Respiratory distress following cesarean section: cryptic presentation of bladder injury

A case documenting the development of massive urinary ascites with associated pleural effusions and respiratory compromise due to an unrecognized cystotomy at the time of a tertiary low-vertical cesarean section is reported. The diagnosis was supported by elevated levels of serum blood urea nitrogen and creatinine and a peritoneal fluid to plasma creatinine ratio of 3:1. Imaging studies confirmed urinary extravasation into the peritoneum as well as bilateral pleural effusions and ascites. Primary intervention was to improve the patient's respiratory status and then to surgically repair the bladder wound.