Urinary calculi increase the risk for adverse pregnancy outcomes: a nationwide study

Maternal-Fetal Complications in Renal Colic during Pregnancy: A Scoping Review

Renal colic is one of the most common non-obstetric causes of hospitalization in pregnant women. Its management is often a challenge for obstetricians/gynecologists, urologists and neonatologists due to the complexity of the problem. The aim of this study was to analyze the possible maternal-fetal complications in renal colic during pregnancy. The authors performed a scoping review of the current literature regarding the analyzed issues. The review was conducted using the PubMed/MEDLINE and Web of Science databases. The search generated a total of 237 articles, out of which 7 original studies were ultimately included in the scoping review. In the women affected by renal colic, the incidence of perinatal complications such as urinary tract infections (UTIs), premature rupture of membranes (pPROM), and preterm birth is markedly higher than reported in the general population of pregnant women. Data regarding the recurrence of other perinatal complications such as gestational diabetes mellitus (GDM), pregnancy-induced hypertension (PIH), preeclampsia (PE), and intrauterine growth restriction (IUGR) are scarce and ambiguous. Further research on these issues is needed to improve the perinatal outcomes of the affected pregnancies.

Management of urolithiasis in pregnancy

Urolithiasis is the most common cause of nonobstetric abdominal pain, resulting in 1.7 admissions per 1000 deliveries. Urolithiasis most commonly occurs in the second and third trimesters, with an incidence between 1:125 and 1:2000. Acute urinary system obstructions are challenging to manage in obstetric patients because they contribute to physiological and anatomical changes that result in pathological outcomes. The restricted use of computed tomography in diagnosing and managing urolithiasis is particularly challenging. In addition, a prompt diagnosis is required because the presence of renal calculi during pregnancy increases the risk of fulminating sepsis and preterm delivery. Affected pregnancies are conservatively managed; however, 1 in 4 requires surgical intervention. Indications for surgical interventions are complex and range from nephrostomy insertion to empirical stent placement or ureteroscopy. Therefore, a multidisciplinary approach is required to optimize patient care. The diagnosis and management of urolithiasis in pregnancy are complex. We reviewed the role, safety, advantages and disadvantages of diagnostic tests and treatment used to manage acute urinary obstructions in pregnancy.

Maternal and fetal outcomes of urolithiasis: A retrospective cohort study

OBJECTIVES

Although urolithiasis is relatively common in the general population, there is limited information on this condition available in the pregnant population. The objectives of this study are to identify the incidence of urolithiasis in pregnancy, as well as to compare maternal and fetal outcomes associated with urolithiasis in pregnancy.

METHODS

Using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database from the United States, a population-based retrospective cohort study consisting of pregnant women who delivered between 1999 and 2015 was conducted. ICD-9-CM code 592.X was used to identify pregnant women with urolithiasis within the cohort, with pregnant women without urolithiasis forming the comparison group. Unconditional logistic regression models were used to estimate the associations between urolithiasis in pregnancy and maternal and neonatal outcomes, while adjusting for baseline maternal characteristics.

RESULTS

A cohort of 13,792,544 pregnant women was identified, of which 11,528 had a urolithiasis-related admission during pregnancy, for an overall incidence of 8.3 per 10,000 pregnancies. Women with urolithiasis had a greater risk of developing preeclampsia/eclampsia, OR 1.35(95% CI 1.24-1.47), gestational diabetes, 1.29(1.20-1.30), abruptio placenta, 1.41(1.22-1.64), placenta previa, 1.55(1.27-1.90), pyelonephritis, 88.87(81.69-96.69), venous thromboembolism, 1.65(1.23-2.22), and more likely to deliver by cesarean, 1.20(1.15-1.25). As well, maternal death was more common among these women, 2.85(1.07-7.60). Congenital anomalies, 2.84(2.43-3.31) and prematurity, 1.92(1.82-2.03) were more commonly found among babies born to women with urolithiasis.

CONCLUSION

Although the mechanism is unclear, women with urolithiasis in pregnancy have an increased risk of adverse pregnancy and newborn outcomes.

Incidence of kidney stones in pregnancy and associations with adverse obstetrical outcomes: a systematic review and meta-analysis of 4.7 million pregnancies

BACKGROUND

Renal stones are a common cause of non-obstetrical abdominal pain in pregnant women. Though the management of renal stones in pregnancy is challenging, it remains unclear how the incidence of kidney stones may affect the course of pregnancy and delivery.

OBJECTIVE

To determine the incidence of renal stones in pregnancy and its impact on adverse obstetrical outcomes.

DATA SOURCES

We conducted a systematic literature search of three databases: Ovid MEDLINE, Ovid EMBASE, and EBSCO CINAHL Plus. After the selection of articles, an additional hand-search of their citations was completed to maximize sensitivity. Databases were examined from the last four decades (19 March 1970) up to the search date (19 March 2020).

