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Management of urinary calculi in pregnancy
MANAGEMENT OF URINARY CALCULI IN PREGNANCY A. S. CASS, M.B.B.S. C. S. SMITH, P GLEICH,
M.D. M.D.
From the Department of Urology, St. Paul-Ramsey Medical Center, St. Paul, and Division of Urology, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACTWhen a calculus is present in the upper urinary tract during pregnancy, the upper tract dilatation seen on radiography and ultrasonography can be due to the calculus or to the pregnancy. This makes the decision on management difficult unless there are associated clinical findings of pain or sepsis. The records of 24 pregnant patients with proved urinary calculi were reviewed. The stone passed spontaneously in 18 patients, and procedures to remove the stone were required in 6 for pain and/or sepsis. With an upper urinary tract calculus and dilatation during pregnancy the deciding factors for intervention were the clinical findings of pain and/or sepsis and not the dilatation alone.
An upper urinary tract calculus with dilatation is indicative of obstruction except during pregnancy which alone can cause upper tract dilatation. The records of 24 pregnant patients with proved urinary calculi were reviewed. It was found that the calculus passed spontaneously in 18 patients (75%), and procedures to remove the stone were required in 6 patients (25 %) for pain and/or sepsis. With an upper urinary tract calculus and dilatation during pregnancy the clinical findings of pain and/or sepsis were the indications for intervention and not the dilatation alone. Material and Methods From 1974 to 1984, 27,113 deliveries were performed at St. Paul Ramsey and Hennepin County Medical Centers, and 24 of the patients were hospitalized during the pregnancy with a proved urinary calculus. The medical records of the 24 patients were reviewed. Results There were 5 primigravidas and 19 multigravidas whose parity averaged 2.1 per patient.
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The duration of pregnancy at the time of diagnosis was the first trimester (up to 13 weeks) in 1 patient, second trimester (14-26 weeks) in 9 patients, third trimester (27-40 weeks) in 9, and postpartum (up to 8 weeks) in 5 patients. The calculi were on the right side in 13, on the left side in 8, on both sides in 1, and side unknown in 2 patients. The urinary calculus passed spontaneously with excess fluid intake in 18 patients (14 during pregnancy and 4 postpartum), and no radiologic evaluation was performed. The stone passed spontaneously during pregnancy in the second trimester in 7 and during the third trimester in 7 patients. Procedures were required in 6 patients (5 during pregnancy and 1 postpartum) for persistent pain in 2, pain and sepsis in 3, and anuria in 1. Excretory urograms and ultrasonography were performed in these 6 patients and revealed the calculus with dilatation or nonfunction of the upper urinary tract. The procedures performed consisted of stone basket manipulation in 2 (5l/2, 37 weeks pregnant), ureterolithotomy in 2 (26 weeks pregnant, 4 weeks postpartum), pyelolithotomy in 1 (20
UROLOGY
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NOVEMBER
1986
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VOLUME XXVIII,
NUMBER 5
weeks pregnant), and bilateral ureteral indwelling catheters in 1 (37 weeks pregnant). The composition of the calculi was known in 15 patients and comprised of calcium carbonate and phosphate in 7, calcium phosphate and oxalate in 5, calcium carbonate in 1, calcium phosphate and uric acid in 1, and uric acid alone in 1. Case Reports Case 1 An eighteen-year-old primigravida was eight weeks pregnant when admitted with left renal colic. Her history revealed a suicide attempt by jumping off a building at fourteen years of age which required two years of hospitalization with surgeries for hip, back, and ankle injuries. Ultrasonography showed dilatation of the left calyces and renal pelvis and a normal right side. With hydration a calculus was passed spontaneously and the pain resolved. There were four readmissions at twelve, fifteen, twenty-four, and thirty-two weeks of pregnancy with left renal colic and with hydration calculi passed spontaneously with resolution of the pain. An intravenous pyelogram at fifteen weeks of pregnancy revealed bilateral renal calculi, which were large and more numerous on the right side, and upper tract dilatation on both sides. The final admission was at 37 weeks of pregnancy with anuria for twelve hours. The serum creatinine was 7.8 mg/lOO ml. Ultrasonography revealed bilateral hydronephrosis which was larger on the left side. Bilateral ureteral catheters were passed and left indwelling after urine drained from them. Labor was induced and a healthy baby delivered. Bilateral pyelolithotomies were performed in the postpartum period.
