CASE REPORT:A healthy 26-year-old nulliparous woman presented for elective induction of labor at 40 weeks 5 days gestation.Her pregnancy, past medical and surgery history were unremarkable.She was given 2 doses of Cytotec cervical ripening followed by spontaneous rupture of membranes.She received epidural anesthesia and was completely dilated 13-1/2 hours later.The second stage of labor lasted 18 minutes before she delivered via NVSD over an intact perineum without laceration.As the epidural analgesia was wearing off, the patient reported severe left sided abdominal pain radiating into her back.Physical exam was significant for guarding and rebound tenderness.A stat hemoglobin was normal, but a CT scan of the abdomen/pelvis demonstrated spontaneous proximal complete ureteral disruption with mild left proximal hydronephrosis and extravasation of urine into the retroperitoneum as well as focal cortical thinning/scar involving the superior and medial left kidney.(Imaging available for publication.)Intravenous narcotics gave no significant pain relief.Urology was immediately consulted, and a left ureteral stent was successfully placed in the operating room.The stent remained in place for 6 weeks and imaging during stent removal confirmed an intact left ureter.Rheumatology consultation ruled out any connective tissue disorder.Two and a half years later the same patient had an uncomplicated pregnancy.She underwent a scheduled prophylactic placement of a left ureteral stent under spinal anesthesia at 38 6/7 weeks.The following day she was admitted for labor induction and had an uncomplicated vaginal delivery.The epidural remained in place for regional anesthesia until the following morning when urology removed the left ureteral stent.An intraoperative left retrograde pyelogram confirmed the left ureter to be intact and she has had no subsequent problems to date.DISCUSSION: Spontaneous ureteral rupture is a rare event, which requires immediate medical intervention.It can present similar to many acute obstetric complications, such as uterine rupture and retroperitoneal hematoma/bleeding.Ureteral rupture most commonly is due to increased pressure within the renal system or increased external forces.Potential causes of intraluminal pressure increases include nephrolithiasis, iatrogenic or post-radiation ureteric strictures, neoplasm, fibrosis, and increased laxity of ureter wall due to connective tissue disorders.External pressure causing compression of the renal system resulting in increased intraluminal pressure may be due to urinary retention, vascular structures, neoplasm, and gravid uterus.This is an exceedingly rare obstetric complication, especially if involving the left ureter.Spontaneous ureteral rupture has been found to occur more commonly in nulliparous women and almost always involves the right ureter.The mechanisms are likely due to physiologic compensations of pregnancy, involving an interplay of both hormonal and anatomical changes that occur during pregnancy.
Prolactinomas resulting in pituitary apoplexy are an uncommon obstetrical complication. The hemorrhage can cause compression and necrosis of the pituitary gland as well as the optic chiasm, necessitating surgical intervention. A 35-year-old woman, G0, presented for an infertility consult with a prior diagnosis of polycystic ovarian syndrome. Evaluation for oligomenorrhea found an elevated prolactin level of 69.76 ng/mL, an elevated DHEA-S of 524, and HgbA1c of 5.7%. The patient denied visual or neurological symptoms. Infertility treatment was started, and magnetic resonance imaging (MRI) of the brain was recommended; however, the patient forewent imaging. Within a few months, she was pregnant. At 27 weeks of gestation, the patient developed sudden visual field loss to the right eye and presented to her optometrist. MRI of the pituitary identified a sellar mass with suprasellar extension, consistent with a recently hemorrhaged pituitary macroadenoma or pituitary apoplexy with displacement of the optic chiasm. Due to the risks of permanent optic nerve damage, the patient underwent endoscopic endonasal transsphenoidal hypophysectomy with intraoperative fetal monitoring at 30 weeks 1 day of gestation. At 39 weeks of gestation a cesarean section was performed due to the recent procedure. Her delivery and postpartum period were without complications. Pituitary apoplexy presenting in pregnancy is a rare and potentially life-threatening disorder due to an acute ischemic infarction or hemorrhage of the pituitary gland. Surgical management of the pituitary gland in pregnancy is rarely recommended, except in cases of severe visual disturbance and uncontrolled Cushing's disease.
Burn injury survival means coping with more than just the physical changes and disabilities often encountered after burn injury. Overall quality of life is important, and issues such as sexuality and intimacy are significant facets of quality of life. A literature review revealed limited research regarding current burn center practices related to sexuality and intimacy concerns of burn survivors and their partners. A 28-item survey, designed by seasoned burn care professionals and survivors, was distributed to burn care practitioners attending general sessions at several burn conferences in the United States. Seventy-one (86%) of the invited respondents completed the survey, with nursing representing the majority (63%). Mean tenure working in burn care was 10 years. Mean age of respondents was 40.5 years, with 75% being female and 25% male. Nearly half (47%) reported that specific staff was not designated to discuss sexuality and intimacy with survivors in their center. Sixty-two percent reported that special training regarding sexuality and intimacy was not available at their burn center. Only 14% of respondents indicated that they were "very comfortable" initiating conversation regarding these topics. Fifty-five percent said they were only likely to discuss sexuality and intimacy if the patient/partner initiated the discussion; however, 95% agreed that the patient should not have this responsibility. Although results represent findings from only 37 burn centers, the issues of sexuality and intimacy are not being effectively addressed in the participating centers. Designated staff to provide education is lacking, and there is limited comfort on the part of health care providers in initiating such conversations. These factors seem to often prevent burn care professionals from adequately addressing burn survivor's sexuality and intimacy needs and establish the need for further development of training and educational materials specific to sexuality, intimacy, and burn injury survival. The limited number and lack of diversity among participants create potential for bias and limit generalizability of results.
Serious burn injuries are a potential threat to patients with seizure disorder. There are limited studies addressing this issue. Therefore, a retrospective study was undertaken with two goals: one to develop better understanding of this potential threat and two to create a prevention message regarding seizure-related burns. The burn center registry was reviewed to ascertain the number of patients who sustained burn injury during or directly after a seizure from 2000 to 2005. Thirty-two patients were admitted (44% female, 56% male) with mean age of 39 years (SD ± 10.4) after sustaining a burn during or after a seizure. Average TBSA was 8.3% (SD ± 4.8) with 72% of patients experiencing full-thickness burns. The three most prevalent etiologies were falling into a stove while cooking (34%; n = 11), falling on hot pavement (31%; n = 10), and falling into a campfire (9%; n = 3). A full 88% of patients (n = 28) reported a previous diagnosis of seizure disorder, whereas the other 9% (n = 3) reported seizures related to alcohol consumption. Laboratory reports revealed 20 patients (63%) had subtherapeutic levels of antiseizure medication, 1 patient (3%) had toxic levels, and 5 patients (16%) were not being treated for seizures. Upon discharge, 23 patients went home with family, 5 were discharged to skilled nursing, 1 to a homeless shelter, 1 died, and 2 patients were lost to follow-up. Because of the severe burns observed in epileptic burn patients, a burn-prevention brochure was developed and is being distributed to seizure patients and their families.
