Epidural analgesia for the treatment of colic attack with retrocaval ureter in late pregnancy complicated with marginal placenta previa: a case report
- 40 Downloads
Retrocaval ureter was diagnosed in a woman complaining of ureteric pain in the last trimester of pregnancy. We describe the rationale behind the administration of epidural analgesia for her colic attack.
A 41-year-old pregnant woman was hospitalized with a diagnosis of a marginal placenta previa at 34 weeks and 5 days of pregnancy. Her right ureter encircled the dorsal aspect of the inferior vena cava (IVC) and was compressed by a growing fetus, causing hydronephrosis. Her right lower back pain was exacerbated every day, till an epidural catheter was inserted. Her estimated glomerular filtration rate (eGFR) and hematocrit worsened, and an elective cesarean section was performed.
Epidural analgesia only provided pain relief for a few days. When a pregnant woman presents with a retrocaval ureter and severe pain, short-term epidural analgesia should be considered after evaluating the complex medical condition and size of the fetus.
KeywordsRetrocaval ureter Hydronephrosis Late pregnancy Epidural analgesia Placenta previa Flank pain
Estimated glomerular filtration rate
Infra vena cava
Magnetic resonance imaging
Numerical rating scale
White blood cell
Retrocaval ureter is a rare developmental anomaly, with an incidence of about 1 in 1000 births . The ureter passes posterior to the inferior vena cava (IVC) and is asymptomatic till the third or fourth decade of life in most cases . Some cases may be accidentally discovered in childhood during urological surgery  and when other congenital diseases  are present. The IVC compresses the ureter posteriorly, causing upstream dilatation of the proximal ureter and the kidney, resulting in flank pain, hematuria, pyelonephephritis, and urolithias . It is a rare disease, with 2.8 to 3.0 times greater predominance [1, 3, 5] in males. Thus, reports of retrocaval ureters in pregnant women are extremely rare. Non-steroidal anti-inflammatory drugs (NSAIDs), or less effective opioids, such as morphine (when NSAIDs  are ineffective or contraindicated), are generally prescribed for acute flank pain in urological disease. However, NSAID administration in late pregnancy is associated with severe adverse neonatal outcomes . No study in the literature describes an axial block for pain relief in pregnancy with retrocaval ureter. In this case, a woman presenting with ureteric pain due to hydronephrosis was diagnosed with retrocaval ureter in the last trimester of pregnancy, and she required continuous thoracic epidural analgesia. We describe the rationale behind the controversial decision to administer epidural analgesia for her colic attack.
Discussion and conclusion
Similar to an earlier report , dilation of the ureter by the IVC also occurred on the right side in our case. Due to compression of the right retrocaval ureter by the IVC and progressive compression by a growing fetus, the pain relief provided by epidural analgesia only lasted for a few days. Failure to alleviate severe pain in a pregnant woman exposes the fetus to undesirable effects due to cortisol exposure . However, abdominal muscle relaxation due to epidural analgesia may itself aggravate compression, as the pressure from the front to the back of the fetus may cause supine hypotension syndrome, which is well known to anesthesiologists.
Surgical management of placenta previa is difficult because of high maternal morbidity and frequent  neonatal complications. Interventional radiology using autologous blood can help control hemorrhage in pregnancies complicated by placenta accreta . Known contraindications for collecting autologous blood include infection, antibiotic use, preoperative anemia, malignancy, and sickle cell disease ; none of these contraindications were present in our patient so we proceeded with the blood collection. However, our patient experienced pain immediately following the autologous blood collection, and it is possible that IVC collapse aggravated her condition. This suggests that clinicians should carefully weigh the risk of autologous blood collection causing pain in patients with diagnosed retrocaval ureter.
As evidenced by this case, epidural analgesia may help to gain time for planning the surgery and for anesthetic management thereafter. Surely, this case was rare. It may repeatedly occur in pregnant women because of the frequency prescribed and mechanism of onset being easy to understand. In this case, from the expiration date of autologous blood transfusion, we expected epidural catheter placement for about a week. There have been reports of epidural abscess in pregnant women , and it is evident that long-term placement increases the risk of epidural abscess. Pain management using epidural anesthesia in the retrocaval ureter in pregnant women should be used to prepare for cesarean section in a short time. Fortunately, severe pain like that described in this case is likely to occur later in pregnancy. The fetus at 35 weeks of gestation is estimated to weigh about 2500 g , and depending on the health condition of the mother, cesarean section is indicated. If there are no symptoms, conservative management is possible while monitoring renal function and infection .
Moreover, pyelonephritis  and ureteral calculi  are not uncommon during pregnancy (their incidence during pregnancy is estimated to be 1–2% and 0.02–0.53%, respectively); therefore, pelvic MRI is essential for the differentiation of pain. We did not consider that this case was successfully managed, but when a retrocaval ureter causes severe pain during pregnancy, the size of the fetus and the complex nature of the mother’s condition should be taken into account and short-term epidural analgesia should be considered, with careful clinical observation.
SI wrote the initial draft of the manuscript. KT, KH, and MT contributed to the analysis and interpretation of data and assisted in the preparation of the manuscript. All other authors contributed to data collection and interpretation, and critically reviewed the manuscript. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
This research did not receive any specific grant from funding agencies in the public, commercial, nor not-for-profit sectors.
Ethics approval and consent to participate
Consent for publication
We obtained informed consent from the patient to publish this case report and save the data in electronic records.
The authors declare that they have no competing interests.
- 7.Damase-Michel C, Christaud J, Berrebi A, Lacroix I, Montastruc JL. What do pregnant women know about non-steroidal anti-inflammatory drugs? c Drug Saf. 2009;18:1034–8.Google Scholar
- 10.Duan X, Chen P, Han X, Wang Y, Chen Z, Zhang X, Chu Q, Liang H. Intermittent aortic balloon occlusion combined with cesarean section for the treatment of patients with placenta previa complicated by placenta accreta: a retrospective study. J Obstet Gynaecol Res. 2018;44:1752–60.CrossRefGoogle Scholar
- 15.Nien JK, Romero R, Hoppensteadt D, Erez O, Espinoza J, Soto E, Kusanovic JP, Gotsch F, Kim CJ, Mittal P, Fareed J, Santolaya J, Chaiworapongsa T, Edwin S, Pineles B, Hassan S. Pyelonephritis during pregnancy: a cause for an acquired deficiency of protein Z. J Matern Fetal Neonatal Med. 2008;21:629–37.CrossRefGoogle Scholar
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.