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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 229-231

An interesting case of abdominal distension and oliguria in postpartum period


Department of Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission06-Mar-2016
Date of Acceptance02-Jun-2016
Date of Web Publication28-Dec-2016

Correspondence Address:
Vinay Pandit
Department of Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-5568.196865

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  Abstract 


A 26-year-old female presented with progressive abdominal distension and oliguria in puerperal period. Diagnosis of spontaneous intraperitoneal rupture of bladder following normal vaginal delivery was made based on the clinical and radiological features. Computed tomography (CT) cystogram suggested the rents in the dome and posterior wall of the urinary bladder and the defects were repaired. She developed multiple complications such as urinary tract infection, sepsis, bacterial peritonitis, and intestinal adhesions. In the presence of large urinary ascites, oliguria, and renal failure in puerperal period, bladder rupture should be considered. Emergency physician should establish the diagnosis early and urgent operative repair has to be performed to reduce complications and morbidity.
The following core competencies are addressed in this article: Medical knowledge, patient care.

Keywords: Ascites, oliguria, postpartum period, spontaneous bladder rupture


How to cite this article:
Pandit V, Goel K, Jadhav D, Ramprakasha S. An interesting case of abdominal distension and oliguria in postpartum period. Int J Acad Med 2016;2:229-31

How to cite this URL:
Pandit V, Goel K, Jadhav D, Ramprakasha S. An interesting case of abdominal distension and oliguria in postpartum period. Int J Acad Med [serial online] 2016 [cited 2022 Jan 19];2:229-31. Available from: https://www.ijam-web.org/text.asp?2016/2/2/229/196865




  Introduction Top


Isolated intraperitoneal urinary bladder rupture following normal vaginal delivery is reported by only a few authors.[1],[2],[3] Bladder rupture in puerperium is commonly associated with uterine rupture. Preexisting bladder disease and incomplete bladder evacuation during delivery predispose for bladder rupture.[1] Sustained pressure of the fetal head against the intraperitoneal portion of the bladder during forceful uterine contractions leads to pressure necrosis of the bladder dome. Women tend to have retention of urine after episiotomy because of pain and chances of rupture increase if bladder is not catheterized. Other contributory factors include prolonged second stage of labor, high birth weight babies, existing underlying bladder diseases, history of recent trauma leading to a rapid deceleration force, and non catheterized patients.[2],[3]

We report a case of abdominal distension and oliguria in a 26-year-old woman during puerperal period. The clinical evaluation and imaging studies confirmed the diagnosis of spontaneous intraperitoneal rupture of urinary bladder. She was successfully treated with surgical intervention. However, she underwent multiple complications such as urinary ascites with peritonitis, urinary tract infection, and postoperative intestinal obstruction due to adhesions. Relevant literature regarding diagnosis and management of this condition is reviewed.


  Case Report Top


A 26-year-old female presented to Emergency Department (ED) 16 days following full-term normal vaginal delivery of the first child with progressive abdominal distension and oliguria. She had no premorbid illness. The second stage of labor lasted for half an hour. No forceps or vacuum devices were used. Median episiotomy was done during the labor. She had consulted physician twice following delivery for abdominal pain and fever; first on day 2 and later on day 5. On her second visit, she was treated with antibiotics for a week with a diagnosis of urinary tract infection and urinary retention and was discharged with catheter in situ. Her vital signs were normal. Abdominal examination revealed generalized distension with tenderness and free fluid. There was no rigidity. The urine drained was very minimal and turbid; hence, urinary catheter block was considered and fresh catheter was inserted. Half a liter of urine was drained initially; subsequently, very little turbid urine output was observed. Ultrasound of abdomen revealed free fluid, moving echoes, and debris in the urinary bladder, bilateral hydrouretero-nephrosis with normal kidneys. Ascitic fluid aspiration and analysis were carried out.

Investigations revealed hemoglobin of 9.8 g/dL, total leukocyte count of 12,400 cell/mm 3 with neutrophilia, and raised urea (124 mg/dL) and creatinine (2.20 mg/dL). Liver function tests, blood glucose, and electrolytes were normal. Ascitic fluid analysis revealed white blood cell of 19,000 cells/mm 3 with neutrophil predominance and creatinine of 2.17 mg/dL. Blood cultures and ascitic fluid cultures were sterile.

