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Dilatation of the Ureters and Renal Pelves in Pregnancy1
DILATATION OF THE URETERS AND RENAL PELVES IN PREGNANCY 1 UROLOGICAL STUDY OF THE NORMAL ANTEPARTUM AND POSTPARTUM WOMAN MAGNUS I. SENG Department of Urology, Royal Victoria Hospital, Montreal
Preliminary to an investigation into the causes of pyelitis in pregnancy it was thought pertinent to study the changes taking place in the normal pregnant and puerperal woman. That changes in the urinary as well as the genital system occur during pregnancy has long been known. When such changes first appear, to what extent they develop, and what their effect might be has been more a matter of supposition than exact knowledge. Cruveilhier (1) in the middle nineteenth century (1843) was the first to report finding dilatation of the ureters in women dying during the latter months of pregnancy and the puerperium; He was followed by other observers such as Olshausen (2), Prutz (3), Lohlein (4). These investigators had to confine their endeavors to the autopsy specimen as it was in the days either just before or just at the beginning of the present era of detailed experimental and clinical study of the urinary system. Two other workers lately have contributed studies of the changes in the ureter occurring during pregnancy. W. J. Carson (5) (1926) and J. Hofbauer (6) (1928) working independently both found hypertrophy and hyperplasia of the muscle and fibrous tissue of the lower ureter. Hofbauer in addition found that the trigone of the bladder was concerned in the same marked change. Numerous writers have studied the pregnant woman who is a victim to pyelitis. The literature is replete with the earnest and 1 Read at the annual meeting of the American Urological Association, Chicago, June, 1928. 475
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tireless endeavors of these authors; notable amongst them being Crabtree (7), Pugh (8), Corbus and Danforth (9), and Runner (10). Except for indefinite references the literature concerning the urinary changes in the healthy pregnant and puerperal woman is almost silent. Kretschmer and Heaney (11) are perhaps the first to contribute to the literature a study of a small series of normal pregnant women. Our study will take in first of all, a small series of healthy nulliparous women as controls; next a series of seventy-eight women, everyone free from symptoms indicative of renal infection. We deemed it advisable to establish, if possible, a standa d by which to judge the earliest moment of change, and the extent and the development of such occurring in the antepartum and the postpartum woman. Our study of ten nulliparous women confirmed the findings of other workers, that the capacity of the normal ureter and renal pelvis varies from 5 cc. to 13 cc. the average being 7.5 cc. Further we demonstrated that the normal ureter and renal pelvis could not be dilated at cystoscopy beyond their normal capacity without evidence of great distress in the patient. The antepartum series consisted of forty-two women; fifteen primiparae and twenty-seven multiparae. The period of pregnancy ranged from the sixth week to term. The postpartum series were made up of thirty-six women who were studied from as early as the ninth to the twenty-fifth postpartum day. One case included in the series was at the twentyfirst month and another nine years after the last pregnancy. The technique consisted in obtaining a catheterized specimen of the bladder urine for complete urinalysis and cultural growth; then the bladder was filled to capacity with 6 per cent sodium iodide solution and a cystogram taken. Following this a cystoscopic examination with ureteral catheterization was performed, specimens from each kidney were taken for analysis and cultural growth. Then the renal pelvis and ureters were filled with a 12 per cent sodium iodide solution and the skiagraphs taken.
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477
Both ureters and renal pelves were injected simultaneously by syringe. No manometer was used. Much care was taken to inject slowly and to stop at the slightest evidence of discomfort to the patient. In but four instances was there any complaint on the part of the patient. The urethra. The urethra of the pregnant woman seems to share, with the rest of the pelvic organs, in the marked general congestion. There existed a noticeable ease with which the
FIG. 1.
CYSTOGRAM OF MULTIPARA AT SEVENTH MONTH,
SHOWING MARKED
DISTORTION
cystoscope could be passed. In the postpartum woman the congestion had disappeared. Bladder. Other than the very pronounced changes occurring in the trigone, the bladder mucosa of the pregnant woman showed very few differences from that of her non-pregnant sister. The vessels were larger, fuller and at times tortuous. Cystography revealed some very interesting and sometimes startling distortions in the contour of the bladder.
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MAGNUS I. SENG
The postpartum bladder had already resumed the appearance of that of the nonpregnant woman as early as the ninth day.
Cystography showed no distortion but considerable relaxation.
FIG. 2.
CYSTOGRAM OF MULTIPARA AT TWELFTH POSTPARTUM DAY, SHOWING MARKED RELAXATION OF BLADDER
Contrary to the findings of Gauss (12) corroborated by Stoeckel (13), Hofbauer, and Luchs (14), we were unable to demonstrate an insufficiency of the uretero-vesical valve at any stage of pregnancy or in any of the puerperal cases in our series.
DILATATION OF URETERS AND RENAL PELVES
479
Trigonum vesicae. This portion of the bladder in the pregnant woman presented a decided change from the normal. Congestion of the mucosa became apparent early-in multiparae at the eighth week, in primiparae the tenth week. As in all the pelvic organs it was progressive as pregnancy proceeded. About the same period of pregnancy a new feature began to make itself apparent. There was a lengthening of the vesical trigone from the urethro-vesical orifice to the inter-ureteric ridge and a broadening of the base of the triangle, so that in many cases the ureteral orifices were really further apart than in the bladder of the nonpregnant woman. The impression obtained at cystoscopy was that a crowding upward of the trigone ocurred, giving less room than usual. This was so pronounced in a number of cases, that the cystoscope passed through the urethra directly onto the trigone but not so far as the inter-ureteric ridge, so that catheterization of the ureters had to be performed from a considerable distance. The elevation of the trigone was most noticeable along the interureteric ridge, which stood out with unusual prominence. The floor of the bladder fell away from the ridge rapidly and acutely, so that it became a valley, or even a "bas fond." Perhaps this fact is responsible for the statement of Curtis (15) that a residuum exists in the bladder of the pregnant woman. Although we en:countered no such finding in our series, it is not difficult to understand that in a certain percentage of cases a residual urine may occur, especially in the last trimester of pregnancy when the congestion, elevation and elongation of the vesical trigone are most pronounced. The ureteral orifices. Presented no change from the normal, except as noted above, they frequently were more widely separated than usual, due to the broadening of the trigone. Ureteral catheterization presented no difficulty whatever from the ureteral orifice to the renal pelvis. Cystoscopic visualization of the bladder and trigone, as early as the ninth postpartum day, showed a complete disappearance of the congestion, elongation and elevation noted in the antepartum cases.
