Spontaneous life-threatening urinary bladder hemorrhage in p
The present case has been reported in the Journal of Obstetrics and Gynaecology of India.

A 20 year old gravida 3, para 2 woman was referred from a peripheral hospital with a provisional diagnosis of rupture uterus at 37 weeks pregnancy. She complained of frank hematuria for last 5 days and there was no history of any recent trauma, intercourse or vaginal bleed. Her first pregnancy had been uneventful but during the second pregnancy, there was history of hematuria 2 days prior to the vaginal delivery of a fresh still born baby boy at 7 months of gestation. The hematuria then had subsided after 5 days of delivery with conservative management.

Ultrasonography revealed an obliquely presenting healthy fetus of 36 weeks maturity and a hypoechoic mass of 120 × 80 mm size anterior to the cervix inside the urinary bladder. Both kidneys were normal, with no evidence of hydroureter or hydronephrosis.

In view of the malpresentation in this term healthy pregnancy, a cesarean section was also planned in the same sitting. On opening the parietal peritoneum in upper part of a vertical incision, the urinary bladder was found distended and of firm consistency, reaching 8 cm above the symphysis pubis, thus leaving no space to access the lower uterine segment. Hence, a classical cesarean section was done to deliver a healthy baby girl weighing 2.5 kg.

Afterwards, the bladder dome was bivalved to view a blood clot of 15 × 15 cm size filling the cavity. After evacuating this large clot weighing 1.2 kg, the bladder walls appeared smooth with no recognizable bleeding site. The bladder was closed in 2 layers over a suprapubic catheter and a retropubic drain was inserted. The woman and the baby had an uneventful postoperative course.

Key takeaways:-
• Management of bladder trauma during pregnancy would depend on the site and extent of injury and on the hemodynamic condition of the woman.

• Though ascending cystography is considered the investigation of choice for establishing the type of bladder rupture in stable nonpregnant cases, contrast studies are avoided during pregnancy for fear of fetal risk.

• Bladder contusions and most extraperitoneal ruptures can usually be managed conservatively with continuous bladder drainage for 7–10 days. Most intraperitoneal and extensive extraperitoneal ruptures need surgical repair.

• In the face of cardiovascular instability as a result of hemorrhage, as occurred in the present case, immediate resort to laparotomy after resuscitation is vital for salvaging maternal and fetal life.

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