|Year : 2015 | Volume
| Issue : 2 | Page : 107-109
Spontaneous rupture of the urinary bladder in the third trimester of pregnancy
Iornum H Shambe1, Jonathan A Karshima1, Kenneth A Ozoilo2
1 Department of Obstetrics and Gynaecology, Jos University Teaching Hospital, Jos, Nigeria
2 Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria
|Date of Web Publication||5-Aug-2015|
Iornum H Shambe
Department of Obstetrics and Gynaecology, Jos University Teaching Hospital, Jos
Source of Support: None, Conflict of Interest: None
Spontaneous rupture of the urinary bladder is defined as rupture of the urinary bladder into the peritoneal cavity without a history of trauma 1. Aetiological factors implicated include but are not limited to radiotherapy, chronic infective diseases like tuberculosis, necrotizing cystitis and in pregnancy, bladder injuries caused in the event of uterine rupture 2. Its incidence is 1 in 126,000 hospital admissions 3. We report a rare case of spontaneous intraperitoneal rupture of the urinary bladder in the early third trimester of pregnancy. This report highlights the diagnostic challenges obstetricians and surgeons may encounter with presentations of acute abdomen in pregnancy. The patient presented with acute abdominal pain, voiding difficulty with pyrexia and features of peritonitis. At laparotomy, 3.5 litres of urine were drained from the abdominal cavity and a 6cm rent in the vault of the bladder was found. Laparotomy, bladder repair with antibiotic cover and indwelling catheterization were the basis for a favourable outcome.
Keywords: Acute abdomen, repair, ruptured bladder, spontaneous
|How to cite this article:|
Shambe IH, Karshima JA, Ozoilo KA. Spontaneous rupture of the urinary bladder in the third trimester of pregnancy. J Med Trop 2015;17:107-9
| Introduction|| |
Rupture of the urinary bladder in pregnancy usually presents as acute abdomen but with its own peculiar diagnostic challenges. This is because the abdominal discomfort it causes may be ascribed to a normal occurrence in pregnancy.  Acute abdomen caused by a ruptured bladder is an uncommon event with a reported incidence of 1 in 126,000 hospital admissions.  It is a potentially fatal event and is defined as rupture of the urinary bladder into the peritoneal cavity or pelvic cellular tissue without a history of trauma.  We hereby present a case of spontaneous rupture of the bladder in pregnancy.
Its rarity and the dire consequences of not considering it as a differential diagnosis in pregnant women with acute abdomen are the reasons that prompted this case to be reported.
| Case Report|| |
The patient was a 30-year-old Nigerian woman who was gravida 3 Para 3 + 0 who presented at our Gynecological Emergency Unit. She was unsure of her last menstrual period, but an ultrasound scan done at presentation estimated the pregnancy to be at a gestational age of 28 weeks. She was referred from the Nigerian Air force Hospital Jos as an emergency with generalized abdominal pain of 4 days duration, which had been increasing in intensity. There was associated low backache. There was no history of trauma or vaginal bleeding or hematuria. She had been admitted and treated for the same symptoms as case of urinary tract infection and was discharged 48 h before an eventual readmission and referral to the obstetric unit of the Jos University Teaching Hospital.
Her first pregnancy was carried to term and delivered via caesarean section on account of breech presentation at term in a primigravida. The second pregnancy was also carried to term and delivered via caesarean section on account of major degree placenta praevia. In the immediate postpartum period she had postpartum hemorrhage secondary to retained products of conception. She with transfused with nine pints of blood at that admission. There was a history of hematuria after the second cesarean section that resolved spontaneously 48 h after it started. Both surgeries were performed at a Tertiary Hospital in Nnewi.
There was hesitancy associated with a feeling of desire to void but passage of only small amounts of urine. There was no hematuria.
On examination, she was conscious and in pains. Her blood pressure was 150/80 mmHg and the pulse rate was 132 bpm. She was febrile with a temperature of 37.7°C.
The abdomen was distended, with generalized tenderness and guarding. A vaginal examination revealed a tender fullness in the posterior fornix. The cervix was closed and anterior.
An abdominal ultrasound showed a large amount of free fluid in her abdominal cavity.
The patient was catheterized, and a minimal amount of clear urine drained. A provisional diagnosis of acute appendicitis was made. A consult was sent to the surgical team on call who reviewed and concurred with this assessment. The patient was resuscitated and prepared for emergency laparotomy. Urea was 11.4 mmol/L (2.5-6.6) and creatinine 349 umol/L (70-126), sodium 133 mmol/L, potassium 5.0 mmol/L (3.5-5 mmol/l) PCV - 37%.