480
MAGNUS I. SENG
Bladder urine. The catheterized bladder urine in both the antepartum and postpartum series showed no gross abnormalities. In our complete investigation of seventy-eight cases, albumen was present in but four, casts were found in only two. Microscopic examination and cultural growth of the catheterized bladder urine of pregnant and puerperal women presented, to our minds, definite findings, which were entitled to thorough study. TABLE 1
Bladder i,rine MICROSCOPIC A~D CULTURE GROWTH
White blood cells .................................... . Frank pus ........................................... . Coliform organisms .................................. . Cocca! organisms. . . . . . . . . . . .................... . No growth .......................................... .
AKTEPARTUM
POSTPARTUM
per cent,
per cent
40 2.4 12 45 20
61 19 13 66 19
TABLE 2
Ureteral urines ANTEPARTU:M
White blood cells ........... Frank pus .................. Coliform organisms .......... Cocca! organisms ............ No growth ..................
POSTPARTUM
Right ureter
Left ureter
Right ureter
Left ureter
per cent
per cent
per cent
per cent
23.8 0.0 9.0 50.0 56.0
9.0 2.4 9.0 35.0 47.0
8.0 2.7 2.7 61.0 36.0
11.0
2.7 11.0 29.7 63.0
We were impressed with the large percentage of the occurrence of white blood cells. In our series we will consider the presence of white blood cells in the urine, when not due to blood, as clinical evidence suggestive of infection. Table 1 demonstrates a 42 per cent incidence in the antepartum cases, which rose in the postpartum ones to 80 per cent. The most surprising finding in the cultural growths, was the evidence of some variety of the coliform bacillus in these apparently healthy pregnant and puerperal women. The presence of
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481
these bacilli must be taken seriously. The very fact that they were found indicates that they were making their way into the bladder from some source. Regarding the coccal infections, which are usually considered as contaminations of technique, their high incidence in our series make us regard them with suspicion and worthy of more extended investigation. Microscopic examination of the urine from both kidneys showed in the presence of white blood cells and frank pus, a marked decrease when viewed with the same picture of the bladder urine. To the contrary, a study of the coliform organisms demonstrated the persistence of these bacteria in the kidney urine in but a slightly lowered percentage. The occurrence of pyelitis in four (5.1 per cent) cases in the series was of decided interest and deep significance. It appeared in the earliest case, three weeks after cystoscopy. Three cases developed prenatally, one in a primigravida, two in the multigravida. One case, demonstrating the attack, on the tenth postpartum day, was in a multipara. Everyone of these cases gave a positive coliform growth in the ureteral and bladder urine at the time of cystoscopy. This would lead us to infer that a cultural study of the bladder and ureteral urines may prognosticate a potential renal complication. URETERAL DILATATION
Ureteral dilatation occurring during pregnancy, has long been recognized. Our effort has been to determine, if possible, the earliest moment of onset, in the primipara and multipara, with a comparison between the two. Secondly to estimate the character of its progress with regard to the period of pregnancy. Finally to determine if this condition is persistent into the postpartum period. Dilatation of the ureter of some degree was noted by us as early as the sixth week in multiparae and at the tenth week in pnm1parae.
482
MAGNUS I. SENG
Regarding the character and progress of the dilatation, when considered with the different periods of pregnancy, our experience seems to show that dilatation, while appearing very early in both primaparae and multiparae, reaches its maximum shortly; at the twenty-fourth week in primiparae and the twenty-second week in multiparae. The amount of sodium iodide solution which could be injected into the ureter, without pain did not vary to any
0
" :n
-!
Fm. 3
Fm. 4
Fm. 3. NU'LLIPARA Ureteropyelograms showing normal renal pelves and ureters. to 8 cc. Fm. 4.
Capacity 7,5
MULTIPARA AT SIXTH WEEK OF PREGNANCY, SHOWING EARLY, ALTHOUGH
DISTINCT, DILATATION OF BOTH URETERS AND MILD HYDRONEPHROSIS
extent, whether in early or late pregnancy. It may be stated that on no occasion was an effort made to instil more than 30 cc. of the iodide solution. The average amount used by us in our examinations was 15 cc. Ureterograms made with 30 cc., in no way showed a greater degree of dilatation or a better definition. Our studies have impressed us more with the tissue factor of each individual woman.
DILATATION OF URETERS AND RENAL PELVES
483
Further the multiparous woman demonstrated dilatation earlier in pregnancy, than the primiparae. In both the right ureter exhibited some degree of hydrometer in every instance. In left sided and bilateral hydrometer the multiparae showed a greater frequency of dilatation than the primiparae. The more pronounced types of hydrometer were found in the multiparae.
FIG. FIG.
5.
5
Frn. 6
PRIMIPARA AT TENTH WEEK OF PREGNANCY, SHOWING DILATATION OF THE URETERS SEEN AT THIS EARLY STAGE OF PREGNANCY
Note ureterograms showing throughout course of lower ureters. FIG.
6.
PRIMIPARA AT FOURTEENTH WEEK OF PREGNANCY
Bilateral dilatation of ureters with hydronephrosis. lower ureterograms.
Note abbreviation of
"\Ve have been impressed with the possible fact that the ureter having once been dilated over a period of many weeks, returned· apparently to normal but in a relaxed state. The study of the ureter in thirty-six cases, from the ninth to the twenty-fifth postpartum day, revealed the fact that while return to normal had taken place rapidly, in a minority of these cases, within these time limits, there still remained a great majority
484
MAGNUS I. SENG
showing right, left, and bilateral dilatation. In fact we have ureterograms of two cases which demonstrate some persistence, in the absence of disease, over periods of twenty-one months and nme years. URETERAL DISTORTIONS
Beginning at the sixthteen th week the antepartum differed from the postpartum ureter in the abrupt termination of the ureteroTABLE 3
Ureteral dilatation ANTEPA.R'I'UM
POSTPARTUM
Primipara
Right .................................. . Left .................................... . Bilateral ............................... . No dilatation right .. No dilatation left.
Mult1para
per cent
per bent
100 0 66.6 66.6
100.0 77.0 77.0
33.3
23.0
per cent
86.0 63.8 66.6 13.8 36.1
TABLE 4
H ydronephrosis ANTEPARTUM POSTPARTUM
Right ................................. . Left .................................... . Bilateral ... . No dilatation right ..................... . No dilatation left ....................... .
Primipara
Multi para
per cent
per cent
per cent
93.0 46.2 46.5 6.6 53.8
96 0 66.0 62.0 3.0 33.0
72.2 52.7 44.4 27.7 47.2
gram at the level of its entry into the parametrium. On the other hand the postpartum ureter could easily be traced to the bladder, in fact, a dilatation of this lower third was in certain instances demonstrated. Redundancy and kinking of the ureter, while a very definite finding in both antepartum and postpartum cases, was much more frequent and in greater degrees in the prenatal skiagraphs. An appreciable stricture revealed itself but once in this whole
DILATATION OF URETERS AND RENAL PELVES
485
series of one hundred and fifty-six ureters. This one case was found in the left ureter of a postpartum woman. HYDRONEPHROSIS
The same observation made concerning hydroureter may be largely applied to hydronephrosis. It begins as early as the sixth
FIG.