Case 2 A twenty-five-year-old para 2 was twentyseven weeks pregnant when admitted with right renal colic which resolved after passage of a calculus. During her next (3rd) pregnancy she had right renal colic at seventeen weeks and left renal colic at twenty-seven weeks and passed calculi on both occasions with relief of symptoms. During her fourth pregnancy she had left renal colic at seventeen weeks and passed a calculus with resolution of the pain. A metabolic workup has been recommended but the patient refuses.
UROLOGY
/ NOVEMBER
1986
/ VOLUME
XXVIII,
Comment The diagnosis of urinary calculi during pregnancy is made more difficult because of the pregnancy-induced upper tract dilatation which is present in most pregnant patients and the increased incidence of acute pyelonephritis associated with the bacteriuria of pregnancy, A calculi must be seen on radiologic evaluation or passed spontaneously and collected before a definite diagnosis of urinary calculus with pregnancy is made. Previous reports give conflicting views on the presentation and management of urinary calculi in pregnancy. Harris and Dunnihoo’ found that acute pyelonephritis was the common presentation after the fourth month of pregnancy (17/19 cases) and that calculi are seldom passed spontaneously after the fourth month of pregnancy. Strong, Murchison, and Lynch2 reported flank pain in all 14 patients with only 1 patient having infected urine at the time of diagnosis and 11 of the 14 patients passing the calculi spontaneously. All 24 patients presented with renal colic with only 3 of the 24 (12.5 %) having acute pyelonephritis and 18 of the 24 passing the stone spontaneously. Since most pregnant patients with urinary calculi pass the calculi spontaneously, the use of radiologic evaluation should be restricted to those patients in whom the pain and/or acute pyelonephritis do not settle with hydration and antibiotics. An excretory urogram with four to six films while delivering 0.4 to 1.6 rad to the maternal and fetal gonads will show the presence of a radiopaque calculus and upper tract dilatation. Renal ultrasonography delivers no radiation and will show upper tract dilatation but is not able to demonstrate calculi with great accuracy. The dilatation with a calculus in the upper urinary tract of a pregnant patient may not be due to the calculus since upper tract dilatation is a physiologic change associated with pregnancy. Evidence of persistent obstruction (pain, nonfunction) and/or infection caused by the calculus should be present before performing a procedure to remove the stone or divert the urine. In the past stone basket manipulation was used for calculi in the lower ureter and open surgery for removal of renal and upper ureteral stones. The newer techniques of percutaneous removal of renal and upper ureteral stones have replaced open surgery, and ureteroscopy is being used for ureteral stone removal. However, the pregnant uterus filling the
NUMBER 5
371
bony pelvis could prevent passage of the ureteroscope. With an upper urinary tract calculus and dilatation during pregnancy the upper tract dilatation can be due to the calculus or to the physiologic change associated with the pregnancy. The records of 24 pregnant patients with proved urinary calculi were reviewed. The calculus passed spontaneously in 18 patients (75 %), and procedures were required in 6 patients (25%) to remove the calculus. With an upper urinary tract calculus and dilatation during pregnancy the clinical findings of per-
372
UROLOGY
sistent pain and/or sepsis were the indications for intervention not the dilatation alone. 640 Jackson Street St. Paul, Minnesota 55101 (DR. CASS) References 1. Harris RE, and Dunnihoo DR: The incidence and significance of urinary calculi in pregnancy, Am J Obstet Gynecol 99: 237 (1967). 2. Strong DW, Murchison RJ, and Lynch DF: The management of ureteral calculi during pregnancy, Surg Gynecol Obstet 146: 604 (1978).
