Spontaneous bilateral perirenal hematomas in two patients with eclampsia

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INTRODUCTION

Spontaneous renal hemorrhage into the subcapsular and perinephric space is a rare clinical problem. In the absence of anticoagulation or trauma it is most likely due to an underlying malignant renal tumor.

Other common causes are angiomyolipomas and vascular disease. It is a potentially life-threatening situa- tion which is rarely associated with eclampsia, and re- quires early recognition and management. We report two cases of spontaneus subcapsular renal hematoma, in patients with eclampsia.

Case 1

A 35-year-old pregnant woman, gravida 5, para 5, was admitted as an emergency at an estimated 37 weeks gestation. Her prenatal course was not assessed and she had not received any prenatal care. There was no history of trauma or drug abuse. At admission, her blood pressure (BP) was 210/130 mmHg with proteinuria at urinalaysis. The hemoglobin value was 12.1 g/dL and the platelet count was 170,000/mm³. The prothrombin time, fibrinogen, and amylase levels were within the normal range. She was agitated and apprehensive on arrival and then had an eclamptic seizure during delivery complicated by a uterine rup-

ture. A cesarean section was performed followed by a hysterectomy. A female infant weighing 2700 gm with Apgar scores at 1- and 5-minute of 4 and 8, was delivered. After resuscitation the patient was very stable, but 16 hours later her hemodynamic status became unstable, she became obtunded and disoriented. In- ternal bleeding was suspected because of a persistent drop in BP and hemoglobin levels despite iterative transfusions. An abdominal ultrasonography (US) showed peritoneal fluid, associated with bilateral perirenal hematomas (Figs. 1, 2). An abdominal CT scan confirmed the presence of bilateral perirenal hematomas (Fig. 3). There was no evidence of an underlying malignancy. The patient returned to the op- erating theater and during an exploratory laparotomy 2 liters of blood clots were evacuated from the peritoneal hematoma. An emergency bilateral hypogastric artery ligation was necessary. The hemoglobin level was 10.8 g/dL and the platelet count was 154,000/

mm³, the coagulation parameters were within the normal range (prothrombin time 13 sec, partial thromboplastin time activated 32 sec, fibrinogen 2.6 g/L), bilirubin, liver and renal function tests were normal (aspartate aminotransferase GOT 55 U/L, alanine aminotransferase GPT 50 U/L). Her clinical course was uneventful, with a decrease in the volume of the perirenal hematomas on US control.

Spontaneous bilateral perirenal hematomas in two patients with eclampsia

Issam M. Kably, Nabil Chikhaoui

Emergency Radiology Department, CHU IbnRochd, Casablanca - Morocco

ABSTRACT: The purpose of this report is to provide two illustrative cases of spontaneous and bilateral perirenal hematomas that occurred during a pregnancy complicated by eclampsia. The sonographic and computed tomo- graphic findings included bilateral perirenal hematoma with no evidence of an underlying malignancy. Since renal hematomas that occur in association with preeclampsia and eclampsia syndrome are extremely rare, but potentially life-threatening complications, prompt laboratory and radiologic evaluations are essential and can reduce the associ- ated morbidity and mortality.

Key words: Kidney hematoma, Spontaneous perirenal hemorrhage, Eclampsia

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Case 2

A 36-year-old pregnant woman, gravida 8, para 8, with no medical follow-up during her pregnancy, was admitted with an estimated full term pregnancy. She denied any history of trauma or medica- tion. The menstrual age had not been accurately determined. Her BP was 190/120 mmHg. Fetal heart sounds and movements were normal. There was proteinuria on urinalysis. Her hemoglobin was 10 g/dL and platelet count was 150 000/mm³. Her renal and hepatic functions were within the normal range, and there was no evidence of blood dyscrasia. A live infant was delivered abdominally.

