The Renal Colic During Pregnancy Essay
The Renal Colic During Pregnancy Essay
Objective: To determine the problems related to renal colic due to urinary stones during pregnancy, and the principles of management of those patients in our hospitals.
Material and Methods: It’s a retrospective analysis of a series of 21 cases of renal colic due to urinary stones during pregnancy from Mar. 2008 to Apr. 2010 at Prince Rashid Ben Al-Hassan Military Hospital, Jordan. Presenting symptoms, diagnostic studies and management of renal stone were evaluated.
Results: There were 15824 deliveries during this period in our study. 21 of them had renal colic due to urinary stones during pregnancy; with an overall incidence in this series was 0.13%. Most of them were in third trimester of pregnancy followed by the second trimester and the least were in the first trimester. The Renal Colic During Pregnancy Essay. The most common complaints were flank pain (95.2 %), urinary symptoms (hematuria, dysuria and urgency) in 80.9%, nausea and vomiting in 14.3% and fever in 28.6 %. Spontaneous passing of stones was noted in 19 cases (90.5%) with conservative treatment. Two patients unresponsive or relapsing after medical treatment were treated surgically in urological department by double J stents insertion, but no maternal or fetal loss was noted.
Conclusion: Majority of renal colic due to urinary stones during pregnancy can be safely managed conservatively. The commonest presenting symptoms in our study were flank pain, urinary symptoms (hematuria, dysuria and urgency), and early surgical intervention resulted in safe maternal and fetal outcome.
Key words: Renal colic, urinary stones, pregnancy.
Introduction:
Pregnancy has been described as a test of renal function. Major anatomical and physiological changes affecting the entire urinary tract occur during pregnancy. Renal function dramatically alters with a 50% increase in renal blood flow and glomerular filtration rate, also increased circulating hormone levels and the pressure effects of the gravid uterus on the collecting system result in dilatation of the ureter, renal pelvis and calyx. All these alternations in urinary tract physiology and anatomic changes during pregnancy may affect the interpretation of renal function tests during pregnancy and make diagnosis and treatment a more challenging issue(1).
Generally though, renal colic due to urinary stones during pregnancy is a relatively uncommon occurrence during pregnancy. The prevalence of renal stone in pregnancy has been estimated at approximately 1 per 1500 women similar to the nongravid woman, with vast majority being asymptomatic and a chance finding(2). Urinary stones complicates 0.026–0.531% of pregnancies and presents an interesting challenge to the obstetrician, radiologist and urologist(3). The Renal Colic During Pregnancy Essay.
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Renal colic can occur at any time during gestation but is most common in the second and third trimester as seen in this study, because enlarging gravid uterus increasing the symptoms of the calculus, as gestation progresses(4). In a pregnant woman with symptoms suggestive of urinary calculi, it is imperative to confirm the diagnosis as quickly as possible with the minimum of risk to the developing fetus. Renal colic can precipitate premature labor and delayed diagnosis and intervention can result in permanent renal impairment(5).
Recurrent renal colic are common complications of renal stones and represent the most common non-gynecological conditions requiring hospitalization and intervention in pregnant woman(6). However, the differential diagnosis of appendicitis, pyelonephritis and premature labor should be considered with the latter two often associated with stones(7).
The use of ultrasound may confirm the diagnosis in the majority of non-gravid patients, but diagnostic accuracy is reduced during pregnancy. As the imaging diagnosis of urolithiasis in pregnancy is further complicated by the physiologic and hemodynamic alterations in the maternal urinary tract. Ultrasound also has limitation in detecting ureteral calculi. Recent use of trans-vaginal ultrasound has improved the detection rate of calculi at the ureterovesical junction(8).
Over three-quarters of renal calculi presenting during pregnancy will pass spontaneously with conservative management comprising bed rest, hydration, analgesia and antibiotics where indicated. In cases where there is calculus causing obstruction of the urinary tract, relief of the obstruction has required minimally invasive techniques as cystoscopic stent placement and percutaneous stent insertion(9). The Renal Colic During Pregnancy Essay.
Our aims in this study were to determine the problems related to renal colic due to urinary stones during pregnancy, to report our experience in its management and its effect on fetus outcome and to found out the overall morbidity and mortality of the disease in our hospitals.
