Delivery after augmentation cystoplasty: Implications and precautions
A 23-year-old female presented to us with history of frequency, bedwetting, and recurrent fever for last 10 years. She also had several episodes of gross hematuria and occasional right flank pain. For last 2 years, urinary frequency gradually increased to every 15 minutes interval. The only significant past history was anti-tubercular treatment for pulmonary Koch's 12 years back. The patient was evaluated outside. Her urine microscopy showed pus cells, but the culture was sterile. Ultrasonography (USG) and intravenous urography showed right gross hydro-ureteronephrosis (HDUN) with small contracted left kidney with severe calcifications. Micturition cysto-urethrogram (MCU) showed no vesico-urethral reflux, but was suggestive of “Thimble bladder.” Cystoscopy showed small contracted bladder and ureteral orifices couldn’t be identified due to edematous changes. Bladder biopsy showed granulomatous changes. In view of solitary functioning right kidney with gross HDUN, percutaneous nephrostomy (PCN) was done outside. The patient was referred to us for further management.\nWe did right nephrostogram, which showed gross HDUN with smooth tapering at the right vesicoureteric junction []. Her serum creatinine was normal. We performed the augmentation ileal cystoplasty with right ureteric reimplantation. Postoperative course was uneventful. Double J stent was removed after confirming normal MCU without leak []. The patient was symptomatically improved.\nShe became pregnant after 1 year of AC. At that time, she had no urinary complaint and her continence was normal. Throughout pregnancy she had two episode of UTI, treated with intravenous antibiotics. We kept her on low dose prophylactic antibiotic therapy. Her antenatal USG showed symmetrical intrauterine growth retardation with polyhydroamnios. On routine antenatal investigation she found to have hypothyroidism, for that the thyronorm (75 μg) was started. Throughout the pregnancy she maintained the normal serum creatinine levels.\nAt full term, the induction of labor was tried, but was unsuccessful. As the pregnancy was high risk in view of primigravida with solitary functioning kidney, hypothyroidism, and the history of previous urological reconstruction, the cesarian section was planned in the presence of urologist. The abdomen was opened with previous midline scar. Intra-operatively the ureterovaginal fold was clearly visible. Urinary bladder was in place []. Few dense adhesions were seen between omentum and parietal peritoneum. Bowel loop, which was used for augmentation, was visible on right side of bladder and was undisturbed []. Incision was given over lower uterine segment and a live female baby of 2 kg was delivered. The cord blood sample was taken for the thyroid screening. The post-operative course was uneventful and the patient was discharged on day 3. At 3 month follow up, the patient had no urinary complaint.