Anatomical Physiological Adaptation

8/3/2019 Anatomical Physiological Adaptation

1/69

DR.MAHMOUD ELBANNA

UROLOGIST

SULAYYIL GENERAL HOSPITAL


2/69


3/69

Mission

Understanding Lower urinary tract adaptations to

pregnancy.

Without such knowledge, it is almost impossible

to understand urinary symptoms that can affectwomen during pregnancy and puerperium.


4/69

Introduction

The anatomical, physiological, and biochemical

adaptations to pregnancy are profound.

Many of these remarkable changes begin soon

after fertilization and continue throughout

gestation, and most occur in response to

physiological stimuli provided by fetus.


5/69


6/69

Urinary system

Striking anatomical changes are seen in kidneys

and ureters during pregnancy.

This is due to changes in pelvic anatomy and is a

feature of 'normal' pregnancy.

Little has been published concerning expected

alterations in bladder anatomy during pregnancy.


7/69

INTRODUCTION

pregnancy can be responsible for many urological disorders,some of which may be life threatening for the mother andfetus, requiring emergency treatment.

Pregnancy often makes diagnosis difficult because manyinvestigative procedures are inadvisable in pregnantwomen.

The therapeutic possibilities are also limited,

and many drugs and certain surgical procedures arecontraindicated, present a risk of inducing labor, or areharmful to the fetus.

Therefore, finding a compromise between the patientscomfort and the normal development of the fetus issometimes necessary.


8/69

Despite hypercalciuria and physiological hyperuricuria,

the incidence of calculi does not rise during pregnancy,

since the rate of factors inhibitory crystallization(

citrate, magnesium, glycoproteins) is also higher

.

Urine, more alkaline because of respiratory alkalosis,

opposesthe formation of uric acid stones despite hyperuricuria.

Physiological dilatation of the upper urinary tract is

found in more than 90%of pregnant women. This dilatation

occurs between the 6th and 10th weeks and disappears

46 weeks after delivery .

For anatomical reasons, it predominates on the

right side.Different theories seek to explain this dilatation


9/69

The hormonal theory involves the inhibiting role of

progesterone on the ureterals mooth musculature

The mechanical theory involves the compressive

role of the uterus, with this effect predominating

on the right because of the uteruss dextrorotation.

Ureteral compression by the ovarian vein and by

the dilated uterine veins has also been suggested.

The protection of the left ureter by the sigmoidreinforces the asymmetric character of thedilatation


10/69

The absence of ureteral dilatation in cases of pelvickidney, after ileal conduit urinary derivation, or inthe quadruped confirms the involvement ofmechanical phenomena in this dilatation

Physiological dilatation during pregnancyis

sometimesthe cause of painful symptoms that usually regress

with the use of mild analgesics.

The persistence of pain or the appearance ofinfectious signs require urine drainage by a

ureteral drainage stent or apercutaneousnephrostomyNephrostomy.


11/69

Pregnancy and delivery may impact the

pelvic floor and result in detrimental effects

on urinary and bowel symptoms

Urinary incontinence is common in pregnant

women with resolution in the earlypostpartum period

Other than a 1-cm increase in the size of the kidneys,

these changes result in an increase in the rate of filteredcreatinine, urea, sodium, calcium, and uric acid


12/69

Urological changes

Kidney Vesical Urethral

* Lengthening of urethra

* Congested & hyperaemic

mucosa

Estrogen p squamiouslike changes

o FUL, AUL.

Ureteral


13/69

Bladder changes

Ant & Sup displ. (at term)

More broad base.. Convex trigone

More an abdominal organ

Bladder wall

Hyperemia, Tortuosity of sup. Vessels

MS Hypertrophy

o Capacity (q tone by Progesterone)

p at term (up to 1 liter) (Barkow 74)

q Voiding Press ?? (q sphincteric funct.) (Rubi & Sala

72)

Bladder changes

Ant & Sup displ. (at term)

More broad base.. Convex trigone

More an abdominal organ

Bladder wall

Hyperemia, Tortuosity of sup. Vessels

MS Hypertrophy

o Capacity (q tone by Progesterone)

p at term (up to 1 liter) (Barkow 74)

q Voiding Press ?? (q sphincteric funct.) (Rubi & Sala

72)


14/69

Physiological hydroureter & hydronephrosis

(Frequency)(apparent normally)

Pyelo-urteral dilatation

20th week .constant.to term schulman 75

Renal

pelvis

48 hows after

delivery up toSeveral week

Harrow 64

Rarely


15/69

Dilatation of renal pelvis in normal preg.