Materials and Methods:
This is a retrospective study at Prince Rashid Ben Al-Hassan Military Hospital from Mar. 2008 to Apr. 2010. All patients with renal colic due to urinary stones during pregnancy who were admitted to the gynecology and obstetrics department were enrolled in treatment protocol.
All diagnoses were made with a combination of medical history and physical examination, laboratory tests (such as WBC, Serum urea, creatinine, also urine analysis and culture was requested) and ultrasonography. All patients were initially managed conservatively. Conservative management varied according with the admission diagnosis. Patients unresponsive or relapsing after medical treatment were considered conservative treatment failures and were referred to urological department. Also surgical measures are reserved for patients with sepsis, intractable pain, and acute renal failure.
We collect data from their medical records on age, gravidity, parity, trimester of pregnancy, symptoms, signs, laboratory and radiological tests, postoperative complication, duration of hospital stay and fetal and maternal outcome. Operative reports were also reviewed.
The local ethics committee approved the protocol and all patients signed an informed consent prior to their inclusion in the present study.
Results:
There were 15824 deliveries during this period in our study. The age these patients ranged from 16 to 40 years. Of those, 21 women were admitted following diagnosis of renal colic due to urinary stones during pregnancy. The overall incidence of renal colic during pregnancy in this series was 0.13%. Most of them were in third trimester of pregnancy 57.1% (no=12) followed by the second trimester 28.6% (no=6) and the least were in the first trimester 14.3% (no=3).
The most common complaints were flank pain in 20 patients (95.2 %), urinary symptoms (hematuria, dysuria and urgency) in 17 women (80.9%), nausea and vomiting in 3 women (14.3%) and fever in 6 women (28.6 %) as shown in Table I. Physical examination of patients revealed that costovertebral angle tenderness was present in 12 patients (57.1%). The Renal Colic During Pregnancy Essay. Only 6 patients were febrile (28.6%) whereas leukocytosis more than 15.000/mm3 were found in 5 patients (23.8%), while abnormal kidney function tests was found in 2 patients (9.5%) and microscopic hematuria in 17 patients (80.9%). Sterile urine culture was seen in 5 patients (23.8%). Also all of these patients underwent renal ultrasound on admission and it was confirmed the diagnosis and visualized stones were obtained in 85.7 per cent of the cases (18 patients). Plain KUB film was done in 3 cases and stones could be seen in 2 cases (66.7%). Limited IVP was done in one case and the diagnosis could be done in all of them (100%). These are shown in table II.
The treatment of such patients requires a multidisciplinary team approach involving the urologist, obstetrician, and radiologist. The initial management should be conservative, consisting primarily of bed rest, adequate hydration with intravenous fluids, correction of electrolytes, and pain management with analgesia when required. Combining opioids with non-steroidal anti-inflammatory drugs (NSAIDs) is the optimal evidence-based regimen to treat severe symptoms.
Conservative medical management is recommended initially, especially during the first and third trimesters, in which surgical intervention may confer risk of abortion or premature labor, respectively. Conservative management varied according with the admission diagnosis, so patients with urinary tract infection also received broad spectrum antibiotics.
Spontaneous passing of stones was noted in 19 cases (90.5%) with conservative treatment. The remaining two patients (9.5%) unresponsive or relapsing after medical treatment were considered conservative treatment failures and were treated surgically during pregnancy in urological department by double J stents insertion. Mean hospitalization time was 4 days. Fetal distress was not evident in any of the patients, also there were no maternal and fetal losses noted.
Discussion
Our incidence of renal colic during pregnancy in this series was 0.13%, which is comparable to other studies(10,11). The most presenting symptoms include flank pain, urinary symptoms (hematuria, dysuria, and urgency), nausea, vomiting, but fever and tachycardia may not present during pregnancy, and also flank pain was the commonest symptoms (95.2%) in the present study, the classic presentation of acute renal colic is the sudden onset of very severe pain in the flank primarily caused by the acute ureteral obstruction as seen by study of Thomas A et al(12).
