DR.

MAHMOUD

ELBANNA

UROLOGIST
SULAYYIL GENERAL HOSPITAL

Mission
 Understanding Lower urinary tract adaptations to pregnancy.

 Without such knowledge, it is almost impossible to understand urinary symptoms that can affect women during pregnancy and puerperium.

Introduction
 The anatomical, physiological, and biochemical adaptations to pregnancy are profound.

 Many of these remarkable changes begin soon after fertilization and continue throughout gestation, and most occur in response to physiological stimuli provided by fetus.

Urinary system
 Striking anatomical changes are seen in kidneys and ureters during pregnancy.  This is due to changes in pelvic anatomy and is a feature of 'normal' pregnancy.  Little has been published concerning expected alterations in bladder anatomy during pregnancy.

INTRODUCTION
pregnancy can be responsible for many urological disorders, some of which may be life threatening for the mother and fetus, requiring emergency treatment. Pregnancy often makes diagnosis difficult because many investigative procedures are inadvisable in pregnant women. The therapeutic possibilities are also limited, and many drugs and certain surgical procedures are contraindicated, present a risk of inducing labor, or are harmful to the fetus. Therefore, finding a compromise between the patient s comfort and the normal development of the fetus is sometimes necessary.

Despite hypercalciuria and physiological hyperuricuria, the incidence of calculi does not rise during pregnancy, since the rate of factors inhibitory crystallization( citrate, magnesium, glycoproteins) is also higher . Urine, more alkaline because of respiratory alkalosis, opposes the formation of uric acid stones despite hyperuricuria. Physiological dilatation of the upper urinary tract is found in more than 90%of pregnant women. This dilatation occurs between the 6th and 10th weeks and disappears 4 6 weeks after delivery . For anatomical reasons, it predominates on the right side. Different theories seek to explain this dilatation

The hormonal theory involves the inhibiting role of progesterone on the ureterals mooth musculature The mechanical theory involves the compressive role of the uterus, with this effect predominating on the right because of the uterus s dextrorotation. Ureteral compression by the ovarian vein and by the dilated uterine veins has also been suggested. The protection of the left ureter by the sigmoid reinforces the asymmetric character of the dilatation

The absence of ureteral dilatation in cases of pelvic kidney, after ileal conduit urinary derivation, or in the quadruped confirms the involvement of mechanical phenomena in this dilatation Physiological dilatation during pregnancyis sometimes the cause of painful symptoms that usually regress with the use of mild analgesics.

The persistence of pain or the appearance of infectious signs require urine drainage by a percutaneous ureteral drainage stent or a nephrostomy
Nephrostomy.

 Pregnancy and delivery may impact the pelvic floor and result in detrimental effects on urinary and bowel symptoms  Urinary incontinence is common in pregnant women with resolution in the early postpartum period
Other than a 1-cm increase in the size of the kidneys, these changes result in an increase in the rate of filtered creatinine, urea, sodium, calcium, and uric acid

Urological changes

Kidney

Ureteral

Vesical

Urethral * Lengthening of urethra * Congested & hyperaemic mucosa Estrogen p squamious like changes o FUL, AUL.

Bladder changes
Ant & Sup displ. (at term) More broad base.. Convex trigone More an abdominal organ Bladder wall Hyperemia, Tortuosity of sup. Vessels MS Hypertrophy  o Capacity (q tone by Progesterone)  p at term (up to 1 liter) (Barkow 74) q Voiding Press ?? (q sphincteric funct.) (Rubi & Sala 72)

Physiological hydroureter & hydronephrosis (Frequency)(apparent normally) Pyelo-urteral dilatation

20th week .constant.to term
Renal pelvis

schulman 75

48 hows after delivery up to Several week Rarely

Harrow 64

Dilatation of renal pelvis in normal preg.

Normal 1st Trimester (N=18) 2nd Trimester (N=90) 3rd Trimester (N=110) 39% 31% 30% Mild 61% 49% 45% Moderate 0 20 22 Sever 0 0 3

None were normal pcause of investigation ante partum bleeding. (Schullman 75)

Hydroureteronephrosis
Onset o severity 1st trimester with gestation
Right Incidence % severe Dilatation Extent of dilatation (scale 1-6) 76% 7.5% 2.4s0.1 Left 35% 1% 1s0.1

Effect of upper dilatation

Delayed excretion on right (5 fold o of time to peak) isotope renography (Due to Reservoir effect), no stasis (Bergstorum 75) Symptomatic Dilatation (No infection) (reported p good response to ureteral cath). Acute renal failure p Bilateral obstruction very rare .(Reported) (Rasmassen & Nielsen 88)

Etiological factions
Endocrinal
 Progesterone pq ureteral cont. Common embryological origin q Tone o Urine flow Finstat 63

Mechanical
 Abrupt onset at mid. gest. Dilatation sharp at pelvic prim. Prompt resolution after delivery. Rasmassan Nelsen 88.

