Journal of Reproductive Medicine Gynaecology & Obstetrics Category: Medical Type: Case Report
Unexpected Injury to the Urinary Bladder in Women with Multiple Previous Cesarean Scars in Labor: Two Cases - Two Mechanisms
- Panicker R1*, Moopil J2, Kharkwal KC2
- 1 Faculty Of Medicine, AIMST University, Bedong-08100, Kedah Darul Aman, Kedah, Malaysia
- 2 Faculty Of Medicine, AIMST University, Kedah, Malaysia
*Corresponding Author:Panicker R
Faculty Of Medicine, AIMST University, Bedong-08100, Kedah Darul Aman, Kedah, Malaysia
Received Date: Apr 26, 2019 Accepted Date: May 13, 2019 Published Date: May 20, 2019
As opposed to injury to the urinary bladder during surgery, this case report of two cases highlights the non-iatrogenic injury that could occur to the urinary bladder, in patients with previous cesarean scars who go into labor. The highlight of the case report is the differing mechanisms of injury to the urinary bladder.
In case1 the patient with previous two cesarean scars presented with features of prolonged labor. The patient was discovered to have a laceration in the bladder, at the time of surgery, though the cesarean scar was intact signifying the possibility of ischaemic injury to the bladder. In case 2 a patient with two previous cesarean scars had injury to the urinary bladder along with violent rupture of the uterine scar. In this case the rupture of the uterine scar had extended to involve the urinary bladder. In both the cases the distortion in anatomy due to the previous surgeries could have contributed to the bladder injuries.
Patients with multiple cesarean scars should be monitored closely in labor. While performing emergency cesarean sections in such patients surgeons should have a high index of suspicion for possible urinary bladder injury.
On passing a Foley’s catheter frank hematuria was observed and a diagnosis of previous two cesarean sections at term with obstructed labor and possible urinary bladder injury was made and she was shifted for emergency cesarean section. The surgery was performed with the Foley’s catheter in situ but bulb deflated. Findings at surgery revealed that the lower uterine segment was intact with no evidence of scar dehiscence. However there was evidence of a subserosal hematoma occupying the lower part of the lower uterine segment at the interphase between the urinary bladder and the lower uterine segment. A high transverse incision on the lower uterine segment, well above the bladder reflection was given. The head which appeared to be crowded was delivered gently without using any instrument. The baby boy was active and weighed 04.1Kg and was handed over to the pediatrician.
After closing the uterine incision in two layers, the hematoma overlying the lower half of the lower uterine segment was explored revealing a rupture of the urinary bladder. The rent in the urinary bladder was separate from the present uterine incision, which as previously mentioned was placed high on the lower uterine segment. The tear in the urinary bladder was repaired in two layers using absorbable suture material. The repair was confirmed water-tight and abdomen was closed. Continuous bladder drainage was continued for seven days postoperatively and thereafter the patient was discharged asymptomatic.
Findings at surgery revealed that the abdomen was filled with blood stained amniotic fluid. The fetus was lying completely outside the uterine cavity and was dead. The placenta too had separated and was lying outside the uterus. The uterus was well contracted with minimal bleeding from the ruptured scar margins. The margins of the ruptured scar appeared to have extended laterally to the right without involving the uterine vessels. The urinary bladder was adherent to the lower uterine segment and appeared advanced. Closer inspection of the lower uterine flap revealed the tip of the Foley’s catheter visible through a rent in the urinary bladder. This rent was in close proximity to the right sided angle of the ruptured uterine scar. The bladder was dissected free from the uterus and repaired in two layers. A peritoneal wash was given and the ruptured scar margins were freshened and approximated. Postoperative recovery was uneventful.
In case 2 the obvious cause of bladder injury is the forceful lower segment scar rupture with extrusion of the fetus and placenta causing the ruptured uterine scar to also involve the urinary bladder. The adhesion of the urinary bladder onto the lower segment, might have also contributed to the injury . The lesson learnt from these cases is that patients with multiple cesarean scars who are allowed to go into labor could develop injury to the urinary bladder. Moreover since spontaneous injury to the urinary bladder could go unrecognized, early diagnosis would be critical in reducing morbidity. In both our patients’ frank hematuria on catheterization was the pointer to the diagnosis. In the absence of frank hematuria the obstetrician needs to have a high index of suspicion and early cystoscopic evaluation/methylene blue dye testing could prevent serious morbidity.
CONFLICT OF INTEREST
- Salman L, Aharony S, Shmueli A, Wiznitzer A, Chen R, et al. (2017) Urinary bladder injury during cesarean delivery: Maternal outcome from a contemporary large case series. Eur J Obstet Gynecol Reprod Biol 213: 26-30.
- Hsu CD, Chen S, Feng TI, Johnson TR (1992) Rupture of uterine scar with extensive maternal bladder laceration after cocaine abuse. Am J Obstet Gynecol 167: 129-130.
- Webb JC, Gilson G, Gordon L (2000) Late second stage rupture of the uterus and bladder with vaginal birth after cesarean section: A case report and review of the literature. J Matern Fetal Med 9: 362-365.
- Png KS, Chong YL, Ng CK (2008) Two cases of intraperitoneal bladder rupture following vaginal delivery. Singapore Med J 49: 327-329.
- Kibel AS, Staskin DR, Grigoriev VE (1995) Intraperitoneal bladder rupture after normal vaginal delivery. J Urol 153: 725-727.
- Pandyan GV, Zahrani AB, Awon AR, Al-Rashid M, Al-Assiri M, et al. (2007) Iatrogenic bladder injuries during obstetric and gynecological procedures. Saudi Med J 28: 73-76.
- Peters PC (1989) Intraperitoneal rupture of the bladder. Urol Clin North Am 16: 279-282.
Citation: Panicker R, Moopil J, Kharkwal KC (2019) Unexpected Injury to the Urinary Bladder in Women with Multiple Previous Cesarean Scars in Labor: Two Cases - Two Mechanisms. J Reprod Med Gynecol Obstet 4: 021.
Copyright: © 2019 Panicker R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.