Monday, July 8, 2013

Facts About Urinary Stones During Pregnancy

Roger Mitnick  /  at  10:37 PM  /  No comments

URINARY STONES DURING PREGNANCY

Urinary Stones occur approximately 1 in 1500 pregnancies

The classic presentation is flank pain, but patients may also present with nonspecific abdominal pain . Uterine contractions may also be present, further complicating the diagnosis, as the onset of preterm labor in patients with urinary calculi has been described.

 Fever may also be present and should raise the index of suspicion for a coexisting urinary tact infection. Urolithiasis should also be suspected in a patient with suspected pyelonephritis who fails to respond to antibiotic management.

Every pregnant patient with flank or abdominal pain should have urine microscopic analysis performed.

The presence of blood in the absence of recent urinary tract instrumentation raises the possibility of urinary calculi and appropriate imaging studies should be used to aid in the diagnosis.

 Other indications for imaging the renal system include a negative urine culture with the clinical diagnosis of pyelonephritis, suspected pyelonephritis with persistent fever after 48 hours of appropriate antibiotics, increasing blood urea nitrogen (BUN) and creatinine levels, and protracted pain. Initial imaging may include a renal ultrasound.

 However, the finding of hydroureteronephrosis in pregnancy is often a nonspecific physiologic finding related to bolus fluid administration, mechanical obstruction from the uterus, or the smooth muscle relaxing effect of progesterone.

Identification of ureteral jets with Doppler sonography may help in excluding ureteral obstruction.

If the diagnosis is still uncertain after sonographic evaluation, a noncontrast abdominal (renal protocol) CT or intravenous pyelogram (IVP) should be done.

A limited IVP, a scout film and an image at 20 minutes, will result in a dose of less than 200 mrad, significantly less than the teratogenic level Patients with urolithiasis should be hydrated and be given appropriate pain control.

Antibiotics are indicated for a concomitant upper or lower urinary tract infection. The urine may also be strained to identify when the stone has passed.

This conservative approach will be successful in the majority of patients Surgical intervention may be required when conservative management fails or complications of ureteral obstruction develop such as worsening renal function or a persistent infection proximal to the stone.

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