Further evidence
 o Intraureteral press.
 Pelvic kidney p No Dilatation.  Rt > left Cross common iliac Rt?, Left? Sigmoid. Cushing effect. Rt ovarian veins..Partial obst. Bellins 70, Versus, Roberts 71 Complete ureteral obst. .. (Can occur.. V. rare)

Shanghnessy 80

Bulk of evidence that

1ry Partial ureteral compression uterus, iliac arteries, ovarian veins)

2ry Endocrinal effect. A contributing factor

Ureter

Elongation o Curvature ?? Smooth kinks

1at. displacement Rt < left (Sigmoid colon) (Schulman 75)

Bladder anatomy and support in pregnancy

 Cystoscopically, an indentation of bladder dome by enlarged uterus is visible during pregnancy  Ureteric orifices are visualized in a higher position than in nonpregnant state

During fluoroscopy, dramatic alterations in bladder profile can be seen

The gravid uterus distorts the bladder, giving it an hourglass shape

 Descent of the presenting part with fetal engagement during late pregnancy would lead to a decrease in bladder capacity and an increase in urinary frequency.

 Symptoms begin early in pregnancy and persist throughout pregnancy.

 Pregnancy have been implicated as antecedents for three disorders:

1. Urinary incontinence 2. Anal incontinence 3. Pelvic organ prolapse

 Causation is difficult to prove because symptoms often occur remote from delivery.  It is unclear from current literature whether changes are secondary to the method of childbirth or to the pregnancy itself.

Pelvic floor support

 Pregnancy has wide-ranging impact on the pelvic floor through neurologic, muscular, hormonal, and traumatic effects  Pregnancy may predispose women to prolapse of pelvic organs, including loss of support for the anterior vaginal wall and bladder.

 Pregnancy is associated with increased mobility and descent of the bladder and other pelvic organs.

 Bladder neck descends with Valsalva approximately 5 mm more in pregnant women than in nonpregnant controls

 Descent of anterior vaginal wall and bladder to the level of hymen by third trimester of pregnancy, usually resolves after delivery.

 presence of anterior vaginal wall descent or cystocele in this setting does not merit investigation or treatment

 During pregnancy, urinary tract function is altered considerably in many women.

 Normal function apparently returns for most women soon after delivery

Renal changes
o GFR o RPF
 q S.Creatinine & B. urea nitrogen q 25%  Rapid urinary excretion of drugs (dosage adjustments) * o Amino acid excretion * o glucose Excretion o GFR o filtered load q resorptive capacity (No insulin changes) o Nicotinic acid o Ascorbic acid excretion. > twice non pregnant

Amino acid excretion

Double of Normal

Lysine, histidine Theonine alanine

Lysine cystine

16 Week

Term

(Tubular failure of absorption (hormonal changes)

Renal physiologic changes in pregnancy

o Secretion of many substances Amino acids Glucose Water Soluble vitamins (Fetal Development)

More capable withstanding variations in fluid & nutrient intake.

Provide p Constant environment for fetus

Urinary System

 loss of smooth muscle tone due to progesterone ,aggravated by mechanical pressure from the uterus at the pelvic brim.  VUR is also increased.  These changes predispose to UTI.

Pregnancy & UTI

 Anatomic and physiologic urinary tract changes in

pregnancy may cause pregnant women with bacteriuria to have an increased susceptibility to pyelonephritis
 smooth muscle relaxation results in decreased

peristalsis of ureters , increased bladder capacity, and urinary stasis.

 The bladder itself is displaced superiorly and

anteriorly during pregnancy

Irritative symptoms


Irritative symptoms are the most bothersome complaints during pregnancy Theoretical mechanisms for these changes include
Hormonal alterations. Expansion of circulating increased GFR Increasing uterine size Pressure on the bladder blood volume, and


1. 2. 3. 4.