STUDY ELIGIBILITY CRITERIA

Articles were excluded if they were not relevant to kidney stones or did not report outcomes related to pregnancy. Case reports, animal studies, and cadaveric studies were excluded. Conference abstracts, gray literature, and unpublished data were not eligible.

STUDY APPRAISAL AND SYNTHESIS METHODS

All screening, extraction, and synthesis were completed in duplicate with two independent reviewers. All outcomes reported in the included studies were systematically evaluated to determine suitability for meta-analysis. Random-effects models and sensitivity analyses were used to account for interstudy variation. Renal stone incidence rates were pooled to generate summary proportions. Risk of bias assessment was completed using the Risk of Bias Assessment tool for Non-randomized Studies.

RESULTS

Twenty-one studies were included through systematic review and approximately 4.7 million pregnancies across nine studies were included for meta-analysis. There are three major findings of this review regarding renal stone incidence in pregnancy and maternal, child, and birth-related outcomes associated with renal stones. First, we found pooled incidence of renal stones was 0.49%, or one case for every 204 pregnancies. Second, renal stones during pregnancy were significantly associated with the development of preeclampsia and urinary tract infection, as well as increased likelihood of low birth weight, preterm labor, and C-section deliveries. However, renal stones were not significantly associated with premature rupture of membranes or infant mortality. Third, there were limited obstetrical complications reported with either medical or surgical therapies although comparative outcomes were not provided in the majority of studies, precluding formal meta-analysis.

CONCLUSIONS

Although renal stones in pregnancy are relatively rare, there may be an associated risk of serious adverse obstetrical outcomes. However, further research is required to understand whether these obstetrical outcomes are causal or due to other confounders. Interdisciplinary care and pregnancy-specific counseling should be advised for pregnant women with kidney stones.

Management of ureteric stone in pregnancy: a review

Background

Urolithiasis in pregnancy is a major health concern and is one of the most common causes for non-obstetrical abdominal pain and subsequent hospital admission during pregnancy. The incidence of urinary calculi during pregnancy varies in the range of 1/200 to 1/2000. Acute ureteric colic in pregnancy is associated with significant potential risks to both mother and fetus. Significant anatomic and functional changes occur in pregnancy which not only lead to stone formation but also create diagnostic dilemma. The diagnosis of ureteric calculi can be incorrect in about 28% of pregnant patients.

Main body

Management of ureteric stone during pregnancy is remaining to be a challenge for the treating urologist. Because of the inability to use good imaging options for the diagnosis confirmation and more invasive approach for the treatment, management continues to be difficult. The main threats are preterm labor with delivery and premature rupture of membranes. Other pregnancy complications are obstructive uropathy, gestational diabetes mellitus, recurrent abortions and pre-eclampsia. Management of diagnosed ureteric stone is unique in the pregnant population and requires multi-disciplinary care. It should be individualized for each patient and moves preferably from conservative to invasive approaches sequentially. With continued advancements in endourological techniques, few definitive treatment options are also available for such patients.

Conclusion

There are several lacunae related with the diagnostic imaging, medical expulsive therapy, reliability of ureteral stent/percutaneous nephrostomy insertions and safety of ureteroscopy during pregnancy. Herein, we review the management of ureteric stone during pregnancy, the various diagnostic modalities and treatment options with their advantages and disadvantages. We also proposed our management algorithm to deal with such clinical scenario in this particular population.

Nephrolithiasis in Pregnancy: Treating for Two

OBJECTIVES

To review the literature regarding the epidemiology of stone disease and develop a management algorithm based on current evidence and societal guidelines.

METHODS

A structured literature review was performed to determine highest quality of evidence guiding care for pregnant patients with symptomatic nephrolithiasis. PUBMED and EMBASE databases were searched using terms "pregnancy," "nephrolithiasis," or "pregnancy" and "renal colic" alone and in combination with "stone", "kidney stone," "ultrasound," "MRI," "CT," "percutaneous nephrostomy," "ureteral stent," or "ureteroscopy." All English-language abstracts were reviewed for relevance and full-length articles were reviewed for content. Articles published prior to 1990 were excluded, and priority for inclusion was given to multi-institutional studies and larger institutional studies, reflecting the highest level of current available evidence and most contemporaneous practice patterns.

RESULTS

Symptomatic nephrolithiasis affects less than 1% of pregnancies but poses unique diagnostic challenges due to the physiologic changes of pregnancy and risks of ionizing radiation exposure to the fetus. Ultrasound remains the imaging modality of choice. Most patients may be managed non-operatively, but drainage with percutaneous nephrostomy or ureteral stent may be performed if warranted. Growing evidence also supports the safety and efficacy of definitive stone treatment.

