- Email: [email protected]
Reversible acute renal failure in association with bilateral ureteral obstruction and hydronephrosis in pregnancy
Reversible acute renal failure in association with bilateral ureteral obstruction and hydronephrosis in pregnancy Niharika Khanna, MD,a and Hien Nguyen, MDb Baltimore, Maryland This is a case report of a 16-year-old girl with renal failure in pregnancy in association with bilateral ureteral obstruction and hydronephrosis. The presenting symptom was a common nonspecific type of abdominal pain. The diagnosis was made on incidental laboratory work to rule out preeclampsia. Renal function reverted back to normal after induced vaginal delivery. (Am J Obstet Gynecol 2001;184:239-40.)
Key words: Reversible acute renal failure, pregnancy, abdominal pain
Bilateral ureteral obstruction is a rare cause of renal failure in pregnancy. Only 18 such cases have been reported in the English literature.1 We report a case of acute renal failure in association with bilateral ureteral obstruction and hydronephrosis that was diagnosed in the third trimester of pregnancy. The acute renal failure resolved rapidly after delivery. Case report A 16-year-old girl, gravida 1, para 0, at 38 weeks’ gestation, was first seen with a chief complaint of 10 hours of left-sided, dull, crampy abdominal pain. There were no clear alleviating or exacerbating factors or other associated symptoms. The prior prenatal course was uncomplicated except for two office visits, during which preterm labor was ruled out. Physical examination was significant for a gravid female subject in labor, 5 ft tall and weight 110 lb. Cardiotocography showed a reactive strip, a fetal heart rate of approximately 140 beats/min, and contractions every 7 minutes. The abdominal examination was significant only for mild tenderness in the left lower quadrant without rebound or guarding. The patient’s cervical examination was dilated .5 cm, 50% effaced, and at –3 station. Admitting blood pressures ranged from 150 to 160/80 to 95 mm Hg. The urine dipstick test result was negative for ketones, protein, and glucose. Laboratory test results for preeclampsia were significant for a blood urea nitrogen level of 8 mg/dL, creatinine level of 2.5 mg/kg per 24 hours, and uric acid level of 5.5 mg/dL. A good urine output was maintained at >50 mL/h. Renal ultrasonography demonstrated severe bilateral hydronephrosis (right and left kidneys mea-
From the Department of Family Medicinea, b and the Greenebaum Cancer Center,a School of Medicine, University of Maryland. Received for publication May 30, 2000; accepted June 14, 2000. Reprint requests: Niharika Khanna, MD, Assistant Professor, Department of Family Medicine, 29 South Paca St, Baltimore, MD 21201. Copyright © 2001 by Mosby, Inc. 0002-9378/2001 $35.00 + 0 6/1/109387 doi:10.1067/mob.2001.109387
sured 13.5 cm and 12.4 cm, respectively) and bilateral hydroureter. The patient was admitted to the hospital, and a renal consultation was obtained. On day 2 of hospitalization, the urine remained negative for protein and the blood pressures ranged from 130 to 140/70 to 80 mm Hg. A good urine output was maintained, and no symptoms of preeclampsia were identified. However, the serum creatinine level increased to 2.7 mg/kg per 24 hours, and the uric acid level increased to 5.7 mg/dL. A decision was made to induce labor because of worsening renal failure. Cervical ripening was initiated with dinoprostone, and labor was augmented with oxytocin. A prolonged second stage of labor was shortened by a mediolateral episiotomy. A healthy 2960-g female infant was delivered vaginally with Apgar scores of 9 and 9 at 1 and 5 minutes. At 48 hours after delivery, the serum creatinine level was 1.2 mg/kg per 24 hours, and the blood pressure, urine output, and laboratory results of tests for preeclampsia were normal. Comment This patient presented us with a diagnostic dilemma because both preeclampsia and hydronephrosis of pregnancy can cause abdominal pain and renal failure. The differential diagnosis of acute renal failure in pregnancy includes obstructive and nonobstructive causes.2 Hydronephrosis of pregnancy is characterized by ureteral dilatation from progesterone-induced smooth muscle relaxation and mechanical pressure of the gravid uterus on the ureters.2 We postulate that bilateral ureteral compression by the gravid uterus resulted in hydronephrosis and obstructive renal failure in this patient. Obstructive uropathy from ureteral compression typically presents between 21 and 39 weeks’ gestation and manifests clinically as oliguria, azotemia, acute renal failure, fluid retention, and hypertension.2 Risk factors for obstructive uropathy from ureteral compression include twin pregnancy, polyhydramnios, pyelonephritis, obstruction of a solitary kidney, renal calculi, ureteral narrowing, and low 239