Urinary incontinence
 Urinary incontinence is common in pregnant women and has an impact on quality of life  Stress incontinence is more common than urge incontinence, although mixed symptoms are frequent

Stress urinary incontinence



Stress urinary incontinence affects up to 32% of primiparous women The causes of stress incontinence during pregnancy are thought to include
Maternal weight gain Increased mechanical pressure on bladder from the enlarging uterus Increased urine production from increased glomerular filtration rates.


1. 2. 3.

Urinary incontinence
 There is some evidence that pelvic floor strengthening during pregnancy can prevent incontinence during pregnancy and in early postpartum period  Urinary incontinence symptoms of pregnancy persist in postpartum period in a significant minority of women

Urinary retention in pregnancy

 Urinary

retention is an uncommon urologic emergency, occurring in about 1 in 3000 to 1 in 8000 pregnancies

 Classically, urinary retention occurs at 12 to 14 weeks

of gestation in a retroverted uterus ,with presence of uterine fibroids as a predisposing factors

 Elevated bladder base associated with

failure of relaxation of urethra during attempts to void (with persistence of posterior urethrovesical angle)

Progesterone &Urinary retention

 Progesterone may promote relaxation of bladder smooth muscle and, in extreme cases, detrusor inactivity and retention  Case reports of patients who had urinary retention after use of assisted reproductive technology, and who had extremely high progesterone levels but who were not pregnant

DIAGNOSTIC PROCEDURES IN THE PREGNANT PATIENT

Doppler Ultrasound Doppler ultrasound is the first-line examination to perform when there is suspicion of renal colic in the pregnant woman. However, it does not differentiate physiological dilatation of pregnancy from pathological dilatation related, for example, to a kidney calculus. Since it only explores the high lumbar ureter or pelvic ureter, it misjudges many cases of calculi. With a sensitivity of 34% and a specificity of 86% , this exam is often flawed as adiagnostic procedure.

Evaluating the Dilatation of the Urinary Tract

Muller-Suur and Tyden (1985) defined the pathological limit for renal pelvis as a diameter greater than 17 mm. beginning with the 2nd trimester, suggest a limit of 27mmon the right and 18mmon the left. Brandt and Desroches (1985) retained the same references for the 2nd and 3rd trimesters,with the pathological limits of 18 mm on the right and 15 mm on the left for the 1st trimester. Finally, discovery of ureter dilatation extending to the pelvic ureter most often indicates pathological dilatation (

Measuring the Resistivity Index

Renal vascular resistance increases during acute obstruction, particularly during the first 6 48 h (Ulrich et al. 1995). This increase is related to vasoconstriction mediated by different factors such as prostaglandins Using these parameters,) indicated that a resistivity index of at least 0.7 diagnoses obstruction,

RISK OF FETAL MALFORMATION

Fetal malformation, developmental delay, growth delay, or in utero death are the usual consequences reported. There is a linear relation between the radiation dose and the risk of delays in mental development (Biyani Below 50 mGy, the risk of malformation seems negligible even if minimal biochemical modifications are possible. This threshold value is well under the dose delivered by radiological diagnostic tests (plain abdomen = 1mGy/radiograph, 1 min of image intensifier = 2 mGy) STewart estimated that an in utero irradiation of 1020 mGy increases the risk of cancer in the child by1.5-2
21.5

MUTAGENIC RISK A dose of 0.51 Gy is necessary to double the spontaneous rate of genetic mutation (Hall 1991). This level of radiation is never reached by the common radiographic diagnostic tests.

In conclusion, even if the consequences of diagnostic irradiation during pregnancy are low, particularly in the second and third trimesters, the riskbenefit ratio of radiological exploration should always be evaluated and compared to the risk of an unrecognized urinary tract obstruction treated late

Intravenous Urography While (IVU) was considered the gold standard of radiological workup for urinary lithiasis, its utility has greatly diminished since the advent of unenhanced helical CT. It is superior to ultrasound in diagnosis but IVU requires an injection of contrast solution and leads to a low but not inconsiderable dose of radiation, especially during the first trimester. Different examination protocols have been proposed aiming to limit the radiation exposure as much as possible to three or four radiographs: plain abdomen, 30 s, 20 min plus or minus one late x-ray plain abdomen, 20 min, late x-ray (It is important to use high-sensitivity films, reduce the aperture as much as possible, have large radiology rooms available, choose digital radiology, and use a lead apron for the side of the healthy kidney . Given bony superposition and the voluminous uterus, identifying small stones is sometimes difficult . The exam does not always differentiate physiological and pathological dilatations

Retrograde Ureteropyelography
(RUP) results in radiation that is not inconsiderable and results in a risk of sepsis when infection is present. Its advantages are limited to a few patients for whom diagnosis remains uncertain, during an operation, and immediately before double-J stenting.