Normal Mild Moderate Sever

1st

Trimester (N=18) 39% 61% 0 0

2nd

Trimester (N=90) 31% 49% 20 0

3rd

Trimester (N=110) 30% 45% 22 3

None were normal pcause of investigation ante

partum bleeding. (Schullman 75)


16/69

Right Left

Incidence 76% 35%

% severe Dilatation 7.5% 1%

Extent of dilatation

(scale 1-6)

2.4s0.1 1s0.1

HydroureteronephrosisOnset 1st trimester

o severity with gestation

HydroureteronephrosisOnset 1st trimester

o severity with gestation


17/69


18/69

Effect of upper dilatation

Delayed excretion on right (5 fold o of time

to peak) isotope renography (Due to

Reservoir effect), no stasis (Bergstorum 75)Symptomatic Dilatation (No infection)

(reportedp good response to ureteral cath).

Acute renal failure p Bilateral obstructionvery rare .(Reported) (Rasmassen &

Nielsen 88)

Delayed excretion on right (5 fold o of time

to peak) isotope renography (Due to

Reservoir effect), no stasis (Bergstorum 75)Symptomatic Dilatation (No infection)

(reportedp good response to ureteral cath).

Acute renal failure p Bilateral obstructionvery rare .(Reported) (Rasmassen &

Nielsen 88)


19/69

Etiological factions

EndocrinalEndocrinal MechanicalMechanical

Progesterone pq ureteral cont.

Common embryological origin

q Tone

o Urine flow

Finstat 63

Abrupt onset at mid. gest.

Dilatation sharp at pelvic prim.

Prompt resolution after delivery.

Rasmassan

Nelsen 88.


20/69

Further evidence

o Intraureteral press.

Pelvic kidneyp No Dilatation.

Rt > left

Cross common iliac Rt?, Left?

Sigmoid. Cushing effect.

Rt ovarian veins..Partial obst.

Bellins 70, Versus, Roberts 71

Complete ureteral obst. .. (Can occur.. V. rare)

Shanghnessy 80

o Intraureteral press.

Pelvic kidneyp No Dilatation.

Rt > left

Cross common iliac Rt?, Left?

Sigmoid. Cushing effect.

Rt ovarian veins..Partial obst.

Bellins 70, Versus, Roberts 71

Complete ureteral obst. .. (Can occur.. V. rare)

Shanghnessy 80


21/69

Bulk of evidence that

1ry Partial ureteral compression

uterus, iliac arteries, ovarian veins)

2ry Endocrinal effect. A contributing

factor

Bulk of evidence that

1ry Partial ureteral compression

uterus, iliac arteries, ovarian veins)

2ry Endocrinal effect. A contributing

factor


22/69

Ureter

Elongation

oCurvature

?? Smooth kinks

1at. displacement

Rt < left (Sigmoid colon)

(Schulman 75)


23/69

Bladder anatomy and support in

pregnancy

Cystoscopically, an indentation of bladder

dome by enlarged uterus is visible duringpregnancy

Ureteric orifices are visualized in a higher

position than in nonpregnant state


24/69

During fluoroscopy, dramatic alterations in bladder profile

can be seen

The gravid uterus distorts the bladder, giving it an hourglass shape


25/69

Descent of the presenting part with fetalengagement during late pregnancy would

lead to a decrease in bladder capacity and an

increase in urinary frequency.

Symptoms begin early in pregnancy andpersist throughout pregnancy.


26/69


27/69

Pregnancy have been implicated as antecedents

for three disorders:1. Urinary incontinence

2. Anal incontinence

3. Pelvic organ prolapse

Causation is difficult to prove becausesymptoms often occur remote from delivery.

It is unclear from current literature whetherchanges are secondary to the method ofchildbirth or to the pregnancy itself.


28/69

Pelvic floor support

Pregnancy has wide-ranging impact on the

pelvic floor through neurologic, muscular,

hormonal, and traumatic effects

Pregnancy may predispose women to prolapse

of pelvic organs, including loss of support for

the anterior vaginal wall and bladder.