7
FIG. 8
7. MuLTIPARA AT THE SIXTEENTH \VEEK OF PREGNANCY Right ureteral dilatation with hydronephrosis. Left ureter and pelvis not dilated. Both ureterograms abbreviated, lower portion. FIG.
FIG.
8.
MULTIPARA AT TWENTY-SECOND WEEK OF PREGNANCY
Type of hydroureter and hydronephrosis showing maximum development of dilatation. Note redundancy, haustration and abbreviation of ureters.
week in multiparae and the tenth in primiparae and reaches its maximum at the twenty-fourth week in primiparae and at the twenty-second week in multiparae. Referring to table 4, the frequent incidence of hydronephrosis in primigravidae and multigravidae and the postpartum patient is emphasized. The continued predomina::ice of right sided dilatation is very evident. Left pelvic dilatation, while not quite so frequent in occurrence as left hydroureter, developed in a large
486
MAGNUS I, SENG
proportion of the three groups. The same remarks may be made of the ratio of bilateral dilatation. The escape of the left renal pelvis, to an even greater degree than the left ureter, must be remarked because of the recognized frequency of right sided pyelitis. A marked pelvic dilatation on the right side in primiparae was found in 73.2 per cent; in multiparae 81 per cent; in the post-
Fm. 9
Fm.IO
Fm. 9. MULTIPARA AT TERM Showing ureteral dilatation with marked hydronephrosis. redundant.
Ureters dilated and
Fm. 10. MuLTIPARA AT TWELFTH POSTPARTUM DAY Dilatation of ureters and renal pelves persisting into puerperal period. Note abbreviation of ureters at brim of pelvis. Definition of ureters below this pointnot seen in antepartum cases after sixteenth weeko
partum 55.5 per cent. The same degree of dilatation in the left was in primigravidae 33 per cent; in multigravidae 40 per cent; in the postpartum 27 per cent. Marked hydronephrosis was found much more frequently in the multiparous woman. While the hydronephrosis in our series of antepartum and
487
DILATATION OF URETERS AND RENAL PELVES
postpartum women have been well defined and even marked dilatations, in no case have we noted the extreme distension mentioned by other authors. The largest amount of urine recovered in our series was 67 cc. the average being 5 cc. Possibly these very much over-dilated renal pelves reported by others, were associated with some degree of infection. Dilatation to the extent of 30 to 480 cc. of urine recovered, has been reported by Crabtree. There is a very evident recovery of the pelvic tone early in the period TABLE5
Stasis in the antepartum TIME IN WHICH RENAL PELVES AND URETERS EMPTY
7 minutes (normal) ...................... . 7 to 30 minutes ......................... . 30 to 60 minutes ......................... . Average time to empty .................. .
LEFT
RIGHT
20 20 60 37
per cent per cent per cent minutes
40 20 40 29
per cent per cent per cent minutes
TABLE 6
Stasis comparison between antepartum and postpartum TIME IN WHICH RENAL PELVIS AND BOTH URETERS EMPTY
7minutes (normal) ....................... . 7 to 30 minutes .......................... . 30 to 60 minutes ......................... . Average time to empty .................. .
ANTEPARTUM
30 10 60 33
per cent per cent per cent minutes
POSTPARTUM
49 42 9 14
per cent per cent per cent minutes
No stasis beyond 45 minutes in postpartum.
of general postpartum involution. In this survey of the postpartum patient, which extended up to the twenty-fifth day, there is a persistence on the right side of pelvic dilatation in 72.2 per cent and on the left of 52.7 per cent of our cases. An impression derived from this point, emphasized by Helmholtz (15), leads us to believe that the dilatation produced in a first pregnancy, must have an influence in the production of the greater frequency and the more marked degree of dilatation found in multiparae.
488
MAGNUS I. SENG STASIS
In our investigation of t his very important factor in the development of pyelitis, we have a series of twenty antepartum and twenty-six postpartum cases. Our technique has been t hat developed by Goldstein (16). Skiagraphs were taken immediately, and at seven, ten, fifteen, twenty, thirty, forty-five and sixty minutes, after the instillation
FIG.
FIG.11
12
11 . PRIMIPARA AT TWE N TIETH WEEK OF PREGNANCY, SHOWING STASIS Skiagraphs taken at 7, 10, 15, 30, 45 and 60 minutes after instillation of iodide solution. FIG.
FIG.
12.
SAME PATIENT A S FIGURE 11
Skiagraph 45 minutes later, showing retention in right pelvis a nd both ureters
of sodium iodide solution into the ureters and renal pelves. In antepartum cases our observations revealed that the left ureter and renal pelvis emptied themselves within the normal limits of seven minutes with double frequency of t he right. Conversely, it was discovered that actual stasis from the mild degree of fifteen minutes, through the moderate type of thirty minutes to the marked group of sixty minutes delay, the right side outnumbered the left in the proportion of four to t hree.
