NC.com

Preexisting urologic conditions

Myelomeningocele

• Family planning: usually normal fertility, 70% successful conceptions, use latex-free condoms and other devices
• Fetal risks: neural tube defect in offspring is 1%-15% (if both parents affected)
• Maternal risks: pre-existing renal insufficiency exacerbated during pregnancy, ncreased risk of stones, pyelonephritis, urinary diversion at risk for ischemia, stenosis, prolapse
• Delivery: avoid vaginal delivery in narrow pelvis, AUS, bladder neck reconstruction, contracted hips, cautious vaginal delivery if prolapse, ureterosigmoidostomy, malpresentation, cautious C-section if VP shunts, intestinal incorporation into GU tract (avoid pedicle)

Bladder exstrophy

• Anatomy: vaginal introitus often narrow and stenotic with horizontal lie
• Prolapse: common (18-30%) due to poor apical support, consider management with bed rest and pessary
• Risks: increased spontaneous abortion risk (35%), ncreased preeclampsia risk (32%), higher if prior renal insufficiency
• Delivery: vaginal delivery difficult, usually undergo C-section

Bladder augmentation

• Pregnancy test: urine exposure to bowel mucosa may give false positive pregnancy test reading
• Catheterization: may be more difficult due to change of channel angle, usually blood supply stretches without issue
• Infection: increased pyelonephritis risk (16-18%), consider antibiotic prophylaxis during pregnancy (no consensus)
• Delivery: perform C-section as high-midline or paramedian incision to avoid injuring reservoir or pedicles, consider catheterizing channels during C-section to assist with identification, complications occur in up to 40%

GU malignancies

• Contrast: if enhanced images required, CT contrast has reportedly lower risks than MR contrast
• AML: increased risk for rupture during pregnancy, consider observation with embolization (risk of premature labor), surgery reserved for urgent indications
• Renal biopsy: consider if it would affect decision to treat or observe during pregnancy
• Renal cancer management: (partial) nephrectomy after delivery (T1a), nephrectomy during pregnancy (T1b-T2, can wait if 3rd trimester), surgery or systemic therapy immediately (T3-T4, M1)
• TURBT: can perform at any stage to obtain tissue for bladder tumor diagnosis, okay to delay NMIBC treatment until after pregnancy
• Bladder cancer management: TURBT +/- intravesical chemo (Ta-T1), NAC during pregnancy + cystectomy after delivery (T2-T4, N1), palliative chemo (M1)

Transplant

• Timing: less risk for graft loss after 1-2yr, pregnancy > 5yr after transplant has potential risk for permanent reduction in renal function
• Ideal conditions: Cr < 1.5, minimal proteinuria, no rejection in past year, controlled HTN, stable medications
• Transplant risks: rejection less likely, no change in graft survival/function
• Fetal risks: IUGR, premature labor, infections
• Safer immunosuppresive drugs: azathioprine, cyclosporine, steroids, tacrolimus
• Monitoring: higher risk for gestational HTN and DM, hydronephrosis, proteinuria, infection
• Delivery: no contraindication to vaginal delivery, consider stress dose of steroids

Urologic conditions that arise during pregnancy

Placenta percreta

• Prevalence: 1 in 500-2500 pregnancies, more common if prior C-sections
• Presentation: hematuria occurs in 25%
• Diagnosis: US and MR have similar rates of sensitivity/specificity, can consider cystoscopy but do not biopsy (risk for bleeding)
• Concerns: 29% ureteral injury rate (compared to 5% for hysterectomy), may require 20-40U blood products, mortality rates 9.5% (mother) and 24% (baby)
• Intraop findings: loss of bladder/uterine plane, dilated vessels overlying bladder serosa
• Gyn management: consider planned C-section at 34wks w/ hysterectomy, posterior approach to hysterectomy (anterior approach risks severe bleeding due to lack of vascular control), retract ureters laterally and uterus medially
• Uro management: recommend prophylactic stent placement (decreases ureteral injury risk), removal of placenta from bladder (do not leave in-situ), 2-layer bladder closure, omental interposition, may require ureteral reimplant or partial cystectomy

Incarcerated uterus

• Prevalence: 1 in 3000 pregnancies, more likely if fibroids, endometriosis, adhesions
• Pathophys: 14% of women have a retroverted uterus, normally flips to anteverted as uterus grows during pregnancy but can occasionally become trapped by sacrum and compress urethra, causing retention
• Presentation: retention, dysuria, constipation
• Complications: renal injury/failure, bladder rupture, premature membrane rupture, miscarriage
• Management: place catheter, pelvic exam to confirm retroversion (cervix behind pubic symphysis, fundus nonpalpable), reposition with knee-chest positioning, manual reduction, colonic insufflation via colonoscopy, amnioreduction, laparoscopy/laparotomy

Renal rupture

• Risk factors: rare, but may be related to prior trauma, surgery, or stones
• Cancer risk: can occur in presence of tumors, perform thorough evaluation
• Management: nephrectomy if parenchymal rupture, stent/PCN if collecting system rupture

Postpartum incontinence

• Pudendal nerve injury: due to stretch/compression, can lead to urinary and fecal incontinence
• Pelvic floor muscle injury: due to injury during delivery
• Management: usually resolves within 3 months, behavioral training, pelvic floor training