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NOVEMBER
1986
i
VOLUME
XXVIII,
NUMBER
5
M.D. M.D.
From the Department of Urology, St. Paul-Ramsey Medical Center, St. Paul, and Division of Urology, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACTWhen a calculus is present in the upper urinary tract during pregnancy, the upper tract dilatation seen on radiography and ultrasonography can be due to the calculus or to the pregnancy. This makes the decision on management difficult unless there are associated clinical findings of pain or sepsis. The records of 24 pregnant patients with proved urinary calculi were reviewed. The stone passed spontaneously in 18 patients, and procedures to remove the stone were required in 6 for pain and/or sepsis. With an upper urinary tract calculus and dilatation during pregnancy the deciding factors for intervention were the clinical findings of pain and/or sepsis and not the dilatation alone.
An upper urinary tract calculus with dilatation is indicative of obstruction except during pregnancy which alone can cause upper tract dilatation. The records of 24 pregnant patients with proved urinary calculi were reviewed. It was found that the calculus passed spontaneously in 18 patients (75%), and procedures to remove the stone were required in 6 patients (25 %) for pain and/or sepsis. With an upper urinary tract calculus and dilatation during pregnancy the clinical findings of pain and/or sepsis were the indications for intervention and not the dilatation alone. Material and Methods From 1974 to 1984, 27,113 deliveries were performed at St. Paul Ramsey and Hennepin County Medical Centers, and 24 of the patients were hospitalized during the pregnancy with a proved urinary calculus. The medical records of the 24 patients were reviewed. Results There were 5 primigravidas and 19 multigravidas whose parity averaged 2.1 per patient.
370
The duration of pregnancy at the time of diagnosis was the first trimester (up to 13 weeks) in 1 patient, second trimester (14-26 weeks) in 9 patients, third trimester (27-40 weeks) in 9, and postpartum (up to 8 weeks) in 5 patients. The calculi were on the right side in 13, on the left side in 8, on both sides in 1, and side unknown in 2 patients. The urinary calculus passed spontaneously with excess fluid intake in 18 patients (14 during pregnancy and 4 postpartum), and no radiologic evaluation was performed. The stone passed spontaneously during pregnancy in the second trimester in 7 and during the third trimester in 7 patients. Procedures were required in 6 patients (5 during pregnancy and 1 postpartum) for persistent pain in 2, pain and sepsis in 3, and anuria in 1. Excretory urograms and ultrasonography were performed in these 6 patients and revealed the calculus with dilatation or nonfunction of the upper urinary tract. The procedures performed consisted of stone basket manipulation in 2 (5l/2, 37 weeks pregnant), ureterolithotomy in 2 (26 weeks pregnant, 4 weeks postpartum), pyelolithotomy in 1 (20
UROLOGY
/
NOVEMBER
1986
/
VOLUME XXVIII,
NUMBER 5
weeks pregnant), and bilateral ureteral indwelling catheters in 1 (37 weeks pregnant). The composition of the calculi was known in 15 patients and comprised of calcium carbonate and phosphate in 7, calcium phosphate and oxalate in 5, calcium carbonate in 1, calcium phosphate and uric acid in 1, and uric acid alone in 1. Case Reports Case 1 An eighteen-year-old primigravida was eight weeks pregnant when admitted with left renal colic. Her history revealed a suicide attempt by jumping off a building at fourteen years of age which required two years of hospitalization with surgeries for hip, back, and ankle injuries. Ultrasonography showed dilatation of the left calyces and renal pelvis and a normal right side. With hydration a calculus was passed spontaneously and the pain resolved. There were four readmissions at twelve, fifteen, twenty-four, and thirty-two weeks of pregnancy with left renal colic and with hydration calculi passed spontaneously with resolution of the pain. An intravenous pyelogram at fifteen weeks of pregnancy revealed bilateral renal calculi, which were large and more numerous on the right side, and upper tract dilatation on both sides. The final admission was at 37 weeks of pregnancy with anuria for twelve hours. The serum creatinine was 7.8 mg/lOO ml. Ultrasonography revealed bilateral hydronephrosis which was larger on the left side. Bilateral ureteral catheters were passed and left indwelling after urine drained from them. Labor was induced and a healthy baby delivered. Bilateral pyelolithotomies were performed in the postpartum period.
