilateral hydronephrosis and hydroureter, with complete obstruction of both ureters at the pelvic brim. Forty-eight hours after admission, bilateral No. 6F ureteral catheters were inserted without difficulty under cystoscopy. There was an immediate return of urine, under increased pressure, from both catheters. Retrograde pyelography at this time confirmed the presence of bilateral hydronephrosis and hydroureter. There was a prompt diuresis of 9 L. of urine over the next 16 hours. Twenty-four hours after insertion of the catheters the BUN was 34 mg. per 100 ml. and 48 hours after insertion the BUN had decreased to 5 mg. per 100 ml. During the next five days, with the catheters in place, the patient continued in a postobstructive diuresis. Urinary output was replaced for the first three days with equal volumes of 5 per cent dextrose in 0.5N saline and other electrolytes were supplemented as required. The anemia was corrected with the administration of 3 U. of packed red blood cells. The nephrology consultant team advised postponement of surgery, with careful observation for signs of internal bleeding, until the acute diuretic phase was over, and until both electrolyte balance and hematocrit values were stabilized. On the seventh hospital day, celiotomy revealed an abdominal pregnancy of approximately 16 weeks’ gestation, with the amniotic sac and fetus displaced to the left side of the pelvis. The placenta was implanted in the cul-de-sac and upon the posterior surface of the vagina, cervix, lower uterine fundus, and right broad ligament. The peritoneum overlying both ureters was covered either by the placenta or by an old hematoma of a partial abruptio placentae. The volume of the organized hematoma was equal in size to that of the placenta. During the removal of the fetus and exploration of the pelvis, this previously abrupted site was again separated, with an immediate blood loss of 1,500 C.C. Approximately 50 per cent of the placenta was removed, along with the fundus of the uterus and the right adnexa. A supracervical hysterectomy was elected because it would have been necessary to dissect directly into
204
Patient
presentations
the placental implantation site in order to remove the cervix. Blood loss during surgery was estimated at 3,000 C.C. and the same volume of blood was replaced by transfusion. The autolyzed fetus measured 14 cm. in sitting height and weighed 115 grams. The placental tissue and organized clot weighed a total of 480 grams. Postoperatively the urinary output was satisfactory, and the ureteral catheters were removed on the third postoperative day. Retrograde pyelograms at the time of removal showed a normal left pelvocalyceal system and ureter but there was ptosis and hydrnnephrosis remaining on the right. All BUN values were normal following the operation. Except for a moderate adynamic ileus, the patient had an uneventful postoperative course and was discharged on the eighth postoperative day. During the next six weeks, she received methotrexate, 10 mg. daily for five days, at two-week intervals. Serum gonadotropin levels were followed weekly by radioimmunoassay. The first three were above pituitary levels but by six weeks after surgery the gonadotropins were well within pituitary levels (less than 20 M.I.U. per mil vs. the Second International Reference Preparation for HMG). Six weeks after sllrgery, there was a definite fullness, but no fixation or tenderness in the cul-de-sac. The patient was lost to follow-up at this time. Although the literature on both dominal pregnancy is extensive,l-:j tient with symptomatic ondary to either of
tubal only
and one
ureteral obstruction these conditions has
abpasecbeen
reported. Hovadhanakul, Eachempati, and Cavanagh,’ in 1971, found partial obstruction of the right ureter associated with a chronic intraligamentous ectopic pregnancy. In this patient, a dilated right ovarian vein was found to compress the ureter. However, these workers considered that the ovarian vein syndrome was a srcondary ohstrllction mrntous
effect and M‘;~s the mass romhined
that the primary pressure of the with periureteral
rause of intraligafibrosis.
The snmp dual mcc-hanisnl of obstruction was present in thiq patient. The pressure of the fixcad combined mass of tho fetus, amniotic sac, and placenta contril)uted to the obstruction. ever. the inflammatory response of urctcral tissue to placental implantation the hematoma of partial abruptio probably played an equal or greater A review of the literature by both and ourselves revealed no other report
Howperiand to placentae role. Cavanagh of this the
problrm. Hobvcver. considering the frequency with which the placenta is implanted upon the posterior broad ligament and pelvic peritoneum it seetns rrasonable to assume that varying degrees of ureteral obstruction, secondary to abdominal pregnanry, occur fairly often. Only in the rare patient in whom the obstruction was symptomatic has the urinary tract been investigated. In addition, the frequently acute and lifethreatening nature of the problem precludes urinary trart study. In our patient, complete urinary obstruction was the dominant presenting symptom, and it posed a greater immediate threat than the abdominal pregnanry itself. Surgical management of the abdominal pregnancy was carried out only after mechanical relief of the obstruction, diuresis, resolution of acute azotemia, and correction of anemia by transfusions were accomplished.
REFERENCES
1. Crawford, J. D., and Ward, J. V.: Obstet. Gynecol. 10: 549, 1957. 2. Cross, J. B., Lester, W. M., and McCain, J. R.: AM. J. OBSTET. GYNECOL. 62: 303, 1951. 3. Ware, H. H.: AM. J. OBSTET. GYNECOL. 55: 561, 1948. 4. Hovadhanakul, P., Eachempati, U., and Cavanagh. D.: 4111. J. OBSTET. GYNECOL. 110: 311. 1971.