Seven hours later, she developed eclamptic seizures followed by a sudden drop in her systolic BP. After 24 hours of mannitol and dexametha- sone treatment, the patient was alert and com- plained of bilateral flank pain. Abdominal ultrasonography revealed bilateral hypoechoic perirenal fluid, predominant around the right kidney, with no signs of organic lesion (Fig. 4). An abdominal CT scan performed 2 days later confirmed the presence of bilateral subcapsular renal hematomas, which appeared as low-attenuation subcapsular non-enhancing lesions (Fig. 5). There was no evidence of a renal tumor. A cerebral CT scan was normal. Her coagulation parameters were within the normal range (prothrombin time 12 sec, partial thromboplastin time activated 30 sec, fibrinogen 2.6 g/L), bilirubin, liver and renal function tests were normal (GOT 45 U/L, GPT 40 U/L), the platelet count was 144 000/mm³. A US

performed 48 hours later showed significant re- duction in the volume of the hematomas, which persisted only around the right kidney. Her clinical course was uneventful, and after 2 months there was no sign of hypertension.

Figs. 1, 2 - US demonstrating bilateral perinephric fluid, with no evidence of abnormal renal mass.

Fig. 3 - Abdominal CT scan findings: axial section image de- monstrating bilateral low-attenuation, non-enhancing perire- nal collections displacing the kidneys anteriorly. No definite mass is discernible.

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DISCUSSION

Spontaneous renal bleeding, in the absence of trauma, is associated with multiple conditions. Polkey and Vynalek (1) reviewed the world literature before 1933 and analysed 178 cases of spontaneous non-traumatic perirenal hematoma. Since then numerous terms have been used including spontaneous perirenal hematoma (2, 3), spontaneous subcapsular renal hemorrhage (4), non-traumatic perirenal hematoma and spontaneous perinephric hematoma. The absence of external trauma has been stressed in virtually all reports. Spontaneous perirenal hematomas essen- tially raise the problem of the etiological diagnosis.

McDougal (4) carried out a review of the English literature up to 1975, adding four cases of his own to the 78 patients included in the review, which met the strict criteria of spontaneous renal bleeding, the most common etiology being found to be a tumor in 57% (24%

benign, mainly angiomyolipoma), vascular disease in 18% and infectious disease in 10%. These findings were confirmed by more recent reports (7-13).

Belville et al (14) reported a series of 18 patients with spontaneous perirenal hemorrhage, and found that renal cell carcinoma was the single most common cause of bleeding (55%), followed by angiomyolipoma (17%) and vascular disease (11%). Reiter et al (15) reviewed the English literature up to 1995, and found that polyarteritis nodosa was the most frequent entity associated with renal hematomas (59% of the cases of renal hematomas and vasculitis). Less frequent causes were represented by renal arteriovenous malformation, renal arter y aneur ysms, Wegener’s

granulomatosis, tuberous sclerosis and atherosclero- sis. In other reports (16), the cause of perirenal hematomas associated with polyarteritis nodosa was the rupture of a renal artery aneurysm. When a spontaneous perirenal hematoma is a presenting symptom of classic polyarteritis nodosa, a delay in making the right diagnosis is likely to occur (17). Angiography can not only provide a quick diagnosis, but it can also be used to perform therapeutic embolization.

During pregnancy, renal causes of non-traumatic retroperitoneal hematoma are associated with spontaneous rupture of the kidney or rupture of an existing renal lesion. Angiomyolipomas are the most common- ly reported tumors and their spontaneous rupture cause perirenal and retroperitoneal hemorrhage (18, 19). Angiomyolipoma is a benign renal neoplasm composed of fat, vascular and smooth muscle ele- ments. The blood vessels in these tumors frequently have an angiomatous arrangement. These vessels are tortuous and thick walled. They do not have elastic tissue. Angiomyolipomas do not have a capsule, but they are often well marginated. The majority (88%) extend through the renal capsule into the perinephric space.

The characteristic absence of elastic tissue in the tumor vessels predisposes the patient to aneurysm for- mation and spontaneous hemorrhage. Rupture of a renal angiomyolipoma during pregnancy is rare and occasionally fatal. Emergency nephrectomy is usually required, with a simultaneous cesarean section in patients at 28 or more weeks of gestation. Tanaka (18) suggests that pressure on the tumor by increased abdominal pressure and the fluctuation of BP during la- bor may cause bleeding of the angiomyolipoma. The

Fig. 4 - Abdominal US demonstrating perirenal collection pre- dominant around the right kidney.

Fig. 5 - Contrast enhanced CT scan: low-attenuation perire- nal non-enhancing lesions. There was no evidence of a renal tumor.

