title: Successful pregnancy in patients with exstrophy-epispadias complex: A University of Washington experience.
abstract: BACKGROUND
  With advances in genitourinary reconstructive surgery, women with exstrophy-epispadias complex (EEC) have improved health and quality of life, and may reach reproductive age and consider pregnancy. Despite literature suggesting impaired fertility and higher risk with pregnancy, childbirth is possible. Medical comorbidities, including müllerian anomalies, contribute to increased risk of obstetric and urologic complications during pregnancy.
  
  
  OBJECTIVE
  We reviewed our experience with EEC patients who achieved pregnancy to investigate (1) urological characteristics of women who achieved pregnancy; (2) pregnancy management, complications, and delivery; and (3) neonatal outcomes. We developed recommendations for managing pregnancy in women with EEC.
  
  
  RESULTS
  This was a retrospective chart review of 36 female patients with EEC seen at our institution between 1996 and 2013. Female patients less than 18 years, and patients who did not have documented pregnancy were excluded. This resulted in a total of 12 patients with 22 pregnancies. All women with successful pregnancy had bladder exstrophy. The majority had undergone prior bladder augmentation (75%) and were on self-catheterization programs (92%). Thirty-six percent had symptomatic urinary tract infections (UTIs) during pregnancy. Five women had more than one pregnancy. There were four terminations of pregnancy. Of 18 desired pregnancies, there were four spontaneous abortions (SABs) (22%) and 16 live births (78%). The cesarean delivery (CD) rate was 100% (14/14), of which the majority were vertical (classical) uterine incisions with a paramedian skin incision. With the exception of one patient, there were no CD surgical complications. The mean gestational age at delivery was 36 weeks (Range 25 4/7 to 39 4/7 weeks) among eight pregnancies with known gestational age. There were no stillbirths, one neonatal death and no birth defects.
  
  
  CONCLUSIONS
  Women with EEC can have successful pregnancies, though at increased risk for preterm delivery and SABs. In our cohort, the rate of SAB is similar to that described in prior studies. Symptomatic UTIs likely due to self-catheterization were common. Cesarean delivery using a paramedian skin incision and classical uterine incision were not associated with major complications in this cohort. Limitations include reliance on retrospective data and small sample size. The strength of this study is the longitudinal detailed management of pregnancies in EEC women by a single team over time. A multidisciplinary approach to providing a continuum of care from pediatrics through adolescence to adulthood optimizes successful transitions, reproductive health, and successful pregnancies. Based on our experience, an algorithm providing guidance for pregnancy management was developed.
authors.affiliation: Department of Urology, University of Washington, Seattle, WA, USA.
authors.forename: Geolani W
authors.initials: GW
authors.lastname: Dy
authors.affiliation: Department of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Katie H
authors.initials: KH
authors.lastname: Willihnganz-Lawson
authors.affiliation: Department of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Margarett
authors.initials: M
authors.lastname: Shnorhavorian
authors.affiliation: Department of Obstetrics/Gynecology, University of Washington, Seattle, WA, USA.
authors.forename: Shani S
authors.initials: SS
authors.lastname: Delaney
authors.affiliation: Department of Obstetrics/Gynecology, University of Washington, Seattle, WA, USA.
authors.forename: Anne-Marie
authors.initials: AM
authors.lastname: Amies Oelschlager
authors.affiliation: Department of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Merguerian
authors.affiliation: Department of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Grady
authors.affiliation: Department of Urology, University of Washington, Seattle, WA, USA.
authors.forename: Jane L
authors.initials: JL
authors.lastname: Miller
authors.affiliation: Department of Obstetrics/Gynecology, University of Washington, Seattle, WA, USA. Electronic address: chengels@u.washington.edu.
authors.forename: Edith Y
authors.initials: EY
authors.lastname: Cheng
mesh_terms: D000328:Adult; D001746:Bladder Exstrophy / Q000150:complications / Q000601:surgery*; D004842:Epispadias / Q000150:complications / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D005865:Gestational Age; D006785:Hospitals, University; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D011247:Pregnancy; D011248:Pregnancy Complications; D011256:Pregnancy Outcome; D011788:Quality of Life; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D013520:Urologic Surgical Procedures / Q000379:methods*; D014861:Washington
keywords: Bladder exstrophy; Cloacal exstrophy; Exstrophy–epispadias complex; Pregnancy; Transition