Recent studies have shown preponderance in the third trimester, with approximately 11.1 % of cases occurring during the first trimester, 33.3% during the second trimester, and 55.5 % during the third trimester(13). The Renal Colic During Pregnancy Essay. Also in our study 57.1 % of cases were seen during the third trimester, and rest during first and third trimester. This finding is probably explained by dilatation of the upper urinary tract start at 6 to 10 weeks of gestation and is present at about 90% of women by the third trimester. Also the alterations appear to be caused chiefly by hormonal and, to a lesser degree, by mechanical factors incidental to the pregnancy.
Conservative management is the first-line treatment for noncomplicated urolithiasis in pregnancy. A conservative approach is recommended if there is no hydronephrosis, sepsis or abnormal renal function, but in 9.5% of patients this form of treatment may prove to be inadequate and further intervention is required in the form of double J stents insertion(14). Also surgical measures are reserved for patients with sepsis, intractable pain, and acute renal failure or for patients who fail to respond to conservative management. In our study sixty sex patients (90.5%) completely recovered on conservative treatment, while two patients (9.5%) needed further intervention in the form of double J stents insertion. This result is quite comparable to other studies(15,16).
Glowacki et al.(17)reviewed 107 asymptomatic patients with renal calculi who received no treatment at the time of diagnosis, with a mean follow-up of 31.6 months; 31.8% became symptomatic during this period, 15% passed their stones spontaneously, whilst 8.4%, 5.6% and 2.8% required SWL, ureteroscopic extraction and percutaneous nephrolithotomy, respectively. These results support the prophylactic treatment of asymptomatic stones, to prevent later disabling episodes of pain and obstruction.
However, if the calculus does not pass, it may initiate premature labor, produce intractable pain, cause urosepsis in the setting of urinary tract infection, or interfere with the progression of normal labor(18). Management of renal colic in pregnancy poses a significant problem because premature labor may be induced, and invasive therapeutic procedures are potentially harmful to the fetus. Conservative temporal treatments are therefore usually recommended(19). In present study, there was no fetal loss and or premature delivery. Admittedly, the number of patients in the present study was too small to draw conclusions. The Renal Colic During Pregnancy Essay.
Conclusions:
Majority of renal colic due to urinary stones during pregnancy can be safely managed conservatively. Few patients who needed surgery can be managed safely during pregnancy. The commonest presenting symptoms in our study were flank pain, urinary symptoms (hematuria, dysuria and urgency), and early surgical intervention resulted in safe maternal and fetal outcome.
Renal colic during pregnancy is a rare urgency but is one of the most common non-obstetric reasons for hospital admission. The management often means a challenge for the urologist and gynecologist due to the complexity involved in preserving the maternal and fetal well-being.
Material and methods
We performed a literature search within the PubMed database. We found 65 related articles in English. We selected 36 for this review prioritizing publications in the last two decades.
Results
The anatomical and functional changes of the genitourinary system during pregnancy are well documented; also during pregnancy, there are several metabolic pro-lithogenic factors. The most common clinical presentation is flank pain accompanied by micro or macro hematuria. US provides data identifying renal obstruction shown by an increased renal resistance index. MRI allows differentiating the physiological dilatation from the pathological caused by an obstructive stone showing peripheral renal edema and renal enlargement. The Renal Colic During Pregnancy Essay.Low dose CT has been determined to be a safe and highly accurate imaging technique. Once the diagnosis is confirmed, the initial management of patients should be conservative. When conservative management fails the interventional treatment is mandatory, a urinary diversion of the obstructed renal unit either by a JJ stent or through a PCN catheter has to be done. The definitive management of the stone can be done in the postpartum or deferred ureteroscopy can be considered during pregnancy.
Conclusions
Renal colic during pregnancy is an uncommon urgency, so it is important for the urologist to know the management of this condition.
INTRODUCTION
Renal colic during pregnancy is relatively rare (1 in 1,500 pregnancies), but it is one of the most common non-obstetric reasons for hospital admission. The management often means a challenge for the urologist and gynecologist due to the complexity involved in preserving the maternal and fetal well-being combined with the pharmacological constraints inherent to the condition of the pregnant patient [1, 2]. Pregnancy certainly complicates the management of renal colic, such as the adverse side effects on the fetus of ionizing radiation and drugs used in anesthesia and analgesia. These effects are often increased during the period of embryogenesis (the first 12 weeks of gestation). Fortunately, 80 to 90% of stones during pregnancy appear in the 2nd and 3rd trimester; however, it is not ruled out that these harmful agents could cause some sort of disturbance in the fetal development at any time during the pregnancy [3].