Magnetic Resonance Imaging

The recent progress in (MRI), providing reduced acquisition time, makes reliable exploration of the urinary tract feasible. To the sequences without injection of contrast medium can be added sequences with injection of gadolinium for a uro-MRI with no iodine injection or irradiation. The exam provides reconstitutions in the different spatial planes (.Although the MRI has no known native implication for the fetus, for reasons of caution this examination is not advised in the course of the first trimester durin the organogenesis phase . MRI does not display small stones well and has the disadvantage of high cost and reduced accessibility to the patient during the study. Although MRI is infrequently used in standard urinary lithiasis workups, it can be useful in difficult cases involving pregnant patients .

Urodynamic studies during pregnancy

 During pregnancy, urinary symptoms do not correspond to urodynamic findings, and testing is not clinically helpful.  Results of urodynamic studies during pregnancy are contradictory  Some reports showed increased bladder compliance and atony during pregnancy
starting at the third month of pregnancy, the bladder capacity slowly increases, reaching its largest limits, up to 1300cc in the eighth month . in the third trimester (the bladder) shows definite evidence of atony.. At this time the bladder sensations are not as clear-cut as in the nonpregnant control.

 In contrast, other reports found no difference in the

bladder capacity of pregnant women and found that women with greatest bladder capacities complained of the greatest urinary frequency
 Women with stress incontinence had lower functional

urethral lengths and closure pressure

 Detrusor instability

was found in 23% during pregnancy and in 15% after pregnancy, with all patients who had detrusor instability postpartum showing detrusor instability during pregnancy.

Treatment Oral Treatment

Analgesics Paracetamol, acetaminophen and dextropropoxyphene can be used with no risk (). Codeine is contraindicated during the first trimester because of its potential teratogenic side effects but can be used episodically during the second and third trimesters (In cases of intense pain, morphine can be necessary. The prescription should be of short duration to prevent any risk of maternofetal dependence, growth delay, or prematurely induced labor (Barron 1985). Morphine should not be used at the beginning of or during labor.

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

Given their blocking action of the synthesis of prostaglandins, NSAIDs should be avoided during pregnancy because of the risk of premature closing of the ductus arteriosus (Rasanen and Jouppila 1995) and of fetal pulmonary hypertension (Aspirin can delay or prolong labor. Also, through its effect on platelet aggregation, it also induces a hemorrhagic risk at delivery

ALPHA 1 ADRENERGIC BLOCKERS

Recent studies show the advantages of alpha 1 blocker, used as a spasmolytic drug, for the spontaneous expulsion of distal ureteral stones (Dellabella et al. 2003). The side effects in pregnant women and the possibility of teratogenicity are not currently known. Further evaluations are necessary before using this class of substances in pregnancy

ANTIBIOTIC THERAPY
Aminopenicillins (Ampicillin, Amoxicillin) Antibiotics of the penicillin group, aminopenicillins have low toxicity and generate few side effects other than a risk of allergy. Forty to 50% of enterobacteria are resistant to these antibiotics (Adding clavulanic acid-inhibiting beta-lactamases has increased the efficacy, but 30%40% of bacteria are currently resistant to it (Goldstein 2000). The aminopenicillins are very effective on streptococci. This group of antibiotics can be usedwithout risk in pregnant women but after having verified the sensitivity of the bacterium on the antibiogram.

THIRD-GENERATION CEPHALOSPORINS
Belonging to the beta-lactam group, third-generation cephalosporins have low toxicity and generate few side effects. They can be administered orally or by intramuscular or intravenous routes. Because of their efficacy, their pharmacological properties, and a low rate of enterobacterial resistance, third-generation cephalosporins are the first-line antibiotic therapy for treating acute pyelonephritis in pregnant women while waiting
for the result of the antibiogram.

AMINOGLYCOSIDES
Aminoglycosides have a synergetic action with betalactamines and a wide spectrum of activity on enterobacteria.They have a risk of nephrotoxicity and ototoxicity. While aminoglycosides have been said by some authors to potentially cause neuromuscular blockade in humans, and have experimentally caused it in animals, there has never been a reported case of human neuromuscular blockade after aminoglycosides administration (Administrable parenterally, they cross the placental barrier. Because of their risk to the fetus, in pregnant patients they can only be used for short periods for severe acute pyelonephritis threatening maternalfetal prognosis.

