Antenatal Spontaneous Renal Forniceal Rupture Presenting as an Acute Abdomen

Abstract

Background Renal forniceal rupture is a lesser-known cause of acute abdomen in pregnancy. The ureteral compression by the gravid uterus places pregnant women at a higher risk. Sequelae in pregnancy could include intractable pain, acute kidney injury, and preterm birth. Case A 22-year-old primigravida with no prior medical history presented with an acute abdomen in her second trimester. The diagnosis of renal forniceal rupture was made by a radiologist using MRI. A percutaneous nephrostomy catheter was placed, and the patient's pain was relieved. She subsequently delivered at term. Conclusion Upon presentation of an acute abdomen in pregnancy, providers may not include renal forniceal rupture in their differential as readily as obstetric or gynecologic causes, resulting in delayed diagnosis, unnecessary invasive interventions, and potentially adverse maternal and neonatal outcomes. Increasing provider awareness could result in improved outcomes.

Spontaneous Renal Rupture During Pregnancy: A Contemporary Literature Review and Guide to Management

“…The most common reported obstetrical complication associated with renal rupture is preterm delivery. 3,9 We found a preterm delivery rate of 26% in our review. Calyceal and parenchymal rupture may lead to preterm labor, preterm delivery, fetal demise, rupture of membranes, fetal growth restriction, nonreassuring fetal heart tracing, and urgent cesarean delivery.…”

“…44 Seventy-six percent of pregnant patients will have right-sided hydroureter to some degree by 20 weeks' gestational age, whereas only 36% will have left-sided hydroureter. 9,39,54 The increase in renal vascular volume and interstitial fluid contributes to this dilation of the ureter. 10 Smooth muscle relaxation within the urinary system due to prostaglandins and progesterone results in increased urinary stasis and has also been implicated as a contributing factor.…”

“…Renal system rupture is suggested if any of the following is seen on CT or MRI: single renal calyx that is irregular in appearance, indiscernibility of fat surrounding the renal sinus, perinephric stranding that is asymmetrically distributed, and perinephric fluid collection. 9,60 An intravenous pyelogram can aid in determining the location and extent of extravasation. 26 A limited intravenous urogram includes 2 films, which is less than the recommended radiation exposure limit of 5 rads set by the American College of Obstetricians and Gynecologists.…”

“…64 Cystoscopy with ureteric double J-stenting and percutaneous nephrostomy tube placement are effective procedures to relieve obstruction secondary to the collecting system insult. 3,9,43,65 Stent placement is more commonly used in pregnant women with spontaneous renal…”

“…These include renal stones, infection (eg, abscess, pyelonephritis), vesicoureteral reflux, tumors, chronically diseased kidneys (nephritis, polycystic kidney disease), anatomic abnormalities, or pregnancy alone. 6,8,9 Pregnancy-associated urinary tract ruptures may be divided into 3 categories: (1) patients in which pregnancy alone is the sole inciting condition, (2) patients with structural renal disease not associated with a tumor, and (3) patients with rupture of a renal mass. 2,10,11 This review focuses on reported renal ruptures during pregnancy not associated with renal masses.…”