Urinary Calculi in Pregnancy*

URINARY CALCULI IN PREGNANCY':' ERNEST

.M.

SOLO.:IION,

}l.D.,

\VINNETKA, ILL.

(From the DctJartment of Obstetrics and Gynecology, N orthwestcrn Unit·crsity Jlr dical School)

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HE occurrence of a ureteral calculus in a recent pregnant patient has stimulated a study of the general subject of urinary calculi in pregnancy. Established therapeutic routine is not well uefined and it is hoped to develop a more specific approach. The textbooks of obstetrics and gynecology and the literature in general reveal a paudty of information on this suhjcd and the English liteJ"atnre of the past twenty years contains only scattered references to this problem. Although the incidence of this complication of pregnancy is low, there is little information available for any physic·ian faced with this acute and often urgt•nt complication. Following a resume of the English literatme of the past twenty years, a survey was made of the obstetrical records of the Evanston Hospital Association for the past ten years to find similar cases and to re-evaluate this syndrome. Etiology '!'here arc several well-known theories of stone formation. These are not pertinent to this diseussion. However, it is well estahllshed ''that more than 85 per C'('nt of pregnant women have clemonstrahle changes in the ureteral tone and anatomic eharacter of the upper urinary iracL' ' 1 The sta~-;is thus produced, together with the resultant urinary tract infection, may lead to formation of calculi. The ineiclence of urinary tract infection in pregnancy varies in reported series "from as low as 0.6 per cent to as high as HS.:J per r·ent; the majority placing it between 1 and 2% per cent.' ' 3 In addition, pregnaney causes alterations in mineral metabolism and there may he responsible endocrine faetors; for instance, experimentally high doses of eRtrogen increase the incidence of calculus formation in miee. 1 'Yhy, therefore, is the ineidence so low in spite of these pregnancy faetors which would seem to invite ston(• formation? There are several possihlc answers: 1. The hlood calcium alll1 phosphorus are not changed remarkably in spite of definite changes in mineral requirements in pregnancy. 2. 'l'he average age at whieh m·inary calculi oecur is considerably higher than the avf't·age agf' of prl:'gmmt women. Inasmueh as time is t•nnsidered to he a fn<'tOJ' in stone fm·mation, this would weigh ng-ainst the more fi'Cf!Ucnt fol'matinn of ealeuli during the ehil
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:J. It is pt·obahly safe to say that tlw anmge JH'egnaney diet of today has a higher vitamin eon tent than the norJilal diet o [ women in general. 'l'his would seem to rnlP out the vitmnin fieien<·~- theory. -1-. '1'1H· physiological dilatation pro
5. Finally, :md most important, th(• stasis with or without infeetion in any one pt·egtHmc:' is wesnmahly of too shm·t n dnrLJtion to allow for calculus formation.

Incidence It is not usually possible to distinguish the ur·inary stone which antedated tlw gestation from one arquirrd in pt'<'l!'ll111H'Y· "'The latter class of ea.ses is proha hly gt·eater than thr Rtatisties Hhow sin<·e there is a C'onsiclerable group of patients in whom the stone is dis<·o\'PreOO in prcgna.ney, and Rtill a thirc1 2 reports nn inC'idenee of Zel'o inlG.OOO ohst<>tt·ie admissions. 'L'hr indc1rme in the white rae(• js t·epm·ted to be gr·eater than in the Negro." It is gTeater in multiparas than in p1'imiparm.;. 9 The same study reportR an an·ragc age of 28 years mHl a parity average of 3.8, with an average duration of gestation at the onset of s,\·mptoms of ~4 weeks. Urrtt'ral calculi were twice as Pommon as renal ealenli. From Nov. 1, 1940, to ::'-Joy, 1, 1~il0. t.h(•re wet·e 1:),484 obstetrical adtnissions to the Bvam;ton Hospital. not imlucling 1,207 a hortions. In theRe 1:3.484 patients thPre were 94 reC'orcleduriuary eomplications. not including hladder retPntion nt· trnnsieilt inahi1ity to void, nn inc-idence of 0.6 per cent. or one in every 14:3 easPs. Thi;; low figure does not aceount for patients treated at home an
Case Reports 'fhe six cases which occurred at the Bvanston Hospital and one at the Highland Park Hospital are briefly summari:r,el1 as follows:

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CASJC 1.-A 33-year-olll gravida iii, para ii, was allmitted when fonr and one-half montl1s pregnant with a diagnosis of stone in the left renal pelvis. She gave a history of a renal stone four ~"ears previously. An ilnmetliate 11ephrectomy was perfonned. 'l'hr postoperative result was goonnicrin
The patient, a CASE 7.-This patient was ueliverecl at the Highland Park HospitaL gmYi
Symptoms and Findings

The symptoms and findings in the order of freqneney, as listed hy Arnell and Getzoff,l are costovertebral pain and tenderness, abdominal pain and tenderness, fever, pyurin, hematuria. nam;ea and Ymniting, frequency of urinntion with dysuria, chills, ancl muscular spasm. This corresponds with th(' findings in our own patients. Comment Some authors state that the diagnosis is difficult. This is not Pnsy to ui1derstand. The Jiffere11tial diag11osis in pregnancy includes i11 the order of frequency: pyelitis, pyelonephritis, acute appendicitis, cholecystitis, a general gall bladder symptom-complex, and extrauterine pregnnncy. The identification of renal caleuli in pregnancy should not be difficult if the clinical features are kept in mind, and if proper diagnostic proeedures are instituted. Any patient with severe costovertebral pain and tenderness or severe abdominal pain and tenderness aceompanied by fever, nausea and vomiting, must be suspected of having a stone with assoeiated infection. If, in addition, the patient complains of urination with burning, ancl intt>rmittent

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chills, the urinary origin of the uisease process heeomes more apparent. U riue specimens must he examined fur pyuria aml helllaiuria and must lw obtained hy eatheter to haw eritieal diagnostil~ signifieall<'l'. Exploratory :-wout tilms aftt•J' suituhle preparation a1·e possible a]l(l inint\enous JI.Vl'lugr;tnts trl'Otomy is neeessary wlwn the uretentl ap]ll'oaeh fails. Ex]wetaut thempy at this time earri<•s the risk of serious eomplications at a later JWriud in preg·naJH·y when surgery is not. only mor·e difficult hut many tillles tnot'f' dangerous, Oth renal Y does not a tnf•liorate the srvrre symptoms and if tlw patit>nt has any <1c·gret' of ohstnwtion whieh is likely to eause permanent damage to the kidney, intrrf('rem·e h(•r•omt>s impe1·ative. The safest method and the one most likely to be suecesr;ful appem·s to he rvaenation of the uterus:' In Case 7, suecessful premature induction of lahnr was followed by spontaneous passage of the stone. A similar outcome oeentTed in the postpartum period in Case 2. Tn thP VVPJtt that this happy rPsult (10f's not follow within a reasonable period of timr, the urinm·;' 1r·ad, with the progTessi\'e daily involution of pregnaney ehangPs, will rapidly lH•~_·omc easily anc1 safely aecfssihle to cystoscopic or surgieal approach. The future health and longevity of the mother may rarely require the sacrifice of a previable baby.

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URINARY CALCULI IN PREGNANCY

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An interesting by-proJuct of this study was the confirmation that urinary tract infeetiou is no long-er a serious complication of pregnancy. 'l'his impro\'CllH:>nt is (lue to the use of elwmotherapy awl antibiotics. It was demonstrated further that too infrequrnt use is being malle of culture aml sensitivity tests in order that specific th(•rapy may he