29/69

Pregnancy is associated with increasedmobility and descent of the bladder and other

pelvic organs.

Bladder neck descends with Valsalva

approximately 5 mm more in pregnant women

than in nonpregnant controls


30/69

Descent of anterior vaginal wall and bladderto the level of hymen by third trimester of

pregnancy, usually resolves after delivery.

presence of anterior vaginal wall descent or

cystocele in this setting does not merit

investigation or treatment


31/69


32/69

During pregnancy, urinary tractfunction is altered considerably inmany women.

Normal function apparentlyreturns for most women soon afterdelivery


33/69

Renal changes

o GFR

o RPF

q S.Creatinine & B. urea nitrogen q 25%

Rapid urinary excretion ofdrugs (dosage adjustments)

*o

glucose Excretiono GFR o filtered load

q resorptive capacity

(No insulin changes)

* o Amino acid excretion

o Nicotinic acid

o Ascorbic acid excretion.

>twice non pregnant


34/69

Amino acid excretion

16Week Term

Double of Normal Lysine, histidineTheonine alanine

Lysine cystine

(Tubular failure of absorption

(hormonal changes)


35/69

Renal physiologic changes in

pregnancy

o Secretion of many

substances

More capable

withstanding variations

in fluid & nutrientintake.

Providep Constant environment for fetus

Amino acids

Glucose

Water Soluble vitamins

(FetalDevelopment)


36/69

Urinary System

loss of smooth muscle tone due

to progesterone ,aggravated bymechanical pressure from the

uterus at the pelvic brim.

VUR is also increased.

These changes predispose to

UTI.


37/69

Pregnancy &UTI

Anatomic and physiologic urinary tract changes inpregnancy may cause pregnant women withbacteriuria to have an increased susceptibility to

pyelonephritis

smooth muscle relaxation results in decreasedperistalsis of ureters , increased bladder capacity,and urinary stasis.

The bladder itself is displaced superiorly andanteriorly during pregnancy


38/69

Irritative symptoms

Irritative symptoms are the most bothersomecomplaints during pregnancy

Theoretical mechanisms for these changesinclude

1. Hormonal alterations.

2. Expansion of circulating blood volume, andincreased GFR

3. Increasing uterine size

4. Pressure on the bladder


39/69

Urinary incontinence

Urinary incontinence is common in pregnant

women and has an impact on quality of life

Stress incontinence is more common than urge

incontinence, although mixed symptoms are

frequent


40/69

Stress urinary incontinence

Stress urinary incontinence affects up to 32%of primiparous women

The causes of stress incontinence duringpregnancy are thought to include

1. Maternal weight gain

2. Increased mechanical pressure on bladder from theenlarging uterus

3. Increased urine production from increasedglomerular filtration rates.


41/69

Urinary incontinence

There is some evidence that pelvic floor

strengthening during pregnancy can prevent

incontinence during pregnancy and in earlypostpartum period

Urinary incontinence symptoms of pregnancy

persist in postpartum period in a significant

minority of women


42/69

Urinary retention in pregnancy

Urinary retention is an uncommon urologicemergency, occurring in about 1 in 3000 to 1 in 8000

pregnancies

Classically, urinary retention occurs at 12 to 14 weeksof gestation in a retroverted uterus ,with presence ofuterine fibroids as a predisposing factors

Elevated bladder base associated with failure ofrelaxation of urethra during attempts to void (with

persistence of posterior urethrovesical angle)


43/69

Progesterone &Urinary retention

Progesterone may promote relaxation of

bladder smooth muscle and, in extreme cases,

detrusor inactivity and retention

Case reports of patients who had urinary

retention after use of assisted reproductive

technology, and who had extremely highprogesterone levels but who were not

pregnant


44/69

DIAGNOSTIC PROCEDURES IN THE

PREGNANT PATIENT

Doppler UltrasoundDoppler ultrasound is the first-line examination toperform when there is suspicion of renal colic in thepregnant woman.

However, it does not differentiate physiologicaldilatation of pregnancy from pathological dilatation

related, for example, to a kidney calculus. Since itonly explores the high lumbar ureter or pelvic ureter, itmisjudges many cases of calculi. With a sensitivity of34% and a specificity of 86% , this exam is often flawedas adiagnostic procedure.