DILATATION OF URETERS AND RENAL PELVES
489
We would emphasize the fact, that in the class of one hour's stasis, the right outnumbered the left in the proportion of two to one. In averaging the time occupied by the two sides in their efforts to empty themselves, we have found that the right side required thirty-seven minutes, the left twenty-nine. While ureteral dilatation and hydronephrosis usually appear and reach their maximum relatively early in pregnancy, stasis, however, does not make its appearance until the twentieth week. Whether it is acute or gradual, from the onset to the development of an hour's retention, we are unable to state, not having had the privilege of following a single case from its inception to the termination of gestation. We may state, that several of our cases from the twentieth to the twenty-sixth week of pregnancy have shown a delay of one hour, conversely we have had several instances in women at full term completely emptying the ureters and pelves in less than thirty minutes. It has been our experience that the multiparous woman presents more frequent, earlier and greater degrees of stasis than the primiparous patient. A comparison of stasis between the antepartum and postpartum series presents striking and interesting differences. The postpartum patient requires but one half the average time necessary to the antepartum patient, to completely empty the renal pelves and ureters. There was no appreciable difference in the time demanded by either side. There was no retention beyond fortyfive minutes. In fact the majority were completely empty within fifteen minutes. In the antepartum series we found that 30 per cent of the ureters and pelves emptied themselves within the normal limit of seven minutes, whereas in the postpartum 49 per cent were empty in the same period of time. In the former group but 10 per cent were empty in from seven to twenty minutes whereas in the latter group 42 per cent were evacuated within the same time limit. In the more marked type of stasis from thirty to sixty minutes, we have in the prenatal class 60 per cent which showed this great delay. Opposed to this latter figure we have in the postpartum series in the same group but 9 per cent,
490
MAGNUS I. SENG
which demonstrated a delay up to and including forty-five minutes. There were no postpartum cases showing stasis up to sixty minutes. The inference to be drawn, we think from this exhibit is that the uterus and its contents must play some part in maintaining stasis. All these postpartum skiagraphs of stasis were taken at or before the twelfth postpartum day. An interesting point exhibited by our examination, was the apparent complete disappearance of the emphasized abbreviation of the dilated ureter at or near the pelvic brim, noted in the antepartum cases. The ureter of the postpartum woman in contradistinction to the antepartum, shows varying degrees of dilatation of its juxtovesical portion. These findings, we think, confirm in the living subject Carson's conclusions on pressure at the pelvic brim demonstrated in the cadaver. SUMMARY AND DISCUSSION
Every pregnant woman has, at some time during her pregnancy, a varying degree of dilatation of one or both ureters and renal pelves. Dilatation may begin as early as the sixth week, and usually reaches its maximum development between the twenty-second and twenty-fourth weeks of pregnancy. It is never enormous unless associated with disease. At about the twentieth week there begins an associated demonstrable stasis which persists throughout the rest of the pregnancy but varies in intensity, not so much according to the period of the pregnancy as to the reaction of the individual woman. What causes dilatation and stasis in the pregnant woman? Graves and Davidoff (17) in their experimental observation on the reaction of the ureter to bladder distension have noted the fact that ureteral peristalsis is increased as soon as the bladder begins to fill. With greater degrees of retention, and increased intravesical pressure, the ureteral action becomes slower but more vigorous. When intravesical pressure has reached a relatively high level ureteral peristalsis again speeds up in frequency, but
DILATATION OF URETERS AND RENAL PELVES
,. ,.'
491
the ureter soon becomes dilated and ultimately unable to empty its load-an actual ureteral retention occurring. Even as early as the sixth week in pregnancy a marked increase in the vascularity of the uterus, particularly the cervix, and the uterine adnexa has taken place. This must have some obstructive influence, due to the enormous congestion, on that portion of the ureter passing through the region of most pronounced change. If the mere filling of the bladder has so distinct a reaction on the activity of the ureter, as observed experimentally, it is not unreasonable to suppose that the dilatation of the ureters and renal pelves found by us even in the early weeks of pregnancy is really a physiological reaction to pressure within the bony pelvis. In the later months of pregnancy it is not difficult to realize that with the uterus enlarging equally and progressively in all dimensions there must occur an increase in pelvic pressure which has a corresponding effect upon the lower ureters as well as the other organs within the pelvic bowl. Practically one-half of the pregnant women in our series and 80 per cent of the puerperal ones show evidences in the urine, of some infection. About one-tenth exhibit definite cultural growth of an organism whose natural habitat is the bowel, and one which is the recognized causative organism of the infection known as pyelitis. Further nearly one third of those showing the organism on cultural growth developed clinical pyelitis some weeks later in pregnancy. The presence in every pregnant woman, of almost every condition thought to be an etiological factor in the production of pyelitis, emphasizes the remarkable fact that the great majority of pregnant women escape this infection. What then causes infection? The pregnant woman is continuously in the presence of it. Organisms are forever storming the barriers of her resistance. Why is she not more often infected? It is the little understood and ill-defined immunity that saves her. We know the infecting organism, we know the factors tending to produce infection but we know next to nothing of the immunity processes. Therein lies the field for investigation.
Ji
492
MAGNUS I. SENG CONCLUSIONS
1. In pregnancy, there is a constant right sided ureteral dilatation; while right hydronephrosis is only slightly less frequent. 2. In pregnancy, the le£ t ureter and renal pelvis escape this dilatation in a markedly higher percentage of cases. 3. Bilateral hydrometer and hydronephrosis were of very frequent occurrence. 4. The multiparous woman showed these conditions earlier, more frequently, and in much more marked degree than the primipara. 5. Stasis, as measured by the inability of the renal pelvis and ureter to empty themselves within the normal time limits, is a definite and almost universal finding in the antepartum woman. 6. In the postpartum woman it is still persistent, in a lesser degree, over a prolonged period of time. 7. Every pregnant woman has obstruction of some degree, a definite dilatation of the ureters and renal pelves, with a well defined stasis. This continues over a long period of time. We have demonstrated, in the apparently healthy pregnant and puerperal patient a probable renal complication in the presence of pus and coliform organisms. In conclusion I wish to thank Dr. James W. Duncan of the Department of Obstetrics and Gynaecology, Royal Victoria Hospital, Montreal, for his kindness in providing the material for this study. I wish to thank also Dr. W. W. Beattie of the Department of Bacteriology, Royal Victoria Hospital, for his untiring laboratory work in this series. Finally I wish to thank the Chief of the Department of Urology, Royal Victoria Hospital, Montreal, Dr. D. W. MacKenzie, for allowing me to present this paper from the Department. REFERENCES (1) (2) (3) (4) (5)
CRUVEILHIER: Traite d'anatomie descriptive, Paris, 1843. OLBHAUBEN: Klin. vort. f . Gyn., 1892, xxxix, 15. PRuTz : Zeitschr. f. Geb. u. Gyn., Bd. 23, 1892. LoHLEIN: Zeitschr. f. Geb. u. Gyn., Bd. IV, S. 49. CARSON, W. J.: Jour. Urol., xvi, no. 3, pp. 167, 1926; Jour. Urol., xviii, no. 1, p . 61, 1927.
DILATATION OF URETERS AND RENAL PELVES
(6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)
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493
HoFBAUEE: Bulletin Johns Hopkins Hosp., xiii, no. 3, 1928. CRABTREE: Surg., Gynecol. and Obstet., 1922, xxxv, 733. PuoH: Jour. Urol., xviii, no. 5, 553, 1927. CoRBu,s AND DANFORTH: Jour. Urol., xviii, no. 5,543, 1927. HuNNER: Amer. Jour. Obstet., and Gynecol., 1925, ix, 47. KRETSCHMER AND HEANEY: Jour. Am. Med. Assn., lxxxv, no. 6, p. 406. GAUSS: Deutsche med. Wchnschr., 1906, 2103. STOECKEL : Deoderlein's Handbuch d. Geburtshilfe, 1925, 111; Munch. med. Wchnschr., 1924, No. 9. LucHs: Arch. f. Gyn., 1927, cxxvi. HELMHOLTZ: Wis. Med. Jour., 1927, xxvi, no. 4, 189. GOLDSTEIN: Jour. Urol., 1921, vi, 125. GRAVES AND DAVIDOFF: Jour. Urol., 1923, x, 185.