The gynecologists’ main objective is to preserve the maternal and fetal health and to maintain the proper course of pregnancy and this at times might antagonize the urologists’ main objective, which is to minimize the damage to the renal unit due to the uropathy secondary to the obstruction of the urinary tract. The Renal Colic During Pregnancy Essay.The diversity of therapies available and the inherent need for a multidisciplinary management among urologists and obstetricians have led us to review the recent and relevant publications on this subject.
Renal colic during pregnancy, in conjunction with low urinary tract symptoms (LUTS), acute urinary retention and urinary incontinence, are some urological pathologies that are considered associates and/or aggravated by pregnancy [3].
Acquisition of evidence
We performed a literature search within the PubMed database using the search words: “renal colic during pregnancy”. We found 65 related articles in English. We selected 36 for this review by prioritizing publications published in the last two decades. All the articles related to the topic were reviewed in order to provide data on diagnostic methods, medical and surgical treatment.
Epidemiology
Renal colic during pregnancy is a rare motive of consultation. The data reporting incidence is very variable: between 1/244 to 1/2400 pregnancies and for complicated renal colic near to 1/3300 pregnancies, this wide variability in the prevalence of this pathology may be due to the known geographical differences in the incidence of urolithiasis and the different diagnostic criteria used in the series reported; a number close to 1 in 1500 pregnancies could correspond to a more realistic view, not being increased than the incidence in the childbearing non-pregnant population [1, 2] (Table 1). There is a higher incidence of renal colic during the 2nd and 3rd trimester of pregnancy and in multiparous women in a ratio of 3:1 vs. first time pregnant women, both kidneys are equally affected [3, 4, 5]. Despite the low prevalence of this condition, renal colic pain in pregnant women is one of the most common non-obstetric reasons for hospital admissions [1, 2, 3].
Table 1
Prevalence of renal colic in pregnancy
| Author | Year | Studied Population | Nephrolithiasis cases | Prevalence | Age (range) | Gestational Age |
|---|---|---|---|---|---|---|
| Ho-Ying Ngai | 2013 | NA | Total: 30 12 -> calculus 18 -> pain (colic) |
NA | 27.2 (18-38) | 1º ->5 (17%) 2º ->15 (50%) 3º ->10 (33%) |
| Lata H (18) | 2011 | 520 | 2 | 0.4% | 26 (16-40) | 3º ->2 (100%) |
| Yung-Shun J | 2007 | 5,042 | 18 | 0.35% | 30.11 (23-39) | 1º ->2 (11.1%) 2º ->6 (33.3%) 3º ->10 (55.5%) |
| Swartz MA | 2007 | 1,297,625 | 2,239 | 0.17% 1.7/1000/year |
26.6 (21-32) | 1º ->101 (4.5%) 2º -> 594 (26.5%) 3º ->1512 (67.5%) |
| Lewis DF | 2003 | 21,010 | 86 | 0.4% | NA | NA |
| Drago JR | 1982 | 1,696 | 9 | 0.5% | NA | NA |
NA – not available
Pathophysiology
The anatomical and functional changes of the genitourinary system during pregnancy are well documented, some of which are: increased glomerular filtration, increased diuresis, hydronephrosis (90% right kidney, 67% in the left kidney) generated by the progesterone in the early stages of pregnancy which acts on the smooth muscle of the ureter reducing its diameter, accompanied by an increased urinary volume. The combination of these two latter phenomenon generates the dilatation of the upper urinary tract. The uterus in anteversion position during the third trimester can cause extrinsic compression and favor the dilatation of the ureter in the latter stages of the pregnancy [6, 7]. The Renal Colic During Pregnancy Essay. Endoscopically, into the bladder of a pregnant woman during the third trimester, an indentation of the bladder dome is observed due to the enlarged uterus and the ureteral meatus is located in a higher position than usual; these changes not only might influence as predisposing factors for nephrolithiasis, but can also hinder the diagnosis of obstructive uropathy in pregnant patients [1, 8].