45/69

Evaluating the Dilatation of the Urinary TractMuller-Suur and Tyden (1985) defined the pathological

limit for renal pelvis as a diameter greater than 17 mm.

beginning with the 2nd trimester,

suggest a limit of 27mmon the right and 18mmon the

left. Brandt and Desroches (1985) retained the samereferences for the 2nd and 3rd trimesters,with thepathological limits of 18 mm on the right and 15 mmon the left for the 1st trimester.

Finally, discovery of ureter dilatationextending to the pelvic ureter most often indicates

pathological dilatation (


46/69

Renal vascular resistance increases during acuteobstruction,

particularly during the first 648 h (Ulrich

et al. 1995). This increase is related tovasoconstriction

mediated by different factors such as

prostaglandins

Using these parameters,) indicated

that a resistivity index of at least 0.7 diagnoses

obstruction,

Measuring the Resistivity Index


47/69

Fetal malformation, developmental delay, growth delay,

or in utero death are the usual consequences reported.There is a linear relation between the radiation

dose and the risk of delays in mental development (Biyani

Below 50 mGy, the risk of malformation

seems negligible even if minimal biochemical

modifications are possible. This threshold value is well

under the dose delivered by radiological diagnostic

tests (plain abdomen = 1mGy/radiograph, 1 min of image

intensifier = 2 mGy)

RISK OF FETAL MALFORMATION

STewart estimated that an in utero irradiation of

1020 mGy increases the risk of cancer in the

child by1.5-21.52


48/69

MUTAGENIC RISK

A dose of 0.51 Gy is necessary to double the spontaneous

rate of genetic mutation (Hall 1991).This level of radiation is never reached by the common

radiographic diagnostic tests.

In conclusion, even if the consequences of diagnostic

irradiation during pregnancy are low, particularly

in the second and third trimesters, the riskbenefit ratio

of radiological exploration should always be evaluated

and compared to the risk of an unrecognized urinarytract obstruction treated late


49/69

IntravenousUrography

While (IVU) was considered the gold standard of radiological workup for

urinary lithiasis, its utility has greatly diminished since the advent

of unenhanced helical CT. It is superior to ultrasound

in diagnosis but IVU requires an injection of

contrast solution and leads to a low but not inconsiderable

dose of radiation, especially during the first trimester.

Different examination protocols have been proposed

aiming to limit the radiation exposure as muchas possible to three or four radiographs: plain abdomen,

30 s, 20 min plus or minus one late x-ray plain abdomen, 20 min, late x-ray (It is

important to use high-sensitivity films, reduce the

aperture as much as possible, have large radiology

rooms available, choose digital radiology, and use a

lead apron for the side of the healthy kidney . Given

bony superposition and the voluminous uterus, identifying

small stones is sometimes difficult . The exam does not always differentiate

physiological and pathological dilatations

R t d U t l h


50/69

Retrograde Ureteropyelography(RUP) results in radiation that is not inconsiderable and results in

a risk of sepsis when infection is present. Its advantages are

limited to a few patients for whom diagnosis remains uncertain,

during an operation, and immediately before double-J stenting.

Magnetic Resonance ImagingThe recent progress in (MRI), providing reduced acquisition time, makes reliable

exploration of the urinary tract feasible. To the sequences

without injection of contrast medium can be

added sequences with injection of gadolinium for auro-MRI with no iodine injection or irradiation.

The exam provides reconstitutions in the different spatial

planes (.Although the MRI has no known native implication

for the fetus, for reasons of caution this examination is

not advised in the course of the first trimester durin the organogenesis phase .

MRI does not display small stones well and has the disadvantage of high cost

and reduced accessibility to the patient during the

study. Although MRI is infrequently used in standard

urinary lithiasis workups, it can be useful in difficult

cases involving pregnant patients .


51/69

Urodynamic studies during pregnancy

During pregnancy, urinary symptoms do not correspondto urodynamic findings, and testing is not clinicallyhelpful.

Results of urodynamic studies during pregnancy are

contradictory

Some reports showed increased bladder compliance andatony during pregnancy

starting at the third month of pregnancy, the bladder

capacity slowly increases, reaching its largest limits, up to

1300cc in the eighth month . in the third trimester (the

bladder) shows definite evidence of atony.. At this time the

bladder sensations are not as clear-cut as in the non-

pregnant control.


