Pregnancy and Cesarean Section in Women with Lower Urinary Tract Reconstruction: What is the Role of the Urologist?
Joshua D. Roth, M.D., Jessica T. Casey, M.D, Benjamin M. Whittam, M.D., Konrad Szymanski, MD, Richard C. Rink, MD, Mark P. Cain, M.D., Rosalia Misseri, M.D..
Indiana University, Indianapolis, IN, USA.
Women with neuropathic bladder (NB) and lower urinary tract reconstruction (LUTR) in childhood often have normal fertility and may become pregnant. We sought to determine the effects of pregnancy and C-section delivery and to assess the role of the urologist in their care.
We reviewed consecutive patients from July 1987 to May 2016 with NB due to spinal dysraphism or spinal cord injury who underwent LUTR in childhood, became pregnant, and delivered via C-section. We collected data on demographics, etiology of NB, upper urinary tract changes, urinary tract infection (UTI), continence and catheterization technique during pregnancy. C-section data was collected including gestational age at delivery, skin incision, uterine incision, and complications.
We identified 10 women who had 16 pregnancies over a 29-year period. Fourteen children were delivered via C-section: 1 very preterm (25 to <32 weeks), 1 moderately preterm (32 to <34 weeks), 5 late preterm (34 to <37 weeks), and 7 term births. . There were 2 miscarriages (12.5%).
Complete pregnancy data was available for 13 of 14 deliveries. Twelve developed de novo (10) or worsening (2) hydronephrosis. Six were asymptomatic and managed expectantly and 6 required nephrostomy tubes (median 30 weeks). Seven had difficulty catheterizing (4 urethra and 3 Monti, 3/7 required indwelling catheters). Five developed urinary incontinence during pregnancy. Nine had symptomatic UTIs (2/9 febrile).
A staff urologist was present at each C-section. Six were scheduled, 7 emergent due to premature labor, and 1 emergent due to failure to progress during attempted vaginal delivery. A midline incision was made in 7, and a Pfannenstiel in 7 (1 required a midline extension). The uterus was incised in a classical fashion in 10 and via low transverse incision in 4. Intraoperative complications were identified in 6/14 (43%). These included cystotomy in 5, a bowel deserosalization in 1, and vaginal extension in 1. A uterine rupture was identified in 1 patient during her second C-section, which occurred on an emergent basis. Tubal ligation was performed concomitantly in 2 women and could not be performed when desired in 2 due to dense adhesions. Three patients developed urinary fistulae following surgery.
Despite routine involvement of urologists, females with neuropathic bladder and LUTR have a high rate of complications during pregnancy and delivery. When possible, preconception counseling should highlight the increased risks of pregnancy in this group.
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