240 Khanna and Nguyen
abdominal wall compliance.2 Our patient’s only risk factor was primigravidity, which may predipose to ureteral obstruction through higher circulating progesterone levels that enhance ureteral dilatation. Alternatively, progesterone may decrease abdominal compliance through changes in smooth muscle relaxation. Successful methods to improve renal function and enhance urine flow have consisted of termination of pregnancy in the patient at term gestation with vaginal delivery, as in this patient, or immediate surgical delivery and amniocentesis.2 However, in a patient who is at preterm gestation, dialysis, recumbency in the lateral decubitus position, and insertion of ureteral stents, pigtail catheters, and nephrostomy tubes have been used to treat renal failure and extend the pregnancy to term. Acute renal failure in association with ureteral compression is accompanied by poor perinatal outcome. There are 18 reported cases of reversible obstructive uropathy and as-
January 2001 Am J Obstet Gynecol
sociated renal failure in the literature, with a fetal mortality rate of 33% and no reported maternal deaths.1 In conclusion, bilateral ureteral obstruction resulting in hydronephrosis is an important, although rare, cause of reversible obstructive renal failure and abdominal pain in pregnancy. We speculate that reversible renal failure in association with hydronephrosis may be underdiagnosed. Accordingly, we recommend routine serum creatinine measurements during prenatal visits for patients with risk factors for obstructive uropathy, particularly if they have flank pain or decreased urine levels. REFERENCES
1. Mitch WE, Jena M. Rapidly reversible acute renal failure from ureteral obstruction in pregnancy. Am J Kidney Dis 1996;28: 457-60. 2. Brandes JC, Fritsche C. Obstructive acute renal failure by a gravid uterus: a case report and review. Am J Kidney Dis 1991;18: 398-401.
Bound volumes available to subscribers Bound volumes of the American Journal of Obstetrics and Gynecology are available to subscribers (only) for the 2001 issues from the publisher, at a cost of $122.00 for domestic, $156.22 for Canada, and $146.00 for international for Vol. 184 (January-June) and Vol. 185 (July-December). Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby, Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887. Telephone (800)654-2452 or (407)345-4000. Fax (407)363-9661. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.
Key words: Reversible acute renal failure, pregnancy, abdominal pain
Bilateral ureteral obstruction is a rare cause of renal failure in pregnancy. Only 18 such cases have been reported in the English literature.1 We report a case of acute renal failure in association with bilateral ureteral obstruction and hydronephrosis that was diagnosed in the third trimester of pregnancy. The acute renal failure resolved rapidly after delivery. Case report A 16-year-old girl, gravida 1, para 0, at 38 weeks’ gestation, was first seen with a chief complaint of 10 hours of left-sided, dull, crampy abdominal pain. There were no clear alleviating or exacerbating factors or other associated symptoms. The prior prenatal course was uncomplicated except for two office visits, during which preterm labor was ruled out. Physical examination was significant for a gravid female subject in labor, 5 ft tall and weight 110 lb. Cardiotocography showed a reactive strip, a fetal heart rate of approximately 140 beats/min, and contractions every 7 minutes. The abdominal examination was significant only for mild tenderness in the left lower quadrant without rebound or guarding. The patient’s cervical examination was dilated .5 cm, 50% effaced, and at –3 station. Admitting blood pressures ranged from 150 to 160/80 to 95 mm Hg. The urine dipstick test result was negative for ketones, protein, and glucose. Laboratory test results for preeclampsia were significant for a blood urea nitrogen level of 8 mg/dL, creatinine level of 2.5 mg/kg per 24 hours, and uric acid level of 5.5 mg/dL. A good urine output was maintained at >50 mL/h. Renal ultrasonography demonstrated severe bilateral hydronephrosis (right and left kidneys mea-
From the Department of Family Medicinea, b and the Greenebaum Cancer Center,a School of Medicine, University of Maryland. Received for publication May 30, 2000; accepted June 14, 2000. Reprint requests: Niharika Khanna, MD, Assistant Professor, Department of Family Medicine, 29 South Paca St, Baltimore, MD 21201. Copyright © 2001 by Mosby, Inc. 0002-9378/2001 $35.00 + 0 6/1/109387 doi:10.1067/mob.2001.109387
