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BACKGROUND:
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.
METHODS:
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.
RESULTS:
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.
CONCLUSIONS:
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.