52/69

In contrast, other reports found no difference in the

bladder capacity of pregnant women and found thatwomen with greatest bladder capacities complained of

the greatest urinary frequency

Women with stress incontinence had lower functionalurethral lengths and closure pressure

Detrusor instability was found in 23% during

pregnancy and in 15% after pregnancy, with allpatients who had detrusor instability postpartumshowing detrusor instability during pregnancy.


53/69

Treatment

Oral Treatment

Analgesics

Paracetamol, acetaminophen and dextropropoxyphene

can be used with no risk ().

Codeine is contraindicated during the first trimester because

of its potential teratogenic side effects but can beused episodically during the second and third trimesters

(In cases of intense pain, morphine can be necessary.

The prescription should be of short duration to prevent any risk of

maternofetal dependence, growth delay, or prematurely

induced labor (Barron 1985).

Morphine should not be used at the beginning of or during labor.


54/69

NONSTEROIDAL ANTI-INFLAMMATORY DRUGSGiven their blocking action of the synthesis of prostaglandins, NSAIDs should be

avoided during pregnancy because of the risk of premature closing of the ductus

arteriosus (Rasanen and Jouppila 1995) and of fetal

pulmonary hypertension (Aspirin can delay or prolong labor. Also, through its effecton platelet aggregation, it also induces a hemorrhagic

risk at delivery

ALPHA 1 ADRENERGIC BLOCKERS

Recent studies show the advantages of alpha 1 blocker,used as a spasmolytic drug, for the spontaneous expulsion

of distal ureteral stones (Dellabella et al. 2003).

The side effects in pregnant women and the possibility

of teratogenicity are not currently known. Further evaluations

are necessary before using this class of substances

in pregnancy

ANTIBIOTIC THERAPY


55/69

ANTIBIOTIC THERAPYAminopenicillins (Ampicillin, Amoxicillin) Antibiotics of the penicillin group,

aminopenicillins have low toxicity and generate few side effects other

than a risk of allergy. Forty to 50% of enterobacteria

are resistant to these antibiotics (Adding clavulanic acid-inhibiting beta-lactamases

has increased the efficacy, but 30%40% of bacteria are currently resistant to it

(Goldstein 2000). The aminopenicillins are very effective on streptococci. This group

of antibiotics can be usedwithout risk in pregnant women

but after having verified the sensitivity of the bacterium on the antibiogram.

THIRD-GENERATION CEPHALOSPORINSBelonging to the beta-lactam group, third-generation

cephalosporins have low toxicity and generate few side

effects. They can be administered orally or by intramuscular

or intravenous routes. Because of their efficacy,

their pharmacological properties, and a low rate ofenterobacterial resistance, third-generation cephalosporins

are the first-line antibiotic therapy for treating

acute pyelonephritis in pregnant women while waitingfor the result of the antibiogram.


56/69

AMINOGLYCOSIDESAminoglycosides have a synergetic action with betalactamines

and a wide spectrum of activity on enterobacteria.They have a risk of nephrotoxicity and

ototoxicity.

While aminoglycosides have been said by some authors to potentially causeneuromuscular blockade in humans, and have experimentally caused it in animals, there

has never been a reported case of human

neuromuscular blockade after aminoglycosides administration

(Administrable parenterally, they cross the placental barrier.Because of their risk to the

fetus, in pregnant patients they can only be used for short periods

for severe acute pyelonephritis threatening maternalfetal prognosis.

FLUOROQUINOLONESare very effective on enterobacteria but also on certain negative-coagulase

staphylococci. They are ineffective against enterococci. Escherichia

coli has a low resistance rate to ciprofloxacin (1%2%)

(They are classically contraindicated in the pregnant patient because of the risk oftoxicity to fetal cartilage and joints. Nevertheless, in cases of severe

acute pyelonephritis presenting a life-threatening

risk to mother and fetus or of multiresistant bacteria, they can be used for a short

period of time.


