Case Report

We present the case of a 34-year-old pregnant woman with chronic urinary retention. The urinary dysfunction was caused by an electrical spinal cord injury approximately 10 years before her pregnancy. Initially, intermittent bladder self-catheterization was used; however, because of frequent episodes of urinary tract infections, her urologist recommended sacral neuromodulation. When she became pregnant, the unknown effects of the device and the increased possibility of premature labor were explained to her; she decided not to deactivate the device fearing that intermittent self-catheterization might lead, once more, to recurrent urinary infections. The risks of urinary tract infections from discontinuing sacral modulation balanced with the potential issues with neuromodulation were discussed with the patient.

Her pregnancy was uneventful with no signs of threatened preterm labor. The anomaly ultrasound scan that was performed at 22 weeks’ gestation revealed no obvious anatomic abnormality of the fetus. Her urinary output remained within normal limits, and urinary infections were not detected. At 39 weeks’ gestation, a healthy male infant was delivered by cesarean section with peridural anesthesia because of breech presentation. There were no issues caused by the neuromodulator to the anesthesiology procedure and no changes to the positioning of the patient during surgery. Sacral neuromodulation was active throughout the pregnancy and postpartum, and no issues were raised regarding malfunction or displacement of the device.

Comment

Sacral neuromodulation therapy helps control urinary dysfunctions through an implanted device that sends mild electrical impulses through a lead to the sacral nerves that innervate the bladder, sphincter, and pelvic floor. It is indicated for the treatment of urinary retention, urge incontinence, overactive bladder, and significant symptoms of urgency-frequency.

Self-catheterization, absorbable pads, and bladder surgery are the alternative treatments for this kind of urinary dysfunctions.

A peripheral nerve stimulation test is performed to the patients before implantation to measure the feedback of the sacral neuromodulation. Local anesthesia is provided through a needle that is used to recognize the appropriate sacral nerves. After the successful identification, a temporary wire lead is entered through the needle and connected to an external device, which is placed on the patient and left there for several days. The results provided by the test are measured to determine whether the patient is suitable for this treatment. The implantation of a permanent device is performed under general anesthesia through 3 incisions. The pulse generator is programmed with the ideal settings for the patient who can turn on and off the pulse generator.

The use of sacral neuromodulation during pregnancy is very uncommon, most likely because of the rarity of bladder dysfunction during the reproductive years of a woman. Consequently, the experience of the effects of this treatment on pregnancy is limited. There is a theoretic risk of teratogenic effect on the developing fetus and a not so theoretic risk of preterm labor because the uterus and the bladder may share the same nerve roots. Review of the relevant literature revealed only 1 article that concluded that a sacral neuromodulation device should be deactivated during pregnancy because the effect on the fetus is unpredictable. Therefore, the International Urogynecological Association has advised women to deactivate their pulse generator as soon as their pregnancy is diagnosed. The alternative methods to handle urinary dysfunction without sacral neuromodulation are self-urinary catheterization, lifetime absorbable pads, and bladder surgery. Self-urinary catheterization is performed widely by patients when there are contraindications for sacral neuromodulation, but urinary infections are a frequent complication of this method.

Six cases of pregnant women with a pulse generator are reported in the literature. In all these cases, the device was deactivated between fourth and ninth gestational weeks. There were no obvious teratogenic effects, but premature birth at 34 weeks’ gestation was noted in one case.

Khunda et al studied 13 pregnancies of women with sacral neuromodulation and came to the conclusion that turning off the neuromodulation is associated with an increased risk of urinary tract infection recurrence and furthermore preterm delivery.

This is the first case, to our knowledge, in which the sacral neuromodulator remained active throughout the pregnancy. The challenge for the obstetric team was to manage the pregnancy without turning off the device, according to her personal wish. Urinary tract infection is the most common complication in patients performing intermittent catheterization and, apart from the discomfort, can predispose to preterm labor. Nevertheless, the pregnancy was uneventful and a healthy term male infant was born. A cesarean section delivery was performed because of breech presentation. Even though the IGUA suggests that sacral neuromodulation is not an indication for elective cesarean delivery, there is uncertainty on that issue because normal labor theoretically can cause displacement of the device.

The use of sacral neuromodulation also extends to the treatment of bowel dysfunction, which makes its use during pregnancy more crucial.

The continuous use of sacral neuromodulation during pregnancy is not necessarily harmful to the fetus, and the risk of preterm labor appears to be theoretic. However, the number of such cases is very limited and prevents investigators from reaching a safe conclusion or issuing guidelines.