CONCLUSIONS

Though rare, symptomatic nephrolithiasis poses significant clinical challenges due to the need to minimize risk for both mother and fetus with diagnostic and therapeutic interventions. A multi-disciplinary approach is paramount, as is shared decision making with the patient at each step of care.

Urolithiasis in pregnancy

Clinicians are faced with multiple diagnostic and treatment challenges when managing pregnant women with urolithiasis. Anatomical and physiological changes during pregnancy have to be taken into account whilst simultaneously considering both the expectant mother and the foetus. Ultrasonography remains the first-choice imaging modality, notwithstanding its potentially poor diagnostic accuracy. There is currently no consensus on second-line investigation for suspected urolithiasis. Low-dose non-contrast CT is highly sensitive, but the long-term effects of ionizing radiation on the foetus remain unknown. As far as treatment is concerned, expectant therapy is the primary option for management in the majority of cases. Percutaneous nephrostomy or ureteric stent placements are safe temporizing measures in relieving an acutely obstructed system and should be expedited in the presence of sepsis. Studies have shown ureteroscopy to be safe and effective during pregnancy with no significant risk to the foetus. It is important for the clinician to explain clearly the risks associated with the investigation and management options to the pregnant patient, including an acknowledgement that some of these remain unquantified, or even unknown.

Association Between Recurrence of Urinary Calculi and Childbirth: A Population-Based Case-Control Study

We examined the recurrence rate of urinary calculi (UC) in women after childbirth. The recurrence of UC is common, but no previous studies mentioned the risk of recurrence after childbirth. We performed a nationwide population-based cohort study to investigate whether childbirth could correlate with the recurrence of UC by using data from the National Health Insurance Research Database in Taiwan. Nulliparous women (age ≥20 years) receiving a diagnosis of first episode of UC between 2000 and 2002 were enrolled. We recorded the events of recurrence between parous patients (n = 737) and matched-control nulliparous patients (n = 737). The average ages for parous patients and controls were 27.41 and 27.54, respectively. The recurrence rate was 11.67% (86 of 737) in the childbirth cohort group and 21.57% (159 of 737) in the nonchildbirth cohort group. The childbirth cohort group was associated with a significantly decreased risk of secondary UC (adjusted hazard ratio, 0.45; 95% confidence interval, 0.35–0.59) compared with those who did not deliver a child. This relationship should be studied further.

Risk of Chronic Low Back Pain Among Parturients Who Undergo Cesarean Delivery With Neuraxial Anesthesia: A Nationwide Population-Based Retrospective Cohort Study

To investigate the risk of chronic low back pain (LBP) in parturients undergoing cesarean delivery (CD) with neuraxial anesthesia (NA). LBP is common during pregnancy and also after delivery, but its etiology is poorly understood. Previous studies that investigated the correlation between epidural labor analgesia and chronic low back pain were inconclusive. These studies lacked objective diagnostic criteria for LBP and did not exclude possible confounders. We performed this nationwide population-based retrospective cohort study to explore the relationship between CD with NA and subsequent LBP. From the Taiwan National Health Insurance Research Database (NHIRD), we identified all primiparas who had given birth between January 1, 2000 and December 31, 2013. Using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes, we identified the women who had vaginal delivery (VD) and those who had CD. The mode of anesthesia was ascertained by the NHI codes. Multivariable logistic regression was used to estimate the odds of postpartum LBP in women undergoing CD with NA compared with those having VD. The outcome was a diagnosis of LBP according to the first ICD-9-CM diagnosis code. The patients were observed for 3 years after delivery or until diagnosis of postpartum LBP, withdrawal from the NHI system, death, or December 31, 2013. Of the 61,027 primiparas who underwent delivery during the observation period, 40,057 were eligible for inclusion in the study. Of these women, 27,097 (67.6%) received VD, 8662 (21.6%) received CD with spinal anesthesia, and 4298 (10.7%) received CD with epidural anesthesia (EA). Women who received CD with EA were found to have higher risk of LBP than did women who received VD, with the adjusted OR being 1.26 (95% CI: 1.17-1.34). CD with EA might increase the risk of subsequent chronic LBP.

Renal stones in pregnancy

Diagnosis and treatment of renal stones during pregnancy is a complex problem. Risks to the fetus from ionising radiation and interventional procedures need to be balanced with optimising clinical care for the mother. Management of such patients requires a clear understanding of available options, with a multidisciplinary team approach. In this review, we discuss the role of different diagnostic tests including ultrasound, magnetic resonance urography, and computerized tomography. We also provide an update on recent developments in the treatment of renal stones during pregnancy. Expectant management remains first-line treatment. Where definitive treatment of the stone is required, new evidence suggests that ureteroscopic stone removal may be equally safe, and possibly better than traditional temporising procedures.