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presenting symptoms of ruptured renal angiomyolipoma during pregnancy include decreasing hemat- ocrit and abdominal pain, making it difficult to differ- entiate it from placental abruption (19).

Severe preeclampsia and eclampsia are risk factors of spontaneous bleeding, and these conditions are usually associated with hepatic hematomas. However, in these contexts, spontaneous renal hematomas are extremely rare, and only three cases have been reported in the world literature (20-22). Two of the three cases were accompanied by hepatic hematomas, and the re- maining one (20) involved only one kidney. Our cases are the first to report bilateral renal hematomas in eclampsia. Jung et al (20) reported a case of spontaneous subcapsular hematoma, involving the left kidney, in a patient with severe preeclampsia and suggest- ed that hypertension might be the major contributing factor of the renal hematoma. In this case, the patient had preeclampsia and severe hypoplastic change of the right kidney. Her history included neither trauma nor anticoagulation treatment. The abdominal mag- netic resonance imaging (MRI) revealed no definite abnormality in the left kidney. Similarly, our two patients did not have coagulation abnormalities indicat- ing disseminated intravascular coagulation or HELLP disease, and no prophylactic anticoagulant treatment had been administered. There was no evidence of renal malignancy after imaging investigation. There- fore, we believe that the major cause of the renal hematomas in our cases was the intractable hypertension associated with severe preeclampsia and eclampsia, causing vascular damage and explaining the rapid resolution, without scars, of the hematomas. The clinical presentation of these patients can vary greatly de- pending on the degree and duration of the bleeding.

A sudden onset of flank or upper abdominal pain, nausea and vomiting, hematuria and decreasing hemoglobin are common findings. Sometimes if hematoma dissects into the retrocaecal region the appearance may resemble acute appendicitis (23). Sonography is a rapid non-invasive technique that can be used as a screening modality, but ultimately the patient will re- quire a CT scan, which is the most valuable examina- tion in the initial evaluation of an acute spontaneous hemorrhage (24). Acute hematoma has a higher attenuation value than the renal parenchyma on the non-enhanced scan and a lower attenuation value than the normal enhancing renal parenchyma on the contrast enhanced CT scan. It can demonstrate quick- ly and accurately the presence and extent of the hemorrhage. Since the association between perinephric hemorrhage and small renal carcinoma is well docu- mented (25), patients should be followed up with CT scans until the abnormality is completely resolved. In our patients there was a 100% diagnostic accuracy. It should be noted that the level of increased mortality

or morbidity that can result from not performing im- mediate surgery in patients who ultimately prove to have an underlying carcinoma has not been defined.

If no underlying cause of hemorrhage is visible on a CT scan, then selective renal angiography can be help- ful in providing the diagnosis. Angiography can demonstrate a renal cell carcinoma or an angiomyolipoma. However, angiography is more useful in the evaluation of vascular disease that is associated with spontaneous renal hemorrhage, for example, arteriovenous malformation, renal artery aneurysms and polyarteritis nodosa (26). In suitable cases diagnostic angiography can be followed by therapeutic embolization of the bleeding vessels during the same proce- dure.

MRI assists in the diagnosis when a CT scan is con- traindicated for some purpose. In acute stages hematomas are hypointense on T1- and T2-weighted images (27). Hypointensity on T1- and T2-weighted images determines the acute age of the hematoma. In acute stage, blood erythrocytes contain deoxyhemo- globin, which is paramagnetic and has a strong T2- shortening effect. Once the hematoma regresses it is possible to make a definite diagnosis.

The possibility of a perirenal hematoma should be considered when a patient with severe preeclampsia presents with a sudden onset of flank pain, or in the presence of an unstable hemodynamic status or a drop in hemoglobin levels in eclamptic patients. To- day with better resolution of imaging modalities the diagnosis can be easily achieved. In suspected cases of underlying malignancy, a follow-up CT scan after 3 - 6 weeks is advised.

Address for correspondence:

Issam M. Kably, M.D.

20 Lot Mimosas, Bd Ibnou Sina Casablanca, 20100, Morocco kably75@hotmail.com

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Received: June 28, 2002 Revised: February 19, 2003 Accepted: March 17, 2003