FLUOROQUINOLONES
are very effective on enterobacteria but also on certain negative-coagulase staphylococci. They are ineffective against enterococci. Escherichia coli has a low resistance rate to ciprofloxacin (1%2%) (They are classically contraindicated in the pregnant patient because of the risk of toxicity to fetal cartilage and joints. Nevertheless, in cases of severe acute pyelonephritis presenting a life-threatening risk to mother and fetus or of multiresistant bacteria, they can be used for a short period of time.

Quinolones (Nalidixic Acid, Pipemidic Acid) Quinolones are active on enterobacteria, but they are contraindicated for patients with G6PD deficit and should be avoided during pregnancy. Their main side effects are digestive problems, photosensitization, and neurosensory phenomena (disturbed vision, somnolence, dizziness, headaches, and more rarely hallucinations and convulsions NITROFURANTOIN Active on enterobacteria, nitrofurantoin only slightly modifies the fecal flora and induces little resistance. It is contraindicated in patients with G6PD deficit. It can be responsible for digestive problems, allergic reactions, and more rarely pulmonary fibrosis, hepatitis, and optical or peripheral neuritis during prolonged use. It can be used during pregnancy except in the last trimester when it can result in hemolytic anemia

TRIMETHOPRIM-SULFAMETHOXAZOLE The association of trimethoprimand sulfamethoxazole is very active on enterobacteria. Resistance rates of 20%40% have been reported, however It is contraindicated during the first trimester of pregnancy because of a potential teratogenic risk (antifolic property) and during the third trimester because of a risk of neonatal jaundice. However, it can be used during the second trimester except in cases of G6PD deficiency suspect in Mediterranean patients or with first-degree relatives affected.

Chloramphenicol and tetracyclines are contraindicated

during pregnancy. Erythromycin have no fetal morbidity, although erythromycin estolate salt compounds can cause cholestatic jaundice and should not be used

Surgical Treatment
Ureteral Stents

When a urinary calculus requires surgery during pregnancy, the classical attitude is to ensure urine flow ,with the definitive treatment undertaken after the child is born ( Placing a double-J ureteral stent easily removes the obstruction. In very septic patients, the stent can be placed without sedation. When urine is thick, it is preferable to first position an open ureteral stent, which can be replaced after a few days with a double-J stent when the sepsis is under control and the urine more liquid (Dore 2004). The double-J stent presents several advantages. It can be placed under local anesthesia and presents no radiation to the patient, as the procedure is guided by ultrasound

It is not always easy to place, especially during

the 3rd trimester, when the bladder is pushed back bythe uterus, the trigone deformed,

and the mucous membrane of the bladder rendered hyperemic by pelvic hypervascularization. In addition, the stent carries a certain number of disadvantages: bladder irritation by the lower J that may cause urinary frequency, increased micturition urge or hematuria, risk of displacement due to dilatation of the excretory tract, and vesi7.4 Treatment 65 corenal reflux, which can cause lower back pain or acute pyelonephritis ( Many authors have reported the risk of incrustation secondary to hypercalciuria of pregnancy This risk is reduced by increasing fluid

intake, controlling calcium intake, and treatment of UTI if necessary (To avoid incrustations, some authors advise changing the double-J stent every 48 weeks ( thus multiplying hospitalizations and the risks related to endoscopic procedures. Other authors prefer to avoid the double-J stent at the beginning of pregnancy and reserve its use for after the 22nd week

PERCUTANEOUS NEPHROSTOMY
An alternative to placing a ureteral stent is percutaneous nephrostomy (). Dilatation of the urinary tract during pregnancy facilitates its placement. Denstedt preferred this procedure before the 22nd week of pregnancy ( It can be done under local anesthesia, ultrasound localization, and in the three-quarter position (Kavoussi et al. 1992). It may result in discomfort of an external derivation, exposes the patient to the risks of stent displacement, cutaneous infection at the site of entry, and bacterial colonization following prolonged use of the stent The risk of incrustation is identical to that of the ureteral stent, requiring that the stent be changed every 48 weeks (In very septic patients, who rarely cannot tolerate intravenous sedation, percutaneous nephrostomy should be a good choice even if the threequarter position is not always possible in such patients.