Case 2 A twenty-five-year-old para 2 was twentyseven weeks pregnant when admitted with right renal colic which resolved after passage of a calculus. During her next (3rd) pregnancy she had right renal colic at seventeen weeks and left renal colic at twenty-seven weeks and passed calculi on both occasions with relief of symptoms. During her fourth pregnancy she had left renal colic at seventeen weeks and passed a calculus with resolution of the pain. A metabolic workup has been recommended but the patient refuses.
UROLOGY
/ NOVEMBER
1986
/ VOLUME
XXVIII,
Comment The diagnosis of urinary calculi during pregnancy is made more difficult because of the pregnancy-induced upper tract dilatation which is present in most pregnant patients and the increased incidence of acute pyelonephritis associated with the bacteriuria of pregnancy, A calculi must be seen on radiologic evaluation or passed spontaneously and collected before a definite diagnosis of urinary calculus with pregnancy is made. Previous reports give conflicting views on the presentation and management of urinary calculi in pregnancy. Harris and Dunnihoo’ found that acute pyelonephritis was the common presentation after the fourth month of pregnancy (17/19 cases) and that calculi are seldom passed spontaneously after the fourth month of pregnancy. Strong, Murchison, and Lynch2 reported flank pain in all 14 patients with only 1 patient having infected urine at the time of diagnosis and 11 of the 14 patients passing the calculi spontaneously. All 24 patients presented with renal colic with only 3 of the 24 (12.5 %) having acute pyelonephritis and 18 of the 24 passing the stone spontaneously. Since most pregnant patients with urinary calculi pass the calculi spontaneously, the use of radiologic evaluation should be restricted to those patients in whom the pain and/or acute pyelonephritis do not settle with hydration and antibiotics. An excretory urogram with four to six films while delivering 0.4 to 1.6 rad to the maternal and fetal gonads will show the presence of a radiopaque calculus and upper tract dilatation. Renal ultrasonography delivers no radiation and will show upper tract dilatation but is not able to demonstrate calculi with great accuracy. The dilatation with a calculus in the upper urinary tract of a pregnant patient may not be due to the calculus since upper tract dilatation is a physiologic change associated with pregnancy. Evidence of persistent obstruction (pain, nonfunction) and/or infection caused by the calculus should be present before performing a procedure to remove the stone or divert the urine. In the past stone basket manipulation was used for calculi in the lower ureter and open surgery for removal of renal and upper ureteral stones. The newer techniques of percutaneous removal of renal and upper ureteral stones have replaced open surgery, and ureteroscopy is being used for ureteral stone removal. However, the pregnant uterus filling the
NUMBER 5
371
bony pelvis could prevent passage of the ureteroscope. With an upper urinary tract calculus and dilatation during pregnancy the upper tract dilatation can be due to the calculus or to the physiologic change associated with the pregnancy. The records of 24 pregnant patients with proved urinary calculi were reviewed. The calculus passed spontaneously in 18 patients (75 %), and procedures were required in 6 patients (25%) to remove the calculus. With an upper urinary tract calculus and dilatation during pregnancy the clinical findings of per-
372
UROLOGY
sistent pain and/or sepsis were the indications for intervention not the dilatation alone. 640 Jackson Street St. Paul, Minnesota 55101 (DR. CASS) References 1. Harris RE, and Dunnihoo DR: The incidence and significance of urinary calculi in pregnancy, Am J Obstet Gynecol 99: 237 (1967). 2. Strong DW, Murchison RJ, and Lynch DF: The management of ureteral calculi during pregnancy, Surg Gynecol Obstet 146: 604 (1978).
/
NOVEMBER
1986
i
VOLUME
XXVIII,
NUMBER
5