The current management of urolithiasis during pregnancy

Urological disorders and pregnancy: An overall experience

AIM

Pregnancy is an anatomical and physiological altered state and the presence of various urological problems not only aggravates the disease itself, but also results in unfavourable pregnancy outcome. Aim is to highlight obstetric outcome in pregnant women with urological problems.

MATERIALS AND METHODS

Longitudinal prospective cohort study conducted in tertiary care hospital, IPGME and R, Kolkata from Jan 2011 to Dec 2012. All pregnant women with urological problems were included as subjects.

RESULTS

A total of 33 subjects were followed up throughout their antenatal period. Among them majority (72.72%) presented with hydro nephrosis followed by hydroureter (60.6%), PUJ obstruction and pyelonephritis each with incidence of 15.15%, then urolithiasis (12.12%), nephrolithiasis (6.06%) and renal abscess (12.12%). Interventions required were DJ stenting (72.72%), pyeloplasty (15.15%) and others were RURSL, abscess drainage and ATT. The pregnancy outcome was complicated with preterm labor in majority of patients (45.45%), oligohydramnious (18.18%), PIH (9.09%) and still birth (6.06%). Twenty four live birth were there. Majority required NICU admissions as predominantly prematurity was an important concern. Majority women with hydronephrosis underwent DJ stenting.

CONCLUSION

Preterm labor is an important obstetric concern. Vaginal delivery is the choicest mode of termination and LSCS can be reserved for obstetric reason. DJ stenting is safe and practical approach for continuation of pregnancy with hydronephrosis. Regular follow up, vigilant antenatal care and multidisciplinary approach from urologist, obstetrician and neonatologist will bring out successful pregnancy outcome.

Intracutaneous sterile water injection versus oral paracetamol for renal colic during pregnancy: a randomized controlled trial

PURPOSE

The aim of this study was to assess the analgesic efficacy of intracutaneous sterile water injection compared with oral paracetamol in pregnant women with acute renal colic caused by urolithiasis.

METHODS

The study included 45 patients randomized into two different groups: Group A (n = 24) received paracetamol (1,000 mg, oral), while group B (n = 21) received sterile water injections. The severity of pain was assessed by a visual analogue scale (VAS) system at baseline and at 15, 30 min, and 1 h after administering the treatments. Subjects with inadequate pain relief at 1 h received rescue analgesia.

RESULTS

The VAS values prior to the start of therapy and 15, 30 min, and 1 h after therapy were 85.42 ± 10.62, 69.17 ± 8.3, 45.42 ± 12.5, and 32.08 ± 14.44 for the paracetamol group, while for the sterile water injection group, the VAS values were 90.48 ± 11.17, 30.95 ± 16.7, 14.76 ± 11.23, and 10.48 ± 8.65, respectively. There was no statistically significant difference between the starting VAS values of the two groups, but the VAS values 15, 30 min, and 1 h after paracetamol administration were statistically less in the group that received sterile water injections. Rescue analgesics at 1 h were required by eight subjects (33 %) receiving paracetamol and one subject (5 %) receiving sterile water injection.

CONCLUSIONS

Intracutaneous injection of sterile water is an efficacious treatment for renal colic caused by urolithiasis in pregnant women. It was significantly superior to oral administration of paracetamol.

Pregnancy and urinary diversion

In most children or premenopausal women who need urinary diversion, the underlying disease is benign. After the problems associated with urinary incontinence have been resolved, and patients have reached puberty, sexuality and fertility become more significant. In women with urinary diversion, numerous influencing factors exist, including, but not limited to, the underlying disease and form of urinary diversion. The authors' center has a large expertise in urinary diversion, although the number of cases with pregnancies is limited. This article uses this prior experience and data from a literature review to provide guidance for urologists, obstetricians, general practitioners, and patients to aid decision making in pregnancies after urinary diversion.

Urologic Radiology During Pregnancy

The pregnant patient presents a unique diagnostic challenge to the urologist because the well-being of both the mother and fetus must be considered. Radiation exposure to the fetus during gestation presents risks such as cell death and teratogenic effects, carcinogenesis, and genetic effects, which must be considered when selecting diagnostic tests. However, with the exercise of good clinical judgment and the use of the armamentarium of diagnostic imaging modalities available, the pregnant patient can be managed with minimal, if any radiation exposure to the fetus.

Urolithiasis in Pregnancy: Current Diagnosis, Treatment, and Pregnancy Complications

Urolithiasis complicates up to one in every 200 pregnancies; consequently, the practicing obstetrician should be aware of the symptoms of urolithiasis, the diagnostic procedures available for its diagnosis, and their associated risks. These include ultrasound, urography, and magnetic resonance imaging. Diagnosis of urolithiasis during pregnancy can be a challenge as a result of the normal physiological changes of pregnancy. Conservative management is the first-line treatment for noncomplicated urolithiasis in pregnancy. If spontaneous passage of the stone does not occur or if complications develop, urologic consultation should be obtained. Several obstetric complications have been associated with urolithiasis, including preterm labor and preterm premature rupture of membranes, although the reported rates of these complications in association with urolithiasis vary widely and overlap normal background rates. Given that urolithiasis will be encountered by most obstetricians, and that obstetricians are often on the front line of management for this condition, an appreciation of current diagnostic modalities, treatment protocols, and associated potential obstetric complications is warranted.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that urolithiasis is common in pregnancy, state that there are a variety of diagnostic procedures, summarize that conservative treatment is usually successful, and explain that complications of pregnancy usually occur when there is failure of conservative treatment.

Imagerie de la lithiase urinaire : « Trois en un »

Urinary lithiasis is very common among the general population, with a high prevalence level. In rich countries it is mainly located inside the upper urinary tract. Helical CToperated with newer devices is the most accurate modality to provide all needed information: diagnosis of stone without contrast medium injection, morphology (size, number) and localization, diagnosis of urinary obstruction, urinary tract aspect and all kind of differential diagnosis in emergency. It must be used during follow up to diagnose residual fragments. Multiplanar reconstructions are essential for the clinicians; but diagnosis is interpreted by scrolling axial views with dynamic analysis on computer screen. Low-dose helical CT is today available. Helical CT provides an "all-in-one" examination. It should soon replace combined plain film-ultrasonography performed in an emergency context of renal colic and intravenous urography for pre- and post-treatment assessments.

Nephrolithiasis and pregnancy

PURPOSE OF REVIEW

Urolithiasis during pregnancy is not common, however, it is a difficult condition to both diagnose and treat. There are many safety concerns that must be considered for both the mother and fetus. In this review we detail the different options available to the urologist and we highlight a treatment algorithm that we use when faced with a pregnant patient suspect of having a urinary calculus.

RECENT FINDINGS

Changes in ultrasound, limited intravenous urograms and magnetic resonance imaging have improved our ability to diagnose urolithiasis in pregnancy. Additionally ureteroscopy has emerged not only as a diagnostic tool but also as a modality for definitive treatment that can safely be used during the intrapartum period.

SUMMARY

When diagnosing urolithiasis in the gravid patient, the first line study should be ultrasound, using change in resistive index and transvaginal ultrasound. If these are not diagnostic, then a limited intravenous urograms should be performed. Once a diagnosis has been established, initial treatment should be conservative since 70-80% of patients will pass their stones. When intervention is necessary, the placements of an internal stent or percutaneous nephrostomy tube or ureteroscopy with definitive stone treatment are all reasonable options.