as
p rt
Spontaneous Renal Rupture During Pregnancy
JO T. VAN WINTER, M.D., PAUL L. OGBURN, Jr., M.D., Department of Obstetrics and Gynecology; DONALD E. ENGEN, M.D., Department of Urology; MAURICE J. WEBB, M.D., Section ofGynecologic Surgery
Spontaneous rupture of the renal parenchyma or renal pelvis during pregnancy has been previously reported in 16 cases. In the case we describe in this report, the patient initially had right flank pain and nausea for 48 hours, which progressed to severe abdominal symptoms that necessitated exploratory laparotomy. Cystoscopic placement of a ureteral stent relieved the obstruction and allowed spontaneous healing of the renal pelvis. Dilatation ofthe urinary collecting system commonly occurs during pregnancy. Spontaneous rupture of the renal parenchyma or renal pelvis, however, Is: unusual and often associated with diseased kidneys. Our case is the 8th one of spontaneous rupture of the renal collecting system with no identifiable underlying pathologic condition and the 17th case of spontaneous renal rupture overall.
REPORT OF CASE
flank pain decreased; concomitantly, abdominal pain in the right lower quadrant and a fever (temperature of 37.8°C) developed. A limited excretory urogram (intravenous pyelogram), obtained after urologic consultation, showed a small amount of extravasated contrast material from the right renal pelvis (Fig. 1) without evidence of formation of calculi. Prominent peritoneal signs with rebound tenderness in the right lower quadrant then gradually developed despite intravenous administration of morphine. A decision was made to proceed with exploratory laparotomy because other causes of an acute abdomen in pregnancy, such as appendicitis or bowel obstruction, could not be excluded with certainty. At laparotomy, a normal appendix was removed, and the only abnormal finding was extravasated urine retroperitoneally in the right paracolic region. A urologic consultation was Address reprint requests to Dr. J. T. Van Winter, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, again obtained, and a right double-J ureteral stent was inserted cystoscopically without diffiMN 55905.
A 20-year-old woman, gravida I, was hospitalized at 34 weeks' gestation for right flank pain and nausea that had persisted for 48 hours. Results of physical examination were normal for her stage of pregnancy except for tenderness in the right costovertebral angle. Complete blood cell count, differential leukocyte count, and chemistry group studies (which included determination of serum urea and creatinine values) yielded normal results. Findings on urinalysis were unremarkable, and a subsequent urine culture was negative. Ultrasonography revealed only hydroureteronephrosis, consistent with pregnancy. Intravenous administration of ampicillin was begun because pyelonephritis with or without formation of stones could not be ruled out. The right
Mayo Clin Proc 66:179-182,1991
179
180
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Mayo Clin Proc, February 1991, Vol 66
culty. The fetus was monitored intraoperatively and did well. A single dose ofindomethacin, 100 mg rectally, was used to treat perioperative uterine contractions. Postoperatively, the patient noticed complete disappearance of the previous pain in the right flank and right lower quadrant of the abdomen. Acute respiratory distress, possibly related to decreased urinary output, fluid overload, or aspiration, developed 48 hours postoperatively. This problem gradually resolved during a 1week period with oxygen supplementation and diuresis. She was dismissed from the hospital at 36 weeks' gestation and was receiving prophylactic cefadroxil for the ureteral stent. The patient was rehospitalized because of active labor at 37 weeks' gestation and was delivered of a healthy female infant. She returned 2 weeks later to have the ureteral stent removed. At that time, an excretory urogram revealed normal (postpartum) collecting systems bilaterally (Fig. 2).
DISCUSSION Spontaneous rupture of the renal collecting system or parenchyma almost always occurs in a previously diseased kidney. 1-3 A review of the literature revealed 16 prior cases of spontaneous renal rupture during pregnancy: 6 were rupture of the renal parenchyma and 10 were rupture of the renal collecting system.v" Pathologic findings associated with spontaneous rupture have included renal cysts, parenchymal angiomyolipomas (hamartomas), other renal tumors, and evidence of chronic infection or formation of an abscess in association with obstruction. 1,2,4-6 Our case is the eighth report of spontaneous rupture ofthe renal collecting system with no pathologic cause. This type of rupture is thought to occur when the gravid uterus shifts and causes ureteral obstruction and a rapid increase in intrarenal preasure.l-"? Spontaneous rupture of the parenchyma of a normal kidney without major trauma is extremely rare and should suggest an underlying pathologic condition, as borne out by evaluation of the six reported cases.t-" The increase in size and changes in the structure ofthe parenchyma
Fig. 1. Limited excretory urogram in 20-year-old pregnant woman, showing extravasation ofcontrast material in lower pole of right kidney (arrow).