57/69

Quinolones (Nalidixic Acid, Pipemidic Acid)

Quinolones are active on enterobacteria, but they are contraindicated forpatients with G6PD deficit and should be avoided during pregnancy. Their

main side effects are digestive problems, photosensitization, and neurosensory

phenomena (disturbed vision, somnolence, dizziness, headaches, and more

rarely hallucinations and convulsions

NITROFURANTOIN

Active on enterobacteria, nitrofurantoin only slightly

modifies the fecal flora and induces little resistance. It

is contraindicated in patients with G6PD deficit. It can

be responsible for digestive problems, allergic reactions,and more rarely pulmonary fibrosis, hepatitis,

and optical or peripheral neuritis during prolonged

use. It can be used during pregnancy except in the last

trimester when it can result in hemolytic anemia

TRIMETHOPRIM-SULFAMETHOXAZOLE


58/69

TRIMETHOPRIM-SULFAMETHOXAZOLE

The association of trimethoprimand sulfamethoxazole

is very active on enterobacteria. Resistance rates of

20%40% have been reported, however It is contraindicated during the firsttrimester of pregnancy because of a potential teratogenic risk (antifolic property)

and during the third trimester because

of a risk of neonatal jaundice.

However, it can be used

during the second trimester except in cases of G6PD deficiency suspect in

Mediterranean patients or with first-degree relatives affected.

Chloramphenicol and tetracyclines are contraindicated

during pregnancy. Erythromycin have no fetal morbidity,although erythromycin estolate salt compounds

can cause cholestatic jaundice and should not be used


59/69

SurgicalTreatmentUreteral Stents

When a urinary calculus requires surgery during pregnancy, theclassical attitude is to ensure urine flow ,with

the definitive treatment undertaken after the child is

born ( Placing a double-J ureteral stent easily removes the

obstruction. In very

septic patients, the stent can be placed without sedation.

When urine is thick, it is preferable to first position

an open ureteral stent, which can be replaced after

a few days with a double-J stent when the sepsis is under

control and the urine more liquid (Dore 2004).

The double-J stent presents several advantages. It can be

placed under local anesthesia and presents no radiation

to the patient, as the procedure is guided by ultrasound

It i t l t l i ll d i


60/69

It is not always easy to place, especially during

the 3rd trimester, when the bladder is pushed back bythe uterus, the trigone deformed,

and the mucous membrane of the bladder rendered hyperemic by pelvic

hypervascularization. In addition, the stent carries

a certain number of disadvantages: bladder irritation

by the lower J that may cause urinary frequency, increased micturition

urge or hematuria, risk of displacement

due to dilatation of the excretory tract, and vesi-

7.4 Treatment 65 corenal reflux, which can cause lower back pain or

acute pyelonephritis ( Many authors have reported the risk of incrustation

secondary to hypercalciuria of pregnancy This risk is reduced by increasing fluid

intake, controlling calcium intake, and treatment ofUTI if necessary

(To avoid incrustations, some authors advise changing the double-J stent every

48 weeks ( thus multiplying hospitalizations and the risks related to endoscopicprocedures.

Other authors prefer to avoid the double-J stent at the beginning of

pregnancy and reserve its use for after the 22nd week


61/69

PERCUTANEOUS NEPHROSTOMY

An alternative to placing a ureteral stent is percutaneous

nephrostomy (). Dilatation of the urinary tract during pregnancy facilitatesits placement. Denstedt preferred this procedure before

the 22nd week of pregnancy (

It can be done under local anesthesia, ultrasound localization,

and in the three-quarter position (Kavoussi et

al. 1992). It may result in discomfort of an external derivation,exposes the patient to the risks of stent displacement,

cutaneous infection at the site of entry, and bacterial

colonization following prolonged use of the stent

The risk of incrustation is identical to that of the ureteral stent, requiring

that the stent be changed every 48 weeks (In very septic patients, whorarely cannot tolerate intravenous sedation, percutaneous nephrostomy

should be a good choice even if the threequarter position is not always

possible in such patients.


62/69

EXTRACORPORAL SHOCK-WAVE LITHOTRIPSY

Pregnancy is one of the common contraindications for

extracorporal shock-wave lithotripsy (ESWL) becauseof the potential risk of the shock waves on the fetus

(reported

fetal growth delay in the pregnant rat treated with

ESWL. The risk of irradiation when the calculus is located

by imaging and premature induction of labor(Vieweg et al. 1992) have also been reported.However,

seven patients have undergone this treatment during

their pregnancy, either because the pregnancy had not

been diagnosed at the time of treatment or after informed

consent ( These women continued their pregnancy to term and delivered

a perfectly healthy child. Despite these encouraging reports, most

learned societies contraindicate ESWL during pregnancy.