sured 13.5 cm and 12.4 cm, respectively) and bilateral hydroureter. The patient was admitted to the hospital, and a renal consultation was obtained. On day 2 of hospitalization, the urine remained negative for protein and the blood pressures ranged from 130 to 140/70 to 80 mm Hg. A good urine output was maintained, and no symptoms of preeclampsia were identified. However, the serum creatinine level increased to 2.7 mg/kg per 24 hours, and the uric acid level increased to 5.7 mg/dL. A decision was made to induce labor because of worsening renal failure. Cervical ripening was initiated with dinoprostone, and labor was augmented with oxytocin. A prolonged second stage of labor was shortened by a mediolateral episiotomy. A healthy 2960-g female infant was delivered vaginally with Apgar scores of 9 and 9 at 1 and 5 minutes. At 48 hours after delivery, the serum creatinine level was 1.2 mg/kg per 24 hours, and the blood pressure, urine output, and laboratory results of tests for preeclampsia were normal. Comment This patient presented us with a diagnostic dilemma because both preeclampsia and hydronephrosis of pregnancy can cause abdominal pain and renal failure. The differential diagnosis of acute renal failure in pregnancy includes obstructive and nonobstructive causes.2 Hydronephrosis of pregnancy is characterized by ureteral dilatation from progesterone-induced smooth muscle relaxation and mechanical pressure of the gravid uterus on the ureters.2 We postulate that bilateral ureteral compression by the gravid uterus resulted in hydronephrosis and obstructive renal failure in this patient. Obstructive uropathy from ureteral compression typically presents between 21 and 39 weeks’ gestation and manifests clinically as oliguria, azotemia, acute renal failure, fluid retention, and hypertension.2 Risk factors for obstructive uropathy from ureteral compression include twin pregnancy, polyhydramnios, pyelonephritis, obstruction of a solitary kidney, renal calculi, ureteral narrowing, and low 239
240 Khanna and Nguyen
abdominal wall compliance.2 Our patient’s only risk factor was primigravidity, which may predipose to ureteral obstruction through higher circulating progesterone levels that enhance ureteral dilatation. Alternatively, progesterone may decrease abdominal compliance through changes in smooth muscle relaxation. Successful methods to improve renal function and enhance urine flow have consisted of termination of pregnancy in the patient at term gestation with vaginal delivery, as in this patient, or immediate surgical delivery and amniocentesis.2 However, in a patient who is at preterm gestation, dialysis, recumbency in the lateral decubitus position, and insertion of ureteral stents, pigtail catheters, and nephrostomy tubes have been used to treat renal failure and extend the pregnancy to term. Acute renal failure in association with ureteral compression is accompanied by poor perinatal outcome. There are 18 reported cases of reversible obstructive uropathy and as-
January 2001 Am J Obstet Gynecol
sociated renal failure in the literature, with a fetal mortality rate of 33% and no reported maternal deaths.1 In conclusion, bilateral ureteral obstruction resulting in hydronephrosis is an important, although rare, cause of reversible obstructive renal failure and abdominal pain in pregnancy. We speculate that reversible renal failure in association with hydronephrosis may be underdiagnosed. Accordingly, we recommend routine serum creatinine measurements during prenatal visits for patients with risk factors for obstructive uropathy, particularly if they have flank pain or decreased urine levels. REFERENCES
1. Mitch WE, Jena M. Rapidly reversible acute renal failure from ureteral obstruction in pregnancy. Am J Kidney Dis 1996;28: 457-60. 2. Brandes JC, Fritsche C. Obstructive acute renal failure by a gravid uterus: a case report and review. Am J Kidney Dis 1991;18: 398-401.
Bound volumes available to subscribers Bound volumes of the American Journal of Obstetrics and Gynecology are available to subscribers (only) for the 2001 issues from the publisher, at a cost of $122.00 for domestic, $156.22 for Canada, and $146.00 for international for Vol. 184 (January-June) and Vol. 185 (July-December). Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby, Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887. Telephone (800)654-2452 or (407)345-4000. Fax (407)363-9661. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.