make the lesions more susceptible to minor trauma from either external or internal sources. Spontaneous extravasation of urine from the renal collecting system through the caliceal fornix may occur because of a sudden increase in the intrapelvic pressure. 8 This extravasation can be seen in the normal (nonpregnant) patient during excretory urography (intravenous pyelography) performed with external compression, in which case the extravasation resolves spontaneously and without sequelae once the obstruction has been relieved." Extravasation of urine may also occur from the caliceal fornix of the "normal" but abruptly obstructed kidney (that is, obstructing ureteral calculus). This type of "benign" extravasation from the fornix must be distinguished from a true rupture or rent of the renal pelvis,"? which may neces-sitate surgical intervention. Whether "benign" extravasation of urine occurs during pregnancy is unknown because excretory urog-
Mayo Clin Proc, February 1991, Vol 66
raphy is infrequently performed, even in symptomatic pregnant patients. The initial clinical manifestations of'pyeloureteralleakage may range from mild flank discomfort to unremitting pain associated with an acute abdomen. Such pain is due to urine or blood dissecting along the fascial planes with or without disrupting the peritoneal covering to produce an infective or chemical peritonitis, as occurred in our patient. 5 Therefore, renal rupture during pregnancy can be confused with cholecystitis, hepatitis, urinary stone disease, appendicitis, pyelonephritis, uterine rupture, abruptio placentae, or other causes of an acute abdomen during pregnancy.2,3,5,1l,12 The diagnosis of renal rupture during pregnancy is often one of exclusion. Chills, fever, flank pain, and bacteriuria usually identify pyelonephritis, whereas normal results of urinalysis are often associated with rupture of the renal collecting system, as in our patient. 2,3 Norma] values on liver function tests are helpful for ruling out hepatic and biliary disease. Ultrasonography is of value for the assessment of cholelithiasis, pelvic masses, renal parenchymal rupture, renal masses, abscesses, or increased pelvic dilatation beyond the physiologic hydronephrosis associated with pregnancy. A limited excretory urogram (intravenous pyelogram) is also useful for determining the site and the nature of the rupture or obstruction, the amount ofextravasation, and the function ofthe kidneys. Management of renal rupture during pregnancy usually depends on whether the rupture occurred through the renal parenchyma or the collecting system. Rupture of the renal parenchyma demands surgical exploration because of the associated hemorrhage. In all previously reported cases, the treatment was nephrectomy; however, as suggested by Oesterling and associates," a more conservative approach (partial nephrectomy) may be possible in future selected cases. As late as 1980, Middleton and colleagues" reported that rapid surgical exploration was imperative for all cases of renal rupture. In addition, they maintained that leaving a ureteral
RENAL RUPTURE DURING PREGNANCY
181
Fig. 2. Normal postpartum excretory urogram, showing a slightly distended right collecting system and ureter, consistent with recent pregnancy.
catheter in position is "contraindicated" because this maneuver involves the risk of introducing infection. Other investigators have suggested that rupture of the renal collecting system may be managed conservatively and successfully with use of an indwelling ureteral catheter.v'" The goal in the management of spontaneous rupture of the renal collecting system should be relief of the outflow obstruction. In a patient with a gravid uterus that compresses an otherwise "normal" ureter, obstruction can be alleviated by placement of an internal stent; appropriate antibiotic coverage and close follow-up are important factors in such patients. The extravasation detected on excretory urography in our patient was not initially treated by placement of a stent. Instead, an exploratory laparotomy was performed because of the uncertainty that the patient's acute, progressive peritonitis could be attributed to urinary extravasation. We were also aware that peritoneal
182
Mayo Clin Proc, February 1991, Vol 66
RENAL RUPTURE DURING PREGNANCY
pain during pregnancy can be caused by appendicitis and bowel accidents, which can progress rapidly and may be associated with increased maternal mortality.v'
CONCLUSION Physiologic dilatation of the urinary tract during pregnancy is common, but spontaneous rupture of either the renal parenchyma or the renal collecting system is rare. Previously, the treatment for most patients with spontaneous renal rupture was nephrectomy. On the basis of our experience, conservative treatment with a ureteral stent may be warranted in patients with rupture of the renal pelvis. REFERENCES
1. Aaro LA, Kelalis PP: Spontaneous rupture of the kidney associated with pregnancy. Am J Obstet Gynecol 111:270-273, 1971 2. Cohen SG, Pearlman CK: Spontaneous rupture ofthe kidney in pregnancy. J Urol 100:365-369, 1968 3. Maresca L, Koucky CJ: Spontaneous rupture of the renal pelvis during pregnancy presenting as acute abdomen. Obstet Gynecol 58:745-747,1981
4.