At laparotomy by a multidisciplinary team of surgeons and gynecologists, the peritoneal cavity was found to be walled off by omentum and contained 3.5 L of a clear yellow fluid. The uterus was anteverted in the pelvis, and both tubes and ovaries looked normal. A rent was found in the vault of the urinary bladder about 6 cm in diameter with ragged edges. There were no signs of trauma in other abdominal organs.
Bladder repair was effected by the urogynecologist. The rent was trimmed and closed in two layers with Vicryl 0 sutures. An omental patch was used to cover the repair and a drain was left in the vesicouterine pouch. Intravenous ceftriaxone and metronidazole were given for 48 h and then oral antibiotics for 10 days. An indwelling Foley catheter (16F) was left in situ for 2 weeks. The urinary catheter was removed on the 14 th postoperative day.
A repeat urea and electrolyte estimation showed all parameters to be within normal limits on the 3 rd post-operative day. A urine culture on the 10 th postoperative day yielded Escherichia coli sensitive to nitrofurantoin. The patient was treated appropriately and discharged to the antenatal clinic for follow-up on the 15 th postoperative day.
She had uneventful antenatal care following discharge and was counseled for an elective cesarean section at 38 weeks. This was performed as scheduled. At surgery, there were minimal pelvic adhesions between then lower uterine segment and the bladder. A live male baby was delivered with Apgar scores of 8 and 9 in the 1 st and 5 th min respectively. The placenta was anterofundal, and the blood loss was 300 ml. The patient had an uneventful recovery from the cesarean section.
| Discussion|| |
Spontaneous rupture of the bladder is an uncommon and life-threatening event particularly in pregnancy where uncertainties in diagnosis may delay prompt surgical intervention that would reduce its attendant morbidity and possible mortality. It is defined as rupture of the urinary bladder into the peritoneal cavity or pelvic cellular tissue without a history of trauma, rupture is more often intraperitoneal as in the presented case than extraperitoneal. 
Etiological factors that have been implicated in bladder rupture are bladder tumors, post-radiotherapy, chronic infective diseases and necrotizing cystitis.  Although a rare event, it has been reported since the early 1900s with its incidence reported as 1 in 126,000 hospital admissions. 
Intraperitoneal bladder rupture may be due to lesions in the bladder or caused by over distension of the bladder. In the former group, tuberculosis is a common cause while urinary retention from impacted pelvic tumors, neurogenic damage or postoperative urinary retention may lead to the bladder rupture caused by over distension; In either case, the bladder vault is commonly involved being the weakest part of the urinary bladder. 
In this patient, no case could be identified for the rupture, but there was a 48 h history of hematuria following the second cesarean delivery, which was for a major degree placenta previa. It is possible that the bladder wall may have been weakened from an injury at that surgery and later ruptured spontaneously in the index pregnancy.
Spontaneous rupture of the bladder typically presents as acute abdomen associated with guarding and rigidity, this is often accompanied by voiding difficulty.  If affected patients present after 24 h, significant peritoneal reabsorption of urea and creatinine that occurs may present a biochemical picture of renal failure.  This is evident in the urea and creatinine values of our patient whose symptoms started 4 days before her referral to our unit. The urea and electrolyte values were elevated.
It is also possible to have spontaneous bladder rupture following obstructed labor either immediately during labor or between the 4 th and 10 th days postpartum.  These varied presentations may present a diagnostic challenge, which was highlighted in a review by Mokoena et al. of 44 patients who had a mean delay of 5.4 days between an identifiable incident or presentation and diagnosis.  The initial diagnoses in our patient were urinary tract infection and acute appendicitis which were both inaccurate.
Diagnosis in this patient was made at laparotomy. A cystogram is another diagnostic aid that has been used with success in the postpartum period, but is contraindicated in pregnancy.  Unlike extraperitoneal traumatic bladder rupture, which can be managed with catheter drainage alone, intraperitoneal bladder rupture particularly in pregnancy requires open repair and long-term catheter drainage; biopsy of the bladder wall may be indicated to rule out infective causes or those due to malignancy.  A majority of patients recover without complications following a two layer bladder closure.  In our patient, the repair was reinforced with an omental patch with the favorable outcome of a subsequently uneventful pregnancy and delivery.
| Conclusion|| |
Diagnosis of spontaneous rupture of the bladder requires a high index of suspicion and should be considered as a possible differential diagnosis in cases of acute abdomen in pregnancy, appropriate diagnostic aids to hasten diagnosis such as ultrasound to demonstrate free fluid in the peritoneal cavity may be used but should not delay laparotomy to confirm diagnosis and effect repair.
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