During pregnancy, there are several metabolic pro-lithogenic factors, such as increased urinary excretion of calcium and uric acid; however, in pregnant women factors that can act as inhibitors of calculus formation are observed such as: increase of magnesium citrate excretion that acts by inhibiting the formation of calcium stones, the excretion of glycosaminoglycans and acid glycoproteins is also increased which inhibits the formation of oxalate, and the relative alkalinity of the urine that can occur as a result of the respiratory alkalosis during pregnancy, which decreases the uric acid formation. The underlying balance of all the factors previously described makes the incidence of urolithiasis and renal colic during pregnancy not greater than the incidence in the childbearing non-pregnant population [3, 8, 9].
The most common obstetric complication related to renal colic during pregnancy is preterm labor [8]. Women admitted with nephrolithiasis have nearly doubled the risk of preterm labor than women without stones; however, performing a surgical procedure (endourological, nephrostomy or others) and the trimester of pregnancy appears to increase the risk of preterm labor. It has been suggested that dehydration from vomiting induced by colic can trigger preterm labor due to the release of antidiuretic hormone and oxytocin [10]. The Renal Colic During Pregnancy Essay.
Diagnosis
The most common clinical presentation of renal colic is flank pain accompanied by micro or macro hematuria (Figure 1). Nevertheless, the condition of acute abdomenduring the second or third trimester of pregnancy is difficult to assess because the pregnant uterus changes the position of the colon, ovaries, appendix and bladder, which can modify the location of the pain. Differential non-obstetrics diagnoses are appendicitis, cholecystitis, pyelonephritis and with regard to obstetric causes of acute abdomen: abruption and preeclampsia with hepatic involvement [11]. The patient should be questioned about the history of nephrolithiasis and the presence of abnormalities in the urinary tract and/or metabolic diseases.
Summary illustrating the management of renal colic during pregnancy.
Blood cell counts, biochemistry and urine sediment are laboratory tests that have proven to be useful in the diagnosis of renal colic [12].
As we have to avoid fetal exposure to radiation, the usage of ultrasound (US) imaging has emerged to be the first-line image test with a positive predictive value of 77%, in addition to its affordability and safety. US imaging allows for the evaluation of other abdominals organs, it can be used with transabdominal and/or transvaginal probes and it also provides data identifying renal obstruction shown by an increased renal resistance index. Some clinical studies have shown that the renal resistance index >0.7 suggests ureteral obstruction with a 95% specificity. The use of doppler to identify ureteral asymmetrical Jet provides valuable information on total ureteral obstructions; however, if a partial obstruction exists it may decrease its effectiveness. The Renal Colic During Pregnancy Essay. The physiological hydronephrosis of a pregnant patient may hinder the diagnosis and decrease the US sensitivity to 74% and the specificity to 67%, which is insufficient for an accurate diagnosis. It has been identified that there are up to 40% of failures using the US imaging as the proper diagnosic tool as in general the US imaging is not only needed to the demonstration of the existence of obstruction, but the US imaging must in addition show stone location and size [11, 13].
Some authors have proposed to perform dilatation curves of the upper urinary tract during pregnancy, showing an upper urinary tract diameter increase of 0.5 mm/per week until 24 to 36 week, or 0.3 mm/per week until the 32nd week, then remaining stable until the end of pregnancy, this would distinguish between physiological and pathologic hydronephrosis [8, 11, 14].
The second line imaging tool used is magnetic resonance (MRI) with a positive predictive value of 80%. The MRI allows for the differentiating of the physiological dilatation from the pathological caused by an obstructive stone showing peripheral renal edema and renal enlargement. MRI combined with urography (MRU) has been extensively studied as an alternative imaging technique when compared to the standard CT. It offers highly accurate anatomical detail of the entire urinary tract, but does not expose the patient to ionizing radiation, an obvious benefit in pregnant patients. However, MRU offers poorer spatial resolution, requires prolonged imaging times, is associated with increased costs and also has inferior sensitivity for detecting calcifications and calculi when compared to the standard and low dose CT. In addition, while MRI is generally considered safe during pregnancy, there is a scarcity of knowledge regarding the safety of magnetic resonance during the first trimester, especially as it pertains to radio frequency exposure [14, 15]. The Renal Colic During Pregnancy Essay.