5.
6. 7.
8. 9. 10. 11. 12. 13.·
Oesterling JE, Besinger RE, Brendler CB: Spontaneous rupture of the renal collecting system during pregnancy: successful management with a temporary ureteral catheter. J Urol 140:588-590, 1988 Meyers SJ, Lee RV, Munschauer RW: Dilatation and nontraumatic rupture of the urinary tract during pregnancy: a review. Obstet Gynecol 66:809-815, 1985 Middleton AW Jr, Middleton GW, Dean LK: Spontaneous renal rupture in pregnancy. Urology 15:60-63, 1980 Smulewicz JJ, Dorfman J, Cagan S, Seery WH: Spontaneous rupture of the collecting system of the kidney: an evaluation. J Urol 104:507-511, 1970 Narath PA: The hydromechanics ofthe calyx renalis. J Urol 43:145-176, 1940 Daughtridge TG: Ureteral compression device for excretory urography. Am J Roentgenol 95:431-438, 1965 Khan AU, Malek RS: Spontaneous urinary extravasation. J Urol 116:161-165, 1976 Brennan DF, Harwood-Nuss AL: Postpartum abdominal pain. Ann Emerg Med 18:83-89, 1989 Munro A, Jones PF: Abdominal surgical emergencies in the puerperium. Br Med J 4:691-694, 1975 Andriole GL, Bettmann MA, Garnick MB, Richie JP: Indwelling double-J ureteral stents for temporary and permanent urinary damage: experience with 87 patients. J Urol 131:239-241, 1984
p rt
Spontaneous Renal Rupture During Pregnancy
JO T. VAN WINTER, M.D., PAUL L. OGBURN, Jr., M.D., Department of Obstetrics and Gynecology; DONALD E. ENGEN, M.D., Department of Urology; MAURICE J. WEBB, M.D., Section ofGynecologic Surgery
Spontaneous rupture of the renal parenchyma or renal pelvis during pregnancy has been previously reported in 16 cases. In the case we describe in this report, the patient initially had right flank pain and nausea for 48 hours, which progressed to severe abdominal symptoms that necessitated exploratory laparotomy. Cystoscopic placement of a ureteral stent relieved the obstruction and allowed spontaneous healing of the renal pelvis. Dilatation ofthe urinary collecting system commonly occurs during pregnancy. Spontaneous rupture of the renal parenchyma or renal pelvis, however, Is: unusual and often associated with diseased kidneys. Our case is the 8th one of spontaneous rupture of the renal collecting system with no identifiable underlying pathologic condition and the 17th case of spontaneous renal rupture overall.
REPORT OF CASE
flank pain decreased; concomitantly, abdominal pain in the right lower quadrant and a fever (temperature of 37.8°C) developed. A limited excretory urogram (intravenous pyelogram), obtained after urologic consultation, showed a small amount of extravasated contrast material from the right renal pelvis (Fig. 1) without evidence of formation of calculi. Prominent peritoneal signs with rebound tenderness in the right lower quadrant then gradually developed despite intravenous administration of morphine. A decision was made to proceed with exploratory laparotomy because other causes of an acute abdomen in pregnancy, such as appendicitis or bowel obstruction, could not be excluded with certainty. At laparotomy, a normal appendix was removed, and the only abnormal finding was extravasated urine retroperitoneally in the right paracolic region. A urologic consultation was Address reprint requests to Dr. J. T. Van Winter, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, again obtained, and a right double-J ureteral stent was inserted cystoscopically without diffiMN 55905.