63/69

Percutaneous Nephrolithotomy

Although some authors have successfully performed

percutaneous nephrolithotomy (PCNL) in women at

the end of pregnancy ( this technique is classically

contraindicated in pregnant patients. It requires a

ventral decubitus position that is

problematic, as well as prolonged anesthesia. It

carries

high irradiation and can induce labor (


64/69

PARTICULAR TREATMENTS OF CERTAIN UROLOGICAL

EMERGENCIES IN PREGNANT WOMEN

1-Urinary Tract CalculiThe incidence of urinary lithiasis during pregnancy is

on the order of 1:200 to 1: 1,500 ) with the mean figure of 1: 1,500

cited most often. This incidence is identical in women who are not

pregnant Onset occurs eight or nine

times out of ten during the 2nd or 3rd trimester

). It is more frequent in multiparous women (. The calculi are essentially composed of calcium

carbonitee and more rarely of struvite

While seven or eight urinary calculi out of ten are

eliminated spontaneously, medical treatment should be

proposed initially. Rest and sufficient hydration (23 l/

24 h) are prescribed. When pain is present, fluid restriction

is routine.


65/69

2-Urinary TractInfections

Because of anatomic, functional, and hormonal modifications,

urinary tract infection is frequent duringpregnancy. It can present as three different entities:

asymptomatic bacteriuria, acute cystitis, or acute pyelonephritis

(Ovalle and Levancini 2001).

Different risk factors have been discussed: maternal

age, socioeconomic status, antecedents ofUTI, sexual

intercourse, hemoglobinopathies, diabetes, immunodepression

ofHIV infection, multiparity, and race

The most frequently encountered bacteria are

enterobacteria,

withE. colirankedfirst(65%90%),althoughstreptococci are found more and more often


66/69

2-SPONTANEOUS RENAL RUPTURE

Spontaneous renal rupture is a rare complication during pregnancy. It can occur in

three circumstances(:spontaneous rupture with no

cause, rupture of the excretory tract related to an obstruction ,and renal rupture

secondary to a tumor, most often an angiomyolipoma.

Clinically,the spontaneous rupture is manifested by lumbar or abdominal pain

with thickening of the lumbar fossa and sometimes

hemorrhagic shock.Ultrasound is a diagnostic aide that shows an effusion ofurine

around the kidney or a retroperitoneal hematoma. When there is rupture of theexcretory tract related to obstruction, placing a double-J stent to remove the

obstruction is the best approach(Oesterling et al. 1988). If this is not possible,

percutaneous nephrostomy can be undertaken. Percutaneous

drainage of a collection is sometimes necessary. When there is renal parenchyma

rupture, strict monitoring isindispensable.

Bleeding can stop spontaneously because of the pressure exerted on the

retroperitoneum. When bleeding cannot be controlled and hemodynamics

are unstable, open surgery is sometimes the only choice possible, with a

nephrectomy often necessary


67/69

3-PLACENTA PERCRETA INVOLVING URINARY BLADDER

The incidence of placenta accreta is estimated fromone

in 540 to one in 93,000 deliveries (Smith and Ferrara

1992). Placenta percreta is a variant of placenta accreta

in which chorionic villi penetrate the entire thickness

of the myometrium and may involve adjacent structures.

Placenta percreta involving the bladder is extremely

rare (less than 60 published cases) (Washeckaand Behling 2002) and is encouraged by uterine scars

and cesarean section.

This potentially catastrophic condition may remain

undiagnosed or underappreciated until delivery (Leaphartet al. 1997) and diagnosis is oftenmade only at the

time of operation in a life-threatening bleeding. In 31%

of cases, hematuria is present during pregnancy and a

preoperative diagnosis established by ultrasound

CONCLUSION


68/69

Urologic emergencies during pregnancy are far from

exceptional. Some can be life-threatening to the mother

or endanger the development or viability of the fetus.

Good knowledge of the diagnostic and therapeutic

Particularities in the pregnant patient and close collaboration

between the urologist and the obstetrician make

for optimal care that limits maternal and fetal risks tothe greatest degree.

CONCLUSION


69/69

Documents

Anatomical Physiological Adaptation