zyxwvutsrqponmlkjihg zyxwvutsrqponm zyxwvutsrqpo zyxwvutsrqpo Aust. NZ J Obstet Gjnaecol 1998; 38: 2: 227 zyxwvut Successful Pregnancy in a Patient with Previous Bladder Exstrophy Damyanti Sharma: Savita Rani Singhal’ and S.K. Singhal’ Departments of Obstetrics and Gynuecology and Anaesthesia Pundit B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, India EDITORIAL COMMENT Usually we do not accept anecdotal case reportsfor publication. Chambers twentieth century dictionary dejines an anecdote as ‘a short narrative of an incident ofprivate life’. Readers can decide ifthis case is anecdotd There appears to be a lot le$ unsaid about this woman’s private life, i f not her private parts. She was admitted to hospital as a nonbooked emergency case in labour: The symphyseal separation shown injigure 2 clinched our decision to accept the case f o r publication. The editor did not see such a case in 38 years of obstetrics practice. Summary: Bladder exstrophy is an unusual congenital anomaly. Patients becoming pregnant with such anomaly after surgical repair are even rarer. The present case reports a lower segment Caesarean section delivery of a living healthy baby in a woman who had been operated on for bladder exstrophy at the age of 18 years. This is the first case of this type seen in our institution in 35 years. Bladder exstrophy is an abnormality of the bladder and anterior abdominal wall in which the anterior abdominal wall is deficient. The incidence is 1 in 30,000 to 1 in 40,000 livebirths (1) with a male to female ratio of 3 or 4 to 1. It is due to an abnormally large or persistent cloaca1 membrane. In this anomaly the pubic bones are widely separated, joined only by a fibrous band and the umbilicus is unusually low. The clitoris and anterior vulva are also split, the perineum is short and the vagina almost horizontal with a short anterior wall (2). The initial problem with exstrophy (ectopia vesicae) is urological and many surgical procedures are advocated (3). With better corrective surgery the patients are surviving to Childbearing age. We report this case because of its rarity. The patient was delivered of a live baby by lower segment Caesarean section after successful surgery for bladder exstrophy done at the age of 18 years. The surgery performed was cystectomy with continent cutaneous diversion with the urinary reservoir (caecal pouch) emptied by intermittent self-catheterization using a nonrefluxing conduit. The appendix was used as the catheterizing conduit. CASE REPORT A 22-year-old gravida 2, para 0, abortus 1 with a 34 weeks’ pregnancy with a transverse fetal lie presented 1. Associate Professor. 2. Lecturer. Address for correspondence: Dr Savita Rani Singhal, 1 1 3/14, 1st Lane, Medical Enclave, Rohtak - 124001, Havana, India. with labour pains as an emergency case. She had had exstrophy of the bladder for which surgical repair (cystectomy with continent cutaneous diversion with urinary reservoir emptied by intermittent self catheterization using a nonrefluxing conduit) was done at the age of 18 years. On examination the patient was poorly built, malnourished, weight 39.5 kg and height 4 feet 10 inches. Abdominal examination revealed a midline vertical midline scar (No.2 in figure 1) and an opening of appendix as catheterizing conduit (No.1 in figure 1). The uterine height corresponded to 32 weeks’ gestation with the uterus shifted to the left side; the fetal head was in the left hypochondrium and the fetal heart was regular. Uterine contractions were occurring every 5-6 minutes and lasting for 20-30 seconds. The pubic bones were about 10 cm apart; the labia majora and minora were hypoplastic, the clitoris was bifid, the perineum was only 1 cm in length and the vagina was present anteriorly with the cervix lying about 1 inch above the introitus. Speculum examination revealed a patulous cervical 0 s with no leaking of liquor amnii or bleeding. The haematological and biochemical profile was within normal limits. An X-ray of the pelvis revealed widely separated pubic bones (figure 2). In view of the preterm labour an intravenous isoxsuprine drip at the rate of 0.6 mglminute was started. The uterine contractions subsided with it. After 48 hours the patient again started having uterine contractions, in spite of receiving isoxsuprine 10 mg intramuscular 8-hourly. Vaginal examination showed the cervix was 4 cm dilated with a bag of membranes bulging. An emergency Caesarean section was decided upon because of the transverse fetal lie. A call was sent to zyxwvu 228 right iliac fossa as advised by the urologist. The uterus was laevo-rotated and the adhesions present between gut. peritoneum and uterus were released. The lower uterine segment was easily approachable and a lower segment Caesarean section was performed; a preterm male baby, birth-weight 1,600 g, with Apgar scores of 8 at I minute and 9 at 5 minutes was delivered. The uterus and the abdomen were closed in layers. Prophylactic broad spectrum antibiotics were given for 7 days. The postoperative period was uneventful. The baby and the mother were discharged in a healthy condition after 2 weeks. zyxw DISCUSSION Ours is a tertiary care hospital. In the year 1996 about 650 Caesarean sections were performed. In the last 35 years this was the first antenatal patient with an operated bladder exstrophy in our institution. With the advent of advanced surgery more and more patients with exstrophy of the bladder are surviving to the reproductive age and becoming pregnant. There are different opinions regarding the role of Caesarean section in these women. Dawson recommended a classical section in all cases (4) but Pedlow disagreed after his experience of vaginal delivery in these women ( 5 ) . Blakeley et al (2) advocated that patients with an ileal conduit should be considered for vaginal delivery whenever possible since the previous surgery might have left adhesions of the bowel to the uterus and hence the risk of complications (2). In these women the decision of classical or lower segment Caesarean section can be taken only after opening the abdomen (2). The most important consideration is that the urologist who operated upon the patient preferably should be available at the time of repeat surgery. If this is not possible then the details of the previous surgery and a urologist should be available at the time of Caesarean section to avoid any injury to the neobladder and the ureters or to tackle problems immediately if injury occurs. zyxwvutsrqpo zyxwvutsrqp Figure 1. Appearance of the patient prior to discharge from hospital. The arrows show: ( I ) appendicular opening as catheterizing conduit, (2) the scar of previous surgery and (3) the scar of the lower segment Caesarean section. References zyxw zyxwv 1. Marc IR, Fri WF, James AN, Arnold GC, Jay LG. Essentials of Pediatric Surgery, United States of America, Maple Vail York Figure 2. X-ray of the pelvis showing marked separation of pubic bones. the urologist who operated upon the patient to help decide the preferred abdominal incision. The abdomen was Opened by a left paramedian incision (No- in figure 1) to avoid injury to the neobladder lying in the 1995; 83: 748. 2. Blakely CR, Mills WG. The obstetrics and gynaecological complications of bladder exstrophy and epispadias. Br J Obstet Gynaecol 1981: 88: 167-173. 3. Hendren WH. Exstrophy of the bladder: an alternative method of management. J Urology 1976; 115: 195-202. 4. Dawson JB. Exstrophy Of bladder associated with pregnancy and labour. J Obstet Gynaecol 1933; 40: 1214-1219. 5.Pedlow PRB. Pregnancy associated with uterosigmoid anastomosis. J Obstet Gynaecol Br Commonw 1961; 68: 822-826.