COTW: Postpartum Complication

 by Rachel

Well, we often see strange and bizarre cases at Kibuye, that has not changed!  But it's been awhile since we've posted our old blog standby of Case of the Week.  FAIR WARNING that if you are squeamish about medical things, this might be a post to skip.  But for all the rest of you, I'm curious if you can figure out the problem.  Also, we could use some advice on how to best fix this patient, so contact me after if you have ideas.

This lady came to the maternity service about 4-5 days after a spontaneous vaginal delivery of her 3rd child at a different hospital.  She had no previous medical or surgical history (no previous C-sections).  She was transferred to us with a suspected small bowel obstruction, with some nausea and vomiting, but was passing gas and stool.  Bleeding was minimal.  She had not passed urine for several days.  She had a low grade fever but otherwise vital signs were normal.  Her belly was significantly tender and distended.  Hemoglobin was normal with a very mild leukocytosis.  

Now, this presentation is not terribly uncommon after C/S.  Many women are transferred to us with peritonitis after a C/S done at an outside hospital, and they end up with frank pus in the abdomen and usually a necrotic uterine incision that needs debridement.  This all causes an ileus, not an obstruction.  We see this at least once a month.  But, this lady had not had a C/S.  Also not uncommon is a diagnosis of uterine rupture after vaginal birth, due to trauma or fundal pressure given during second stage of labor.  But, this lady didn't seem to have the classic signs of uterine rupture.  No bleeding, no fluid wave in the belly, and a normal hemoglobin.

On ultrasound, nothing was visible due to a massive amount of gas in the pelvis.  So, we ordered an abdominal X-ray.  And saw this:

I know that it's not a great image (and remember we have no CT scans here) but that's a giant collection of air/gas in her bladder, and in real life we could see a very tiny amount of free air under the diaphragm.  So, we placed a Foley catheter and got out a large amount of gas and around 600cc of cloudy urine.  Strange.  She was started on antibiotics for a UTI and improved significantly within 24 hours of placing the Foley.  We discussed with surgery the need for an ex-lap, but given the patient's significant improvement decided to send her home with the foley for 7 days, and then have it removed at the first hospital.

She came back two weeks later.  After the Foley had been removed, her pain had returned and continued to increase.  She was unable to pass urine, and once we replaced the catheter, cloudy yellow urine came out, but the pain did not improve.  She was taken to the OR, where the surgeons found this:

You can see her urethra with the foley in place.  The small tubes on either side are her ureters.  But the bladder was just a necrotic pile of mush.  Best as we can figure, during her delivery her bladder had ruptured (??), but the uterus remained intact.  Given the late diagnosis, the bladder was not repaired immediately, and perhaps developed an infection, but regardless all bladder tissue died.  She's currently hospitalized with drains and a foley catheter, but there's no awesome urologist to send a case like this to, to create an artificial bladder.  Any ideas? 

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