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Preliminary to an investigation into the causes of pyelitis in pregnancy it was thought pertinent to study the changes taking place in the normal pregnant and puerperal woman. That changes in the urinary as well as the genital system occur during pregnancy has long been known. When such changes first appear, to what extent they develop, and what their effect might be has been more a matter of supposition than exact knowledge. Cruveilhier (1) in the middle nineteenth century (1843) was the first to report finding dilatation of the ureters in women dying during the latter months of pregnancy and the puerperium; He was followed by other observers such as Olshausen (2), Prutz (3), Lohlein (4). These investigators had to confine their endeavors to the autopsy specimen as it was in the days either just before or just at the beginning of the present era of detailed experimental and clinical study of the urinary system. Two other workers lately have contributed studies of the changes in the ureter occurring during pregnancy. W. J. Carson (5) (1926) and J. Hofbauer (6) (1928) working independently both found hypertrophy and hyperplasia of the muscle and fibrous tissue of the lower ureter. Hofbauer in addition found that the trigone of the bladder was concerned in the same marked change. Numerous writers have studied the pregnant woman who is a victim to pyelitis. The literature is replete with the earnest and 1 Read at the annual meeting of the American Urological Association, Chicago, June, 1928. 475
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MAGNUS I. SENG
tireless endeavors of these authors; notable amongst them being Crabtree (7), Pugh (8), Corbus and Danforth (9), and Runner (10). Except for indefinite references the literature concerning the urinary changes in the healthy pregnant and puerperal woman is almost silent. Kretschmer and Heaney (11) are perhaps the first to contribute to the literature a study of a small series of normal pregnant women. Our study will take in first of all, a small series of healthy nulliparous women as controls; next a series of seventy-eight women, everyone free from symptoms indicative of renal infection. We deemed it advisable to establish, if possible, a standa d by which to judge the earliest moment of change, and the extent and the development of such occurring in the antepartum and the postpartum woman. Our study of ten nulliparous women confirmed the findings of other workers, that the capacity of the normal ureter and renal pelvis varies from 5 cc. to 13 cc. the average being 7.5 cc. Further we demonstrated that the normal ureter and renal pelvis could not be dilated at cystoscopy beyond their normal capacity without evidence of great distress in the patient. The antepartum series consisted of forty-two women; fifteen primiparae and twenty-seven multiparae. The period of pregnancy ranged from the sixth week to term. The postpartum series were made up of thirty-six women who were studied from as early as the ninth to the twenty-fifth postpartum day. One case included in the series was at the twentyfirst month and another nine years after the last pregnancy. The technique consisted in obtaining a catheterized specimen of the bladder urine for complete urinalysis and cultural growth; then the bladder was filled to capacity with 6 per cent sodium iodide solution and a cystogram taken. Following this a cystoscopic examination with ureteral catheterization was performed, specimens from each kidney were taken for analysis and cultural growth. Then the renal pelvis and ureters were filled with a 12 per cent sodium iodide solution and the skiagraphs taken.
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DILATATION OF URETERS AND RENAL PELVES
477
Both ureters and renal pelves were injected simultaneously by syringe. No manometer was used. Much care was taken to inject slowly and to stop at the slightest evidence of discomfort to the patient. In but four instances was there any complaint on the part of the patient. The urethra. The urethra of the pregnant woman seems to share, with the rest of the pelvic organs, in the marked general congestion. There existed a noticeable ease with which the
FIG. 1.
CYSTOGRAM OF MULTIPARA AT SEVENTH MONTH,
SHOWING MARKED
DISTORTION
cystoscope could be passed. In the postpartum woman the congestion had disappeared. Bladder. Other than the very pronounced changes occurring in the trigone, the bladder mucosa of the pregnant woman showed very few differences from that of her non-pregnant sister. The vessels were larger, fuller and at times tortuous. Cystography revealed some very interesting and sometimes startling distortions in the contour of the bladder.
478
MAGNUS I. SENG
The postpartum bladder had already resumed the appearance of that of the nonpregnant woman as early as the ninth day.
Cystography showed no distortion but considerable relaxation.
FIG. 2.
CYSTOGRAM OF MULTIPARA AT TWELFTH POSTPARTUM DAY, SHOWING MARKED RELAXATION OF BLADDER
Contrary to the findings of Gauss (12) corroborated by Stoeckel (13), Hofbauer, and Luchs (14), we were unable to demonstrate an insufficiency of the uretero-vesical valve at any stage of pregnancy or in any of the puerperal cases in our series.
DILATATION OF URETERS AND RENAL PELVES
479
Trigonum vesicae. This portion of the bladder in the pregnant woman presented a decided change from the normal. Congestion of the mucosa became apparent early-in multiparae at the eighth week, in primiparae the tenth week. As in all the pelvic organs it was progressive as pregnancy proceeded. About the same period of pregnancy a new feature began to make itself apparent. There was a lengthening of the vesical trigone from the urethro-vesical orifice to the inter-ureteric ridge and a broadening of the base of the triangle, so that in many cases the ureteral orifices were really further apart than in the bladder of the nonpregnant woman. The impression obtained at cystoscopy was that a crowding upward of the trigone ocurred, giving less room than usual. This was so pronounced in a number of cases, that the cystoscope passed through the urethra directly onto the trigone but not so far as the inter-ureteric ridge, so that catheterization of the ureters had to be performed from a considerable distance. The elevation of the trigone was most noticeable along the interureteric ridge, which stood out with unusual prominence. The floor of the bladder fell away from the ridge rapidly and acutely, so that it became a valley, or even a "bas fond." Perhaps this fact is responsible for the statement of Curtis (15) that a residuum exists in the bladder of the pregnant woman. Although we en:countered no such finding in our series, it is not difficult to understand that in a certain percentage of cases a residual urine may occur, especially in the last trimester of pregnancy when the congestion, elevation and elongation of the vesical trigone are most pronounced. The ureteral orifices. Presented no change from the normal, except as noted above, they frequently were more widely separated than usual, due to the broadening of the trigone. Ureteral catheterization presented no difficulty whatever from the ureteral orifice to the renal pelvis. Cystoscopic visualization of the bladder and trigone, as early as the ninth postpartum day, showed a complete disappearance of the congestion, elongation and elevation noted in the antepartum cases.
480
MAGNUS I. SENG
Bladder urine. The catheterized bladder urine in both the antepartum and postpartum series showed no gross abnormalities. In our complete investigation of seventy-eight cases, albumen was present in but four, casts were found in only two. Microscopic examination and cultural growth of the catheterized bladder urine of pregnant and puerperal women presented, to our minds, definite findings, which were entitled to thorough study. TABLE 1
Bladder i,rine MICROSCOPIC A~D CULTURE GROWTH
White blood cells .................................... . Frank pus ........................................... . Coliform organisms .................................. . Cocca! organisms. . . . . . . . . . . .................... . No growth .......................................... .
