Preterm Delivery in the Setting of Left Calyceal Rupture

Abstract

Spontaneous rupture of the renal collecting system is a rare but serious complication of pregnancy. We report a case of nontraumatic left renal calyceal rupture in a pregnancy which ultimately progressed to preterm delivery. A 29-year-old primigravida with a remote history of urolithiasis presented with left flank pain, suprapubic pain, and signs of preterm labor at 33 weeks of gestation. The patient was believed to have urolithiasis, although initial renal ultrasound failed to demonstrate definitive calculi. After a temporary improvement in flank pain with medication, the patient experienced acute worsening of her left flank pain. Urology was consulted and further imaging was obtained. Magnetic resonance imaging (MRI) was consistent with bilateral hydronephrosis and rupture of the left renal calyx. Given the patient's worsening pain in the setting of left calyceal rupture, the urology team planned for placement of a left ureteral stent. However, before the patient could receive her stent, she progressed to active labor and delivered a viable female infant vaginally. Following delivery, the patient's flank pain resolved rapidly and spontaneously, so no surgical intervention was performed. A summary of the literature and the details of this specific clinical situation are provided.

Antenatal Spontaneous Renal Forniceal Rupture Presenting as an Acute Abdomen

“…Presentation of an acute abdomen in pregnancy requires prompt and directed evaluation while also ensuring patient stability and fetal reassurance. The differential should be organized into the following etiological categories: obstetric/gynecologic (placental abruption, preterm labor, ectopic or heterotopic pregnancy, ovarian cysts or tumors, pelvic inflammatory disease, and degeneration of fibroid tumors), renal/urologic (nephrolithiasis, pyelonephritis, spontaneous forniceal rupture, and renal malignancy), and gastrointestinal/hepatobiliary (appendicitis, pancreatitis, gallbladder disease, inflammatory bowel disease, and bowel obstruction) [ 4 , 7 ]. While spontaneous renal forniceal rupture does not invariably present as an acute abdomen, improving provider awareness of this entity can prevent delaying accurate diagnosis.…”

“…After an unremarkable ultrasound, she was conservatively managed for renal colic, until repeated episodes of pain prompted an MRI showing calyceal rupture and leak. Stent placement was planned by urology, but rapidly progressing preterm labor resulted in delivery 3 hours later [ 4 ]. Not enough cases of rupture exist in the literature to draw a conclusion about the correlation between forniceal rupture and preterm birth, but the pathophysiology is plausible with inflammation, tissue injury, and peritoneal irritation from urine resulting in preterm labor.…”

“…Ideal examinations include CT with IV contrast using renal protocol or IV urogram, which are not ideal in pregnancy [ 1 ]. MRI or ultrasound has been successfully used in the cases presented [ 1 , 4 ]. The diagnosis can be made by any one of the following criteria being met: irregularity of a single renal calyx, loss of the ability to discern renal sinus fat, asymmetrically distributed perinephric stranding, and a discreet perinephric fluid collection [ 2 ].…”

“…Lack of provider awareness of the diagnosis has led to unnecessary open surgery [ 3 ]. In addition, untreated or undertreated forniceal rupture has been associated with preterm birth and acute kidney injury requiring hemodialysis [ 4 – 6 ]. The documented cases of preterm birth associated with this condition followed spontaneous preterm labor or was the result of emergent cesarean for nonreassuring fetal status.…”

Ureteroscopy and Laser Lithotripsy for Treatment of Ureteral Stones in Pregnants: Single Center Experience

“…Ancak, gebelerde meydana gelen fizyolojik ve anatomik değişikler nedeni ile renal taşların üretere düşmesi sonucu obstrüksiyon ve ağrı daha sık olabilir [3]. Gebelikte ürolitiazis, hem anne (azotemi, ürosepsis, ağrı, renal rüptür, akut renal yetmezlik ) hem de fetüs (prematür doğum) için potansiyel riskler taşır [2,4].…”