A 20-year-old woman, gravida I, was hospitalized at 34 weeks' gestation for right flank pain and nausea that had persisted for 48 hours. Results of physical examination were normal for her stage of pregnancy except for tenderness in the right costovertebral angle. Complete blood cell count, differential leukocyte count, and chemistry group studies (which included determination of serum urea and creatinine values) yielded normal results. Findings on urinalysis were unremarkable, and a subsequent urine culture was negative. Ultrasonography revealed only hydroureteronephrosis, consistent with pregnancy. Intravenous administration of ampicillin was begun because pyelonephritis with or without formation of stones could not be ruled out. The right
Mayo Clin Proc 66:179-182,1991
179
180
RENAL RUPTURE DURING PREGNANCY
Mayo Clin Proc, February 1991, Vol 66
culty. The fetus was monitored intraoperatively and did well. A single dose ofindomethacin, 100 mg rectally, was used to treat perioperative uterine contractions. Postoperatively, the patient noticed complete disappearance of the previous pain in the right flank and right lower quadrant of the abdomen. Acute respiratory distress, possibly related to decreased urinary output, fluid overload, or aspiration, developed 48 hours postoperatively. This problem gradually resolved during a 1week period with oxygen supplementation and diuresis. She was dismissed from the hospital at 36 weeks' gestation and was receiving prophylactic cefadroxil for the ureteral stent. The patient was rehospitalized because of active labor at 37 weeks' gestation and was delivered of a healthy female infant. She returned 2 weeks later to have the ureteral stent removed. At that time, an excretory urogram revealed normal (postpartum) collecting systems bilaterally (Fig. 2).
DISCUSSION Spontaneous rupture of the renal collecting system or parenchyma almost always occurs in a previously diseased kidney. 1-3 A review of the literature revealed 16 prior cases of spontaneous renal rupture during pregnancy: 6 were rupture of the renal parenchyma and 10 were rupture of the renal collecting system.v" Pathologic findings associated with spontaneous rupture have included renal cysts, parenchymal angiomyolipomas (hamartomas), other renal tumors, and evidence of chronic infection or formation of an abscess in association with obstruction. 1,2,4-6 Our case is the eighth report of spontaneous rupture ofthe renal collecting system with no pathologic cause. This type of rupture is thought to occur when the gravid uterus shifts and causes ureteral obstruction and a rapid increase in intrarenal preasure.l-"? Spontaneous rupture of the parenchyma of a normal kidney without major trauma is extremely rare and should suggest an underlying pathologic condition, as borne out by evaluation of the six reported cases.t-" The increase in size and changes in the structure ofthe parenchyma
Fig. 1. Limited excretory urogram in 20-year-old pregnant woman, showing extravasation ofcontrast material in lower pole of right kidney (arrow).
make the lesions more susceptible to minor trauma from either external or internal sources. Spontaneous extravasation of urine from the renal collecting system through the caliceal fornix may occur because of a sudden increase in the intrapelvic pressure. 8 This extravasation can be seen in the normal (nonpregnant) patient during excretory urography (intravenous pyelography) performed with external compression, in which case the extravasation resolves spontaneously and without sequelae once the obstruction has been relieved." Extravasation of urine may also occur from the caliceal fornix of the "normal" but abruptly obstructed kidney (that is, obstructing ureteral calculus). This type of "benign" extravasation from the fornix must be distinguished from a true rupture or rent of the renal pelvis,"? which may neces-sitate surgical intervention. Whether "benign" extravasation of urine occurs during pregnancy is unknown because excretory urog-
Mayo Clin Proc, February 1991, Vol 66
raphy is infrequently performed, even in symptomatic pregnant patients. The initial clinical manifestations of'pyeloureteralleakage may range from mild flank discomfort to unremitting pain associated with an acute abdomen. Such pain is due to urine or blood dissecting along the fascial planes with or without disrupting the peritoneal covering to produce an infective or chemical peritonitis, as occurred in our patient. 5 Therefore, renal rupture during pregnancy can be confused with cholecystitis, hepatitis, urinary stone disease, appendicitis, pyelonephritis, uterine rupture, abruptio placentae, or other causes of an acute abdomen during pregnancy.2,3,5,1l,12 The diagnosis of renal rupture during pregnancy is often one of exclusion. Chills, fever, flank pain, and bacteriuria usually identify pyelonephritis, whereas normal results of urinalysis are often associated with rupture of the renal collecting system, as in our patient. 2,3 Norma] values on liver function tests are helpful for ruling out hepatic and biliary disease. Ultrasonography is of value for the assessment of cholelithiasis, pelvic masses, renal parenchymal rupture, renal masses, abscesses, or increased pelvic dilatation beyond the physiologic hydronephrosis associated with pregnancy. A limited excretory urogram (intravenous pyelogram) is also useful for determining the site and the nature of the rupture or obstruction, the amount ofextravasation, and the function ofthe kidneys. Management of renal rupture during pregnancy usually depends on whether the rupture occurred through the renal parenchyma or the collecting system. Rupture of the renal parenchyma demands surgical exploration because of the associated hemorrhage. In all previously reported cases, the treatment was nephrectomy; however, as suggested by Oesterling and associates," a more conservative approach (partial nephrectomy) may be possible in future selected cases. As late as 1980, Middleton and colleagues" reported that rapid surgical exploration was imperative for all cases of renal rupture. In addition, they maintained that leaving a ureteral
RENAL RUPTURE DURING PREGNANCY
181
Fig. 2. Normal postpartum excretory urogram, showing a slightly distended right collecting system and ureter, consistent with recent pregnancy.