AKTEPARTUM
POSTPARTUM
per cent,
per cent
40 2.4 12 45 20
61 19 13 66 19
TABLE 2
Ureteral urines ANTEPARTU:M
White blood cells ........... Frank pus .................. Coliform organisms .......... Cocca! organisms ............ No growth ..................
POSTPARTUM
Right ureter
Left ureter
Right ureter
Left ureter
per cent
per cent
per cent
per cent
23.8 0.0 9.0 50.0 56.0
9.0 2.4 9.0 35.0 47.0
8.0 2.7 2.7 61.0 36.0
11.0
2.7 11.0 29.7 63.0
We were impressed with the large percentage of the occurrence of white blood cells. In our series we will consider the presence of white blood cells in the urine, when not due to blood, as clinical evidence suggestive of infection. Table 1 demonstrates a 42 per cent incidence in the antepartum cases, which rose in the postpartum ones to 80 per cent. The most surprising finding in the cultural growths, was the evidence of some variety of the coliform bacillus in these apparently healthy pregnant and puerperal women. The presence of
DILATATION OF URETERS AND RENAL PELVES
481
these bacilli must be taken seriously. The very fact that they were found indicates that they were making their way into the bladder from some source. Regarding the coccal infections, which are usually considered as contaminations of technique, their high incidence in our series make us regard them with suspicion and worthy of more extended investigation. Microscopic examination of the urine from both kidneys showed in the presence of white blood cells and frank pus, a marked decrease when viewed with the same picture of the bladder urine. To the contrary, a study of the coliform organisms demonstrated the persistence of these bacteria in the kidney urine in but a slightly lowered percentage. The occurrence of pyelitis in four (5.1 per cent) cases in the series was of decided interest and deep significance. It appeared in the earliest case, three weeks after cystoscopy. Three cases developed prenatally, one in a primigravida, two in the multigravida. One case, demonstrating the attack, on the tenth postpartum day, was in a multipara. Everyone of these cases gave a positive coliform growth in the ureteral and bladder urine at the time of cystoscopy. This would lead us to infer that a cultural study of the bladder and ureteral urines may prognosticate a potential renal complication. URETERAL DILATATION
Ureteral dilatation occurring during pregnancy, has long been recognized. Our effort has been to determine, if possible, the earliest moment of onset, in the primipara and multipara, with a comparison between the two. Secondly to estimate the character of its progress with regard to the period of pregnancy. Finally to determine if this condition is persistent into the postpartum period. Dilatation of the ureter of some degree was noted by us as early as the sixth week in multiparae and at the tenth week in pnm1parae.
482
MAGNUS I. SENG
Regarding the character and progress of the dilatation, when considered with the different periods of pregnancy, our experience seems to show that dilatation, while appearing very early in both primaparae and multiparae, reaches its maximum shortly; at the twenty-fourth week in primiparae and the twenty-second week in multiparae. The amount of sodium iodide solution which could be injected into the ureter, without pain did not vary to any
0
" :n
-!
Fm. 3
Fm. 4
Fm. 3. NU'LLIPARA Ureteropyelograms showing normal renal pelves and ureters. to 8 cc. Fm. 4.
Capacity 7,5
MULTIPARA AT SIXTH WEEK OF PREGNANCY, SHOWING EARLY, ALTHOUGH
DISTINCT, DILATATION OF BOTH URETERS AND MILD HYDRONEPHROSIS
extent, whether in early or late pregnancy. It may be stated that on no occasion was an effort made to instil more than 30 cc. of the iodide solution. The average amount used by us in our examinations was 15 cc. Ureterograms made with 30 cc., in no way showed a greater degree of dilatation or a better definition. Our studies have impressed us more with the tissue factor of each individual woman.
DILATATION OF URETERS AND RENAL PELVES
483
Further the multiparous woman demonstrated dilatation earlier in pregnancy, than the primiparae. In both the right ureter exhibited some degree of hydrometer in every instance. In left sided and bilateral hydrometer the multiparae showed a greater frequency of dilatation than the primiparae. The more pronounced types of hydrometer were found in the multiparae.
FIG. FIG.
5.
5
Frn. 6
PRIMIPARA AT TENTH WEEK OF PREGNANCY, SHOWING DILATATION OF THE URETERS SEEN AT THIS EARLY STAGE OF PREGNANCY
Note ureterograms showing throughout course of lower ureters. FIG.
6.
PRIMIPARA AT FOURTEENTH WEEK OF PREGNANCY
Bilateral dilatation of ureters with hydronephrosis. lower ureterograms.
Note abbreviation of
"\Ve have been impressed with the possible fact that the ureter having once been dilated over a period of many weeks, returned· apparently to normal but in a relaxed state. The study of the ureter in thirty-six cases, from the ninth to the twenty-fifth postpartum day, revealed the fact that while return to normal had taken place rapidly, in a minority of these cases, within these time limits, there still remained a great majority
484
MAGNUS I. SENG
showing right, left, and bilateral dilatation. In fact we have ureterograms of two cases which demonstrate some persistence, in the absence of disease, over periods of twenty-one months and nme years. URETERAL DISTORTIONS
Beginning at the sixthteen th week the antepartum differed from the postpartum ureter in the abrupt termination of the ureteroTABLE 3
Ureteral dilatation ANTEPA.R'I'UM
POSTPARTUM
Primipara
Right .................................. . Left .................................... . Bilateral ............................... . No dilatation right .. No dilatation left.
Mult1para
per cent
per bent
100 0 66.6 66.6
100.0 77.0 77.0
33.3
23.0
per cent
86.0 63.8 66.6 13.8 36.1
TABLE 4
H ydronephrosis ANTEPARTUM POSTPARTUM
Right ................................. . Left .................................... . Bilateral ... . No dilatation right ..................... . No dilatation left ....................... .
Primipara
Multi para
per cent
per cent
per cent
93.0 46.2 46.5 6.6 53.8
96 0 66.0 62.0 3.0 33.0
72.2 52.7 44.4 27.7 47.2
gram at the level of its entry into the parametrium. On the other hand the postpartum ureter could easily be traced to the bladder, in fact, a dilatation of this lower third was in certain instances demonstrated. Redundancy and kinking of the ureter, while a very definite finding in both antepartum and postpartum cases, was much more frequent and in greater degrees in the prenatal skiagraphs. An appreciable stricture revealed itself but once in this whole
DILATATION OF URETERS AND RENAL PELVES
485
series of one hundred and fifty-six ureters. This one case was found in the left ureter of a postpartum woman. HYDRONEPHROSIS
The same observation made concerning hydroureter may be largely applied to hydronephrosis. It begins as early as the sixth
FIG.
