Arch Gynecol Obstet (2008) 278:397–398 DOI 10.1007/s00404-008-0721-5
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Obstructive anuria due to blood clot Anjali Gupta · Smiti Nanda · Savita Rani Singhal · Anshu Gupta
Received: 11 May 2008 / Accepted: 19 June 2008 / Published online: 5 August 2008 © Springer-Verlag 2008
Abstract An unusual case of anuria due to the obstruction caused by blood clot following repair of ruptured uterus is presented. Although the blood clot usually dissolves, the awareness of this complication is important to avoid the unnecessary procedures. Keywords Blood clot
Anuria · Obstructed labor · Rupture uterus ·
Dear Editor, We would like to present an unusual case of anuria due to obstruction caused by blood clot following repair of ruptured uterus. Mrs. M, aged 21 years, gravida Wve, para four with two live children presented with 38 weeks pregnancy with ruptured membranes for 8 h. At the time of admission, she was dehydrated, exhausted and extremely pale. Her pulse rate was 104/min and blood pressure was 110/80 mm Hg. Per abdomen examination revealed term sized uterus, distention of lower uterine segment up to the umbilicus, presence of Bandl’s ring and absent fetal heart sound. On vaginal examination, fetal hand was seen prolapsed into the vagina, A. Gupta (&) Department of Obstetrics and Gynaecology, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, 1408/13, Opposite Model School, Civil Road, Rohtak, Haryana 124001, India e-mail:
[email protected] S. Nanda · S. R. Singhal Department of Obstetrics and Gynaecology, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Medical Campus, Rohtak, Haryana 124001, India A. Gupta Department of Pathology, IHBAS, Delhi, India
cervix was fully dilated with shoulder presentation. Ultrasonography conWrmed intrauterine fetal death. Self-retaining catheter was inserted with diYculty. A total of 5 ml of hemorrhagic urine was obtained. The decision for caesarean section was taken in view of obstructed labor with impending uterine rupture. A T-shaped uterine rent, with fetal parts visible through it, was present in the lower uterine segment. A dead male baby along with the placenta and membranes was extracted. The rent was extending laterally into the broad ligament and vertically up to the vagina. Bladder was edematous. Uterus was exteriorized and repair of uterine rent followed by bilateral tubal ligation was done. Three units of blood was transfused intraoperatively. Postoperatively, her vitals were stable. There was no urine output in 12 h even after changing the catheter. Patient started complaining of abdominal pain and distress. Abdomen was tense and distended. Renal function tests were found to be normal. On abdominal aspiration from the Xank, urine was obtained. Suspecting urinary ascites and failure to diagnose ureteric injury at the time of surgery, relaparotomy was undertaken. At the operation, bladder was distended up to the umbilicus. There was no urinary ascites and ureteric injury. Four attempts were made to change the catheter and 800 ml of clear urine and last 200 ml of hemorrhagic urine was drained but still the bladder could not be emptied completely and again started distending. Cystotomy was done and hemorrhagic urine was drained. Blood clot of 500 ml was removed from the bladder. It was then realized that anuria was due to the blood clot obstructing the bladder neck. Bladder rent was closed in two layers and retropubic drain was put. Now, the catheter was draining clear urine and the patient recovered uneventfully. Uterine rupture can occur in multigravida following obstructed labor. Chabra et al. 1 detected intraoperative complete rupture in 5.9% cases of obstructed labor. The
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close embryologic development and anatomic proximity of the urinary and genital organs predisposes the urinary tract to injury during surgical procedures in the female pelvis 2. Incidence of ureter and bladder injury in obstetric operations is 0.25 and 0.3%, respectively 3. Ureteral injury most commonly occlusion or transaction, usually is not recognized during the time of operation. Anuria is highly suggestive of obstructive uropathy in the absence of shock. Therefore, in the present case, failure to recognize ureteral injury was suspected and relaparotomy was done. Anuria was due to the presence of blood clot in the bladder, obstructing the bladder neck. Following obstructed labor, the bladder might have got compressed between the presenting part and the pubis symphsis resulting in rupture of the vessels inside the bladder and formation of blood clot. To our knowledge, such a case of anuria due to blood clot has not been reported previously.
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Arch Gynecol Obstet (2008) 278:397–398
Although, blood clots usually dissolve, awareness of this complication is important. Had we thought of blood clot as a cause of obstructive uropathy, relaparotomy would have been avoided.
References 1. Chabra S, Gandhi D, Jaiswal M (2000) Obstructed labour—a preventable entity. J Obstet Gynaecol 20:151–153. doi:10.1080/ 01443610062913 2. Raut V, Shrivastava A, Nandanwar S, Bhattacharya M (1991) Urological injuries during obstetric and gynaecological surgical procedures. J Postgrad Med 37:21–23 3. Park RC, DuV WP (1980) Role of caesarean hysterectomy in modern obstetric practice. Clin Obstet Gynaecol 23:601–620. doi:10.1097/00003081-198006000-00027
