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Mise au point : urgences urologiques au cours de la grossesse

Focus: urological emergencies during pregnancy

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Pelvi-périnéologie

Résumé

En raison de modifications anatomiques, physiologiques et fonctionnelles des voies urinaires, la grossesse peut être responsable de nombreuses pathologies urologiques s’exprimant parfois dans un contexte d’urgence et dont certaines peuvent menacer le pronostic vital materno-foetal. L’état de grossesse rend le diagnostic souvent plus difficile car de nombreuses investigations, dont certaines radiologiques, sont déconseillées chez la femme enceinte. Les possibilités thérapeutiques sont limitées, de nombreuses molécules ou certaines procédures chirurgicales étant contre-indiquées ou présentant un risque de déclencher le travail ou d’être déléte`res pour le foetus. Entre le confort de la patiente et le développement normal du foetus, des compromis sont parfois nécessaires. Le rapport bénéfice/ risque doit être particulie`rement bien analysé ce qui nécessite une parfaite connaissance des particularités des pathologies urologiques chez la femme enceinte.

L’incidence de la lithiase urinaire au cours de la grossesse est de l’ordre de 1/1500. Elle survient préférentiellement au deuxième et troisième trimestres, se manifestant surtout par une lombalgie et/ou une hématurie, mais la symptomatologie est parfois trompeuse. Si sept à huit calculs s’éliminent spontanément, un geste urologique est parfois nécessaire, l’attitude classique étant d’assurer, par un cathéter double J ou une néphrostomie percutanée, le libre écoulement des urines, le traitement définitif du calcul étant réalisé apre`s l’accouchement.

Les infections urinaires sont fréquentes au cours de la grossesse et peuvent se présenter sous trois aspects : bactériurie asymptomatique, cystite aiguë, pyélonéphrite aiguë. Une bactériurie non traitée induit un risque de pyélonéphrite de 20 à 50 %. Entre traitement minute et traitement classique de sept jours, il n’existe pas de consensus sur la durée optimale de traitement d’une cystite aiguë. La pyélonéphrite nécessite une antibiothérapie (souvent une céphalosporine de troisie`me génération) de 10 à 14 jours. Le risque de récidive d’infection urinaire nécessite une surveillance mensuelle des urines.

La rupture rénale spontanée est une complication rare au cours de la grossesse. Elle peut survenir dans trois circonstances: rupture spontanée sans cause, rupture de la voie excrétrice liée à une obstruction, rupture secondaire à une tumeur (angiomyolipome). L’échographie est essentielle au diagnostic. La prise en charge va de la simple surveillance, au drainage des urines et/ou de la collection périrénale. Le recours à une néphrectomie en urgence est exceptionnel.

Le placenta percreta envahissant la vessie est une variante exceptionnelle du placenta accreta. Il est favorisé par l’existence de cicatrices utérines favorisant la pénétration de villosités placentaires dans le myome`tre et le détrusor. Une hématurie n’est notée pendant la grossesse qu’une fois sur trois. La cystoscopie est souvent peu contributive. Lorsque ce diagnostic est évoqué, la biopsie endoscopique de la lésion doit absolument être évitée en raison du risque hémorragique. Le diagnostic est malheureusement fait deux fois sur trois tardivement en salle d’opération devant une hémorragie préoccupante pour laquelle le seul objectif chirurgical est de contrôler le saignement ce qui peut nécessiter une hystérectomie d’hémostase avec parfois cystectomie partielle.

Abstract

In view of anatomical, physiological, and functional changes, pregnancy can be responsible for many urological disorders, some of which can be life threatening for the mother and fetus and require 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. The riskbenefit ratio should be particularly well analyzed, requiring perfect knowledge of the particularities of urological disorders in pregnant women. The incidence of urinary lithiasis during pregnancy is 1:1500. In 80–90% of cases, onset occurs during the 2nd or 3rd trimester. The revealing symptom is usually low back pain and hematuria, but symptoms can be deceptive. Although 70–80% of calculi are eliminated spontaneously, urological intervention is sometimes necessary to ensure urine flow (double J stent or percutaneous nephrostomy), with the definitive treatment performed after childbirth.

Urinary tract infections are frequent during pregnancy and can present as three entities: asymptomatic bacteriuria, acute cystitis and acute pyelonephritis. Untreated bacteriuria results in a 20–50% risk of acute pyelonephritis. Between single-dose and one-week treatment, there is no consensus on the duration of the optimal treatment of acute cystitis. Acute pyelonephritis requires antibiotic therapy, often a third-generation cephalosporin, for 10–14 days. The risk of recurrence requires the monthly monitoring of urine.

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 angiomyolipoma. Treatment requires monitoring, sometimes a double-J stent to remove an obstruction, percutaneous drainage of fluid and, in exceptional cases, nephrectomy.

Placenta percreta involving the bladder is extremely rare (less than 60 published cases) (90) and is encouraged by uterine scars and cesarean sections. This potentially catastrophic condition can remain undiagnosed or underappreciated until delivery, and diagnosis is often made only at the time of surgery to treat life-threatening bleeding. The goal of surgical treatment must be to control bleeding, which may require hysterectomy, resection of all the tissue involved by the infiltrating placenta and eventually partial cystectomy or ureteral reimplantation. As the tissue planes are often very indurated and extremely difficult to dissect, some authors prefer to leave the invasive portion in situ.

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    J. -F. Hermieu

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Emergencies in urology, 2007, pp. 61-72, Urologic emergencies in pregnant women : special considerations, J.-F. Hermieu, L. Boccon-Gibod, 2 figures

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Hermieu, J.F. Mise au point : urgences urologiques au cours de la grossesse. Pelv Perineol 2, 251–261 (2007). https://doi.org/10.1007/s11608-007-0142-0

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