Abstract
Introduction: The management of nephrolithiasis during pregnancy can be stressful for urologists due to concerns for investigations and treatments that may pose risk of fetal harm, and unfamiliarity with optimal management of these complex patients. In response, we created multi-disciplinary evidence-based guidelines to standardize the care for obstetric patients presenting with flank pain and suspicion for nephrolithiasis.Methods: A multi-disciplinary team involving Urology, Obstetric Anesthesiology, Obstetrics and Gynecology, Diagnostic Radiology, and Interventional Radiology from a single academic medical center was assembled. A PubMed search was performed using keywords of pregnancy/antepartum, nephrolithiasis/calculi/kidney stones, ureteroscopy, non-obstetric surgery, complications, preterm delivery, MRI, computerized tomography, renal bladder ultrasound (RBUS), and anesthesia to identify relevant articles. Team members reviewed their respective areas to create a comprehensive set of guidelines. One invited external expert reviewed the guidelines for validation purposes.Results: A total of 54 articles were reviewed for evidence synthesis. Four guideline statements were constructed to guide diagnosis and imaging, and seven statements to guide intervention. Guidelines were then used to create a diagnostic and intervention flowchart for ease of use. In summary, RBUS should be the initial diagnostic study. If diagnostic uncertainty still exists, a non-contrast CT scan should be obtained. For obstetric patients presenting with a septic obstructing stone, urgent decompression should be achieved. We recommend ureteral stent placement as the preferred intervention if local factors allow.Conclusions: We present a standardized care pathway for the management of nephrolithiasis during pregnancy. Our aim is to standardize and simplify the clinical management of these complex scenarios for urologists.
Highlights
The management of nephrolithiasis during pregnancy can be stressful for urologists due to concerns for investigations and treatments that may pose risk of fetal harm, and unfamiliarity with optimal management of these complex patients
Due to the potential negative outcomes for the mother and fetus and fears of litigation, management of nephrolithiasis during pregnancy can be anxiety provoking for urologists
These two factors result in hypercalciuria [4] and rapid encrustation of ureteral stents or percutaneous nephrostomy tubes that may be placed for obstructing upper urinary tract stones
Summary
The management of nephrolithiasis during pregnancy can be stressful for urologists due to concerns for investigations and treatments that may pose risk of fetal harm, and unfamiliarity with optimal management of these complex patients. During pregnancy there is a physiologic increase in the glomerular filtration rate as well as elevated 1, 25 Dihydroxy Vitamin D levels. These two factors result in hypercalciuria [4] and rapid encrustation of ureteral stents or percutaneous nephrostomy tubes that may be placed for obstructing upper urinary tract stones. The high rate of encrustation necessitates frequent tube exchanges and repeated exposures to anesthesia [5, 6], which carries risks of aspiration, hypotension, and pre-term labor to the mother and fetus [7]. There has been increased interest in performing primary ureteroscopy, which would avoid indwelling tubes and the need for repeat anesthetic exposures
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