EXTRACORPORAL SHOCK-WAVE LITHOTRIPSY

Pregnancy is one of the common contraindications for extracorporal shock-wave lithotripsy (ESWL) because of the potential risk of the shock waves on the fetus (reported fetal growth delay in the pregnant rat treated with ESWL. The risk of irradiation when the calculus is located by imaging and premature induction of labor (Vieweg et al. 1992) have also been reported. However, seven patients have undergone this treatment during their pregnancy, either because the pregnancy had not been diagnosed at the time of treatment or after informed consent ( These women continued their pregnancy to term and delivered a perfectly healthy child. Despite these encouraging reports, most learned societies contraindicate ESWL during pregnancy.

Percutaneous Nephrolithotomy
Although some authors have successfully performed percutaneous nephrolithotomy (PCNL) in women at the end of pregnancy ( this technique is classically contraindicated in pregnant patients. It requires a ventral decubitus position that is problematic, as well as prolonged anesthesia. It carries high irradiation and can induce labor (

PARTICULAR TREATMENTS OF CERTAIN UROLOGICAL EMERGENCIES IN PREGNANT WOMEN 1-Urinary Tract Calculi The incidence of urinary lithiasis during pregnancy is on the order of 1:200 to 1: 1,500 ) with the mean figure of 1: 1,500 cited most often. This incidence is identical in women who are not pregnant Onset occurs eight or nine times out of ten during the 2nd or 3rd trimester ). It is more frequent in multiparous women ( . The calculi are essentially composed of calcium carbonitee and more rarely of struvite While seven or eight urinary calculi out of ten are eliminated spontaneously, medical treatment should be proposed initially. Rest and sufficient hydration (23 l/ 24 h) are prescribed. When pain is present, fluid restriction is routine.

2-Urinary Tract Infections

Because of anatomic, functional, and hormonal modifications, urinary tract infection is frequent during pregnancy. It can present as three different entities: asymptomatic bacteriuria, acute cystitis, or acute pyelonephritis (Ovalle and Levancini 2001). Different risk factors have been discussed: maternal age, socioeconomic status, antecedents of UTI, sexual intercourse, hemoglobinopathies, diabetes, immunodepression of HIV infection, multiparity, and race

The most frequently encountered bacteria are enterobacteria, with E. coli ranked first (65%90%), although streptococci are found more and more often

2-SPONTANEOUS RENAL RUPTURE Spontaneous renal rupture is a rare complication during pregnancy. It can occur in three circumstances(:spontaneous rupture with no cause, rupture of the excretory tract related to an obstruction ,and renal rupture secondary to a tumor, most often an angiomyolipoma.

Clinically,the spontaneous rupture is manifested by lumbar or abdominal pain with thickening of the lumbar fossa and sometimes hemorrhagic shock.Ultrasound is a diagnostic aide that shows an effusion ofurine around the kidney or a retroperitoneal hematoma. When there is rupture of the excretory tract related to obstruction, placing a double-J stent to remove the obstruction is the best approach(Oesterling et al. 1988). If this is not possible, percutaneous nephrostomy can be undertaken. Percutaneous drainage of a collection is sometimes necessary. When there is renal parenchyma rupture, strict monitoring isindispensable.

Bleeding can stop spontaneously because of the pressure exerted on the retroperitoneum. When bleeding cannot be controlled and hemodynamics are unstable, open surgery is sometimes the only choice possible, with a nephrectomy often necessary

3-PLACENTA PERCRETA INVOLVING URINARY BLADDER The incidence of placenta accreta is estimated fromone in 540 to one in 93,000 deliveries (Smith and Ferrara 1992). Placenta percreta is a variant of placenta accreta in which chorionic villi penetrate the entire thickness of the myometrium and may involve adjacent structures. Placenta percreta involving the bladder is extremely rare (less than 60 published cases) (Washecka and Behling 2002) and is encouraged by uterine scars and cesarean section.

This potentially catastrophic condition may remain undiagnosed or underappreciated until delivery (Leaphart et al. 1997) and diagnosis is oftenmade only at the time of operation in a life-threatening bleeding. In 31% of cases, hematuria is present during pregnancy and a preoperative diagnosis established by ultrasound

CONCLUSION
Urologic emergencies during pregnancy are far from exceptional. Some can be life-threatening to the mother or endanger the development or viability of the fetus. Good knowledge of the diagnostic and therapeutic

Particularities in the pregnant patient and close collaboration between the urologist and the obstetrician make for optimal care that limits maternal and fetal risks to the greatest degree.