Cystogram showed extensive extravasation of contrast above urinary bladder into the peritoneum outlining bowel loops and along the paracolic gutter, suggesting possibility of intraperitoneal bladder rupture [Figure 1]. Computed tomography (CT) cystogram was performed for better visualization and it showed large volume contrast in the peritoneal cavity outlining bowel loops and postpartum uterus [Figure 2] and [Figure 3]. The patient was shifted to operation room and open laparotomy was carried out. Inflamed urinary bladder, four rents in the dome and a posterior wall tear of 2–3 cm size, was noted intraoperatively. The bladder was repaired after debriding necrosed tissue and an intraperitoneal drain was placed. Postoperative period was uneventful and suprapubic catheter was removed on the 9th day. Three weeks later, she was readmitted with severe constipation. Diagnosis of intestinal obstruction due to multiple adhesions was considered and was treated conservatively. CT abdomen done after 2 weeks was normal.
Figure 1: Cystogram shows extravasation of contrast above urinary bladder as shown in lower arrow. Contrast entering into the peritoneum outlining bowel loops and along the paracolic gutter suggesting possibility of bladder rupture as shown in upper arrow

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Figure 2: Sagittal view of computed tomography cystogram showing rent in upper part of urinary bladder and contrast entering peritoneal cavity as shown by the arrow

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Figure 3: Coronal view of computed tomography cystogram showing large volume contrast in the peritoneal cavity outlining bowel loops and postpartum uterus as shown by the arrow suggesting intraperitoneal bladder rupture

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  Discussion Top


A case of intraperitoneal rupture of bladder following normal delivery is described. Normally, bladder rupture occurs during the second stage of labor; however, as such, this stage is painful and pain due to bladder rupture may not be perceived. Few patients manage to pass a small amount of urine and retention may go unnoticed.[4] In the case, we described symptoms of bladder rupture were evident as early as 48 h. The abdominal distension she had developed was due to urinary ascites which resulted in oliguria. Episiotomy might have precipitated urinary retention predisposing to bladder rupture. The infection of ascitic fluid resulted in bacterial peritonitis. The development of multiple adhesions might have resulted in intestinal obstruction. Coexisting urinary tract infection may lead to confusing clinical picture and delay the diagnosis.

Symptoms of isolated bladder rupture include lower abdominal pain, ascites, decreased urine output, hematuria, and symptoms related to sepsis in case sepsis occurs. Hematuria may be experienced as high as 95% of patients, but chance to consider it as lochia is also high especially in primipara.[3] The serum urea and creatinine levels are elevated in 100% cases who present after 24 h of bladder rupture.[5],[6] In the puerperal period, abdominal distension, oliguria, and biochemistry suggestive of renal failure should alert the physician about possible bladder rupture. Initial imaging of choice is retrograde cystogram by instilling contrast via urinary catheter. CT cystogram may delineate the bladder rupture site. Diagnosis should be established by retrograde cystogram followed by CT cystogram. Noncontrast CT is not useful in the diagnosis of bladder rupture. Contrast CT scan is limited in setting of renal failure.[5]

Prolonged urinary retention is an important factor for the development of bladder rupture in postpartum period. During delivery, bladder catheterization and drainage are essential. Adequate bladder emptying and monitoring urinary output in postpartum period are necessary to identify bladder rupture. One of the reasons for the development of ascites in postpartum period is urinary ascites due to bladder rupture. Rapid urine absorption from peritoneal cavity to plasma results in abnormal serum urea and creatinine. Predisposing factor for bladder rupture may be multifactorial; however, in some cases, no clear identifiable factor may be present. Most of the cases occur in young women and prognosis is better compared to other etiologies of bladder rupture. Urgent operative repair is essential after confirming the diagnosis. Secondary bacterial peritonitis may develop if not treated early. Postpartum urinary tract infection and sepsis may coexist with urinary bladder rupture posing diagnostic problem and delay.


  Conclusion Top


Postpartum urinary bladder rupture may go unnoticed in ED. Abdominal distension, oliguria, and abnormal biochemical parameters in puerperal period are clues for the diagnosis. Delay in the diagnosis may result in multiple complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Baheti VH, Wagaskar VG, Patwardhan SK. Missed iatrogenic bladder rupture following normal vaginal delivery. J Clin Diagn Res 2015;9:PD01-2.  Back to cited text no. 1
    
2.
Kibel AS, Staskin DR, Grigoriev VE. Intraperitoneal bladder rupture after normal vaginal delivery. J Urol 1995;153(3 Pt 1):725-7.  Back to cited text no. 2
    
3.
Ekuma-Nkama EN, Garg VK, Barayan S. Spontaneous rupture of bladder in a primipara. Ann Saudi Med 1997;17:646-7.  Back to cited text no. 3
    
4.
Roberts C, Oligbo N, Swinhoe J. Spontaneous bladder rupture following normal vaginal delivery: A postpartum emergency. Br J Obstet Gynaecol 1996;103:381-2.  Back to cited text no. 4
    
5.
Png KS, Chong YL, Ng CK. Two cases of intraperitoneal bladder rupture following vaginal delivery. Singapore Med J 2008;49:e327-9.  Back to cited text no. 5
    
6.
Heyns CF, Rimington PD. Intraperitoneal rupture of the bladder causing the biochemical features of renal failure. Br J Urol 1987;60:217-22.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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