7
FIG. 8
7. MuLTIPARA AT THE SIXTEENTH \VEEK OF PREGNANCY Right ureteral dilatation with hydronephrosis. Left ureter and pelvis not dilated. Both ureterograms abbreviated, lower portion. FIG.
FIG.
8.
MULTIPARA AT TWENTY-SECOND WEEK OF PREGNANCY
Type of hydroureter and hydronephrosis showing maximum development of dilatation. Note redundancy, haustration and abbreviation of ureters.
week in multiparae and the tenth in primiparae and reaches its maximum at the twenty-fourth week in primiparae and at the twenty-second week in multiparae. Referring to table 4, the frequent incidence of hydronephrosis in primigravidae and multigravidae and the postpartum patient is emphasized. The continued predomina::ice of right sided dilatation is very evident. Left pelvic dilatation, while not quite so frequent in occurrence as left hydroureter, developed in a large
486
MAGNUS I, SENG
proportion of the three groups. The same remarks may be made of the ratio of bilateral dilatation. The escape of the left renal pelvis, to an even greater degree than the left ureter, must be remarked because of the recognized frequency of right sided pyelitis. A marked pelvic dilatation on the right side in primiparae was found in 73.2 per cent; in multiparae 81 per cent; in the post-
Fm. 9
Fm.IO
Fm. 9. MULTIPARA AT TERM Showing ureteral dilatation with marked hydronephrosis. redundant.
Ureters dilated and
Fm. 10. MuLTIPARA AT TWELFTH POSTPARTUM DAY Dilatation of ureters and renal pelves persisting into puerperal period. Note abbreviation of ureters at brim of pelvis. Definition of ureters below this pointnot seen in antepartum cases after sixteenth weeko
partum 55.5 per cent. The same degree of dilatation in the left was in primigravidae 33 per cent; in multigravidae 40 per cent; in the postpartum 27 per cent. Marked hydronephrosis was found much more frequently in the multiparous woman. While the hydronephrosis in our series of antepartum and
487
DILATATION OF URETERS AND RENAL PELVES
postpartum women have been well defined and even marked dilatations, in no case have we noted the extreme distension mentioned by other authors. The largest amount of urine recovered in our series was 67 cc. the average being 5 cc. Possibly these very much over-dilated renal pelves reported by others, were associated with some degree of infection. Dilatation to the extent of 30 to 480 cc. of urine recovered, has been reported by Crabtree. There is a very evident recovery of the pelvic tone early in the period TABLE5
Stasis in the antepartum TIME IN WHICH RENAL PELVES AND URETERS EMPTY
7 minutes (normal) ...................... . 7 to 30 minutes ......................... . 30 to 60 minutes ......................... . Average time to empty .................. .
LEFT
RIGHT
20 20 60 37
per cent per cent per cent minutes
40 20 40 29
per cent per cent per cent minutes
TABLE 6
Stasis comparison between antepartum and postpartum TIME IN WHICH RENAL PELVIS AND BOTH URETERS EMPTY
7minutes (normal) ....................... . 7 to 30 minutes .......................... . 30 to 60 minutes ......................... . Average time to empty .................. .
ANTEPARTUM
30 10 60 33
per cent per cent per cent minutes
POSTPARTUM
49 42 9 14
per cent per cent per cent minutes
No stasis beyond 45 minutes in postpartum.
of general postpartum involution. In this survey of the postpartum patient, which extended up to the twenty-fifth day, there is a persistence on the right side of pelvic dilatation in 72.2 per cent and on the left of 52.7 per cent of our cases. An impression derived from this point, emphasized by Helmholtz (15), leads us to believe that the dilatation produced in a first pregnancy, must have an influence in the production of the greater frequency and the more marked degree of dilatation found in multiparae.
488
MAGNUS I. SENG STASIS
In our investigation of t his very important factor in the development of pyelitis, we have a series of twenty antepartum and twenty-six postpartum cases. Our technique has been t hat developed by Goldstein (16). Skiagraphs were taken immediately, and at seven, ten, fifteen, twenty, thirty, forty-five and sixty minutes, after the instillation
FIG.
FIG.11
12
11 . PRIMIPARA AT TWE N TIETH WEEK OF PREGNANCY, SHOWING STASIS Skiagraphs taken at 7, 10, 15, 30, 45 and 60 minutes after instillation of iodide solution. FIG.
FIG.
12.
SAME PATIENT A S FIGURE 11
Skiagraph 45 minutes later, showing retention in right pelvis a nd both ureters
of sodium iodide solution into the ureters and renal pelves. In antepartum cases our observations revealed that the left ureter and renal pelvis emptied themselves within the normal limits of seven minutes with double frequency of t he right. Conversely, it was discovered that actual stasis from the mild degree of fifteen minutes, through the moderate type of thirty minutes to the marked group of sixty minutes delay, the right side outnumbered the left in the proportion of four to t hree.