Historically 3-shot or limited intravenous urography (IVP) has been considered as an imaging modality of choice in pregnant patients suspected of having renal colic. Limited IVP is consistent of a preliminary radiography before and after 30 minutes after contrast injection with each simple abdominal x-ray exposing the fetus to a radiation of 0.1 to 0.2 rad, below the threshold of 1.2 rad from which the risk of damage begins to increase. The disadvantages of this method are fetal radiation exposure, the need to use intravenous contrast and the difficulty of its interpretation with the fetal skeleton in the images and perhaps most importantly, our generalized dependence on the cross-sectional imaging has largely rendered IVP obsolete and, in some facilities, unavailable. The radiation exposure should be avoided particularly during the first trimester of embryogenesis. It has demonstrated that the use of leaded thyroid shields on the uterus decreases the fetal radiation exposure [16].
Computerized tomography (CT) is an image test that uses a large dose of radiation exceeding the recommended as safe, therefore its use is not recommended. CT is associated with an increase of 2.4 times the risk of cancer in children and an increased incidence of fetal malformations [17]. The Renal Colic During Pregnancy Essay.CT should only be used when the benefits outweigh the risks. If there is a life-threatening situation of the mother and/or fetus, ureteroscopy may be considered as a diagnostic option, especially in the period when the fetus is at or near the term condition [8–11, 18, 19].
Low dose CT has been determined to be a safe and highly accurate imaging technique. When CT is required, the use of a low dose protocol CT is preferable in the pediatric population and among patients with recurrent stone disease due to concerns regarding the initial and cumulative radiation exposure, respectively. For many reasons significant concern remains prevalent among radiologists and urologists regarding the indications of low dose CT in the setting of pregnancy. These fears persist despite the longitudinal data that support the relative safety of imaging using this technique during pregnancy in the obstetrics and teratology literature. Of note, the American College of Obstetricians and Gynecologists currently recognizes and endorses the prudent use of CT during pregnancy to aid in the diagnosis and management of significant medical problems, including the evaluation of urinary stone disease [14, 15].
Treatment
Once the diagnosis is of ureteral stone is confirmed, the initial management of the patient should be conservative, with a success rate of 70–80% with spontaneous passage of the stone. The medical treatment involves the administration of analgesics, hydration and antibiotics if any indication of urinary infection or sepsis exists [20]. The Renal Colic During Pregnancy Essay.
Subcutaneous injection of sterile water has been compared with paracetamol use in a randomized study supporting its effectiveness. Continuous epidural blockade (T11-L2) has been recommended as an option and seems to benefit the spontaneous expulsion of the stone [21]. When conservative management fails or one of these conditions applies: sepsis, renal failure, solitary kidney and bilateral obstructive uropathy; the interventional treatment is mandatory, a urinary diversion of the obstructed renal unit either by a JJ stent or through a percutaneous nephrostomy (PCN) catheter has to be done. Both procedures have been performed in pregnant patients successfully, with assumable risks and complications.
The definitive management of the stone can be done in the postpartum or deferred ureteroscopy can be considered during pregnancy. There are reports of extracorporeal lithotripsy being performed in pregnant patients without the knowledge of being pregnant and no congenital and/or chromosomal abnormalities have been reported, however, it is contraindicated during pregnancy. Percutaneous lithotripsy has been successfully performed during pregnancy although is not a procedure to be done routinely due to the need of anesthesia, radiological control and prone position [22–26].
The choice of analgesic to be used should be performed carefully, with the avoidance of using NSAIDs due to their association with pulmonary hypertension and premature closure of the ductus arteriosus when used during the third trimester. Furthermore, another choice of analgesic, codeine, should be avoided during the first trimester as it has been linked to birth defects when used during this period. An analgesic that can be used safely during pregnancy is morphine with apparently no reported side effects when used in small doses and over a limited time [27, 28] (Table 2). The Renal Colic During Pregnancy Essay.
