Ruptured renal artery aneurysm in pregnancy and puerperium: literature review of 53 cases.

Purpose: To summarize and define the most appropriate diagnostic methods and therapeutic options for ruptured renal artery aneurysms in pregnancy based on rarely published data.
Methods: Literature searches of English-, German-, Spanish-, and Italian-language articles were performed in PubMed (1946-2018), PubMed Central (1900-2018) and Google Scholar. The search terms included renal artery aneurysm, renal artery rupture, pregnancy, puerperium, nierenarterienaneurysma, schwangerschaft, wochenbett, aneurisma de la arteria renal, el embarazo, puerperio, aneurisma dell'arteria renale and gravidanza. Additional studies were identified by reviewing reference lists of retrieved studies.
Results: Fifty-three cases were collected. The average maternal age was 31 ± 6 years; 71.4% were multiparous and significantly older than primiparas. The majority presented in the third trimester (62.3%), followed by second (20.7%) and the first (5.7%), while 11.3% presented postpartum. All postpartum patients presented during the first week postpartum and 50% during the first 24 h postpartum. Parity was not associated with the trimester of presentation. The left renal artery was affected slightly more frequently (58.5% vs. 41.5%). There were no differences in the affected side according to trimester of presentation, including postpartum. 25 out of 53 cases underwent ipsilateral nephrectomy (47.1%) and 18 underwent aneurysm repair or coil embolization (34.0%). There was no difference in maternal (25.8%) vs. 4 (18.1%) and fetal mortality according to the side of rupture. There were no differences in the distribution of maternal or fetal mortality frequency according to the trimester of presentation.
Conclusions: The clinical presentation is easily confused with more common conditions and time to diagnosis is often delayed. Diagnostic delay is associated with high maternal and fetal mortality. Ruptured renal artery aneurysm should be included in the differential diagnosis for pregnant or peripartum patients presenting with acute and severe flank pain, especially if followed by a drop in blood pressure. Early diagnosis and immediate intervention are important for achieving better maternal and fetal outcomes. There are several methods of managing asymptomatic or ruptured renal artery aneurysm during pregnancy although no established guidelines exist.