DILATATION OF URETERS AND RENAL PELVES
489
We would emphasize the fact, that in the class of one hour's stasis, the right outnumbered the left in the proportion of two to one. In averaging the time occupied by the two sides in their efforts to empty themselves, we have found that the right side required thirty-seven minutes, the left twenty-nine. While ureteral dilatation and hydronephrosis usually appear and reach their maximum relatively early in pregnancy, stasis, however, does not make its appearance until the twentieth week. Whether it is acute or gradual, from the onset to the development of an hour's retention, we are unable to state, not having had the privilege of following a single case from its inception to the termination of gestation. We may state, that several of our cases from the twentieth to the twenty-sixth week of pregnancy have shown a delay of one hour, conversely we have had several instances in women at full term completely emptying the ureters and pelves in less than thirty minutes. It has been our experience that the multiparous woman presents more frequent, earlier and greater degrees of stasis than the primiparous patient. A comparison of stasis between the antepartum and postpartum series presents striking and interesting differences. The postpartum patient requires but one half the average time necessary to the antepartum patient, to completely empty the renal pelves and ureters. There was no appreciable difference in the time demanded by either side. There was no retention beyond fortyfive minutes. In fact the majority were completely empty within fifteen minutes. In the antepartum series we found that 30 per cent of the ureters and pelves emptied themselves within the normal limit of seven minutes, whereas in the postpartum 49 per cent were empty in the same period of time. In the former group but 10 per cent were empty in from seven to twenty minutes whereas in the latter group 42 per cent were evacuated within the same time limit. In the more marked type of stasis from thirty to sixty minutes, we have in the prenatal class 60 per cent which showed this great delay. Opposed to this latter figure we have in the postpartum series in the same group but 9 per cent,
490
MAGNUS I. SENG
which demonstrated a delay up to and including forty-five minutes. There were no postpartum cases showing stasis up to sixty minutes. The inference to be drawn, we think from this exhibit is that the uterus and its contents must play some part in maintaining stasis. All these postpartum skiagraphs of stasis were taken at or before the twelfth postpartum day. An interesting point exhibited by our examination, was the apparent complete disappearance of the emphasized abbreviation of the dilated ureter at or near the pelvic brim, noted in the antepartum cases. The ureter of the postpartum woman in contradistinction to the antepartum, shows varying degrees of dilatation of its juxtovesical portion. These findings, we think, confirm in the living subject Carson's conclusions on pressure at the pelvic brim demonstrated in the cadaver. SUMMARY AND DISCUSSION
Every pregnant woman has, at some time during her pregnancy, a varying degree of dilatation of one or both ureters and renal pelves. Dilatation may begin as early as the sixth week, and usually reaches its maximum development between the twenty-second and twenty-fourth weeks of pregnancy. It is never enormous unless associated with disease. At about the twentieth week there begins an associated demonstrable stasis which persists throughout the rest of the pregnancy but varies in intensity, not so much according to the period of the pregnancy as to the reaction of the individual woman. What causes dilatation and stasis in the pregnant woman? Graves and Davidoff (17) in their experimental observation on the reaction of the ureter to bladder distension have noted the fact that ureteral peristalsis is increased as soon as the bladder begins to fill. With greater degrees of retention, and increased intravesical pressure, the ureteral action becomes slower but more vigorous. When intravesical pressure has reached a relatively high level ureteral peristalsis again speeds up in frequency, but
DILATATION OF URETERS AND RENAL PELVES
,. ,.'
491
the ureter soon becomes dilated and ultimately unable to empty its load-an actual ureteral retention occurring. Even as early as the sixth week in pregnancy a marked increase in the vascularity of the uterus, particularly the cervix, and the uterine adnexa has taken place. This must have some obstructive influence, due to the enormous congestion, on that portion of the ureter passing through the region of most pronounced change. If the mere filling of the bladder has so distinct a reaction on the activity of the ureter, as observed experimentally, it is not unreasonable to suppose that the dilatation of the ureters and renal pelves found by us even in the early weeks of pregnancy is really a physiological reaction to pressure within the bony pelvis. In the later months of pregnancy it is not difficult to realize that with the uterus enlarging equally and progressively in all dimensions there must occur an increase in pelvic pressure which has a corresponding effect upon the lower ureters as well as the other organs within the pelvic bowl. Practically one-half of the pregnant women in our series and 80 per cent of the puerperal ones show evidences in the urine, of some infection. About one-tenth exhibit definite cultural growth of an organism whose natural habitat is the bowel, and one which is the recognized causative organism of the infection known as pyelitis. Further nearly one third of those showing the organism on cultural growth developed clinical pyelitis some weeks later in pregnancy. The presence in every pregnant woman, of almost every condition thought to be an etiological factor in the production of pyelitis, emphasizes the remarkable fact that the great majority of pregnant women escape this infection. What then causes infection? The pregnant woman is continuously in the presence of it. Organisms are forever storming the barriers of her resistance. Why is she not more often infected? It is the little understood and ill-defined immunity that saves her. We know the infecting organism, we know the factors tending to produce infection but we know next to nothing of the immunity processes. Therein lies the field for investigation.
Ji
492
MAGNUS I. SENG CONCLUSIONS
1. In pregnancy, there is a constant right sided ureteral dilatation; while right hydronephrosis is only slightly less frequent. 2. In pregnancy, the le£ t ureter and renal pelvis escape this dilatation in a markedly higher percentage of cases. 3. Bilateral hydrometer and hydronephrosis were of very frequent occurrence. 4. The multiparous woman showed these conditions earlier, more frequently, and in much more marked degree than the primipara. 5. Stasis, as measured by the inability of the renal pelvis and ureter to empty themselves within the normal time limits, is a definite and almost universal finding in the antepartum woman. 6. In the postpartum woman it is still persistent, in a lesser degree, over a prolonged period of time. 7. Every pregnant woman has obstruction of some degree, a definite dilatation of the ureters and renal pelves, with a well defined stasis. This continues over a long period of time. We have demonstrated, in the apparently healthy pregnant and puerperal patient a probable renal complication in the presence of pus and coliform organisms. In conclusion I wish to thank Dr. James W. Duncan of the Department of Obstetrics and Gynaecology, Royal Victoria Hospital, Montreal, for his kindness in providing the material for this study. I wish to thank also Dr. W. W. Beattie of the Department of Bacteriology, Royal Victoria Hospital, for his untiring laboratory work in this series. Finally I wish to thank the Chief of the Department of Urology, Royal Victoria Hospital, Montreal, Dr. D. W. MacKenzie, for allowing me to present this paper from the Department. REFERENCES (1) (2) (3) (4) (5)
CRUVEILHIER: Traite d'anatomie descriptive, Paris, 1843. OLBHAUBEN: Klin. vort. f . Gyn., 1892, xxxix, 15. PRuTz : Zeitschr. f. Geb. u. Gyn., Bd. 23, 1892. LoHLEIN: Zeitschr. f. Geb. u. Gyn., Bd. IV, S. 49. CARSON, W. J.: Jour. Urol., xvi, no. 3, pp. 167, 1926; Jour. Urol., xviii, no. 1, p . 61, 1927.
DILATATION OF URETERS AND RENAL PELVES
(6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)
-I
493
HoFBAUEE: Bulletin Johns Hopkins Hosp., xiii, no. 3, 1928. CRABTREE: Surg., Gynecol. and Obstet., 1922, xxxv, 733. PuoH: Jour. Urol., xviii, no. 5, 553, 1927. CoRBu,s AND DANFORTH: Jour. Urol., xviii, no. 5,543, 1927. HuNNER: Amer. Jour. Obstet., and Gynecol., 1925, ix, 47. KRETSCHMER AND HEANEY: Jour. Am. Med. Assn., lxxxv, no. 6, p. 406. GAUSS: Deutsche med. Wchnschr., 1906, 2103. STOECKEL : Deoderlein's Handbuch d. Geburtshilfe, 1925, 111; Munch. med. Wchnschr., 1924, No. 9. LucHs: Arch. f. Gyn., 1927, cxxvi. HELMHOLTZ: Wis. Med. Jour., 1927, xxvi, no. 4, 189. GOLDSTEIN: Jour. Urol., 1921, vi, 125. GRAVES AND DAVIDOFF: Jour. Urol., 1923, x, 185.
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