catheter in position is "contraindicated" because this maneuver involves the risk of introducing infection. Other investigators have suggested that rupture of the renal collecting system may be managed conservatively and successfully with use of an indwelling ureteral catheter.v'" The goal in the management of spontaneous rupture of the renal collecting system should be relief of the outflow obstruction. In a patient with a gravid uterus that compresses an otherwise "normal" ureter, obstruction can be alleviated by placement of an internal stent; appropriate antibiotic coverage and close follow-up are important factors in such patients. The extravasation detected on excretory urography in our patient was not initially treated by placement of a stent. Instead, an exploratory laparotomy was performed because of the uncertainty that the patient's acute, progressive peritonitis could be attributed to urinary extravasation. We were also aware that peritoneal
182
Mayo Clin Proc, February 1991, Vol 66
RENAL RUPTURE DURING PREGNANCY
pain during pregnancy can be caused by appendicitis and bowel accidents, which can progress rapidly and may be associated with increased maternal mortality.v'
CONCLUSION Physiologic dilatation of the urinary tract during pregnancy is common, but spontaneous rupture of either the renal parenchyma or the renal collecting system is rare. Previously, the treatment for most patients with spontaneous renal rupture was nephrectomy. On the basis of our experience, conservative treatment with a ureteral stent may be warranted in patients with rupture of the renal pelvis. REFERENCES
1. Aaro LA, Kelalis PP: Spontaneous rupture of the kidney associated with pregnancy. Am J Obstet Gynecol 111:270-273, 1971 2. Cohen SG, Pearlman CK: Spontaneous rupture ofthe kidney in pregnancy. J Urol 100:365-369, 1968 3. Maresca L, Koucky CJ: Spontaneous rupture of the renal pelvis during pregnancy presenting as acute abdomen. Obstet Gynecol 58:745-747,1981
4.
5.
6. 7.
8. 9. 10. 11. 12. 13.·
Oesterling JE, Besinger RE, Brendler CB: Spontaneous rupture of the renal collecting system during pregnancy: successful management with a temporary ureteral catheter. J Urol 140:588-590, 1988 Meyers SJ, Lee RV, Munschauer RW: Dilatation and nontraumatic rupture of the urinary tract during pregnancy: a review. Obstet Gynecol 66:809-815, 1985 Middleton AW Jr, Middleton GW, Dean LK: Spontaneous renal rupture in pregnancy. Urology 15:60-63, 1980 Smulewicz JJ, Dorfman J, Cagan S, Seery WH: Spontaneous rupture of the collecting system of the kidney: an evaluation. J Urol 104:507-511, 1970 Narath PA: The hydromechanics ofthe calyx renalis. J Urol 43:145-176, 1940 Daughtridge TG: Ureteral compression device for excretory urography. Am J Roentgenol 95:431-438, 1965 Khan AU, Malek RS: Spontaneous urinary extravasation. J Urol 116:161-165, 1976 Brennan DF, Harwood-Nuss AL: Postpartum abdominal pain. Ann Emerg Med 18:83-89, 1989 Munro A, Jones PF: Abdominal surgical emergencies in the puerperium. Br Med J 4:691-694, 1975 Andriole GL, Bettmann MA, Garnick MB, Richie JP: Indwelling double-J ureteral stents for temporary and permanent urinary damage: experience with 87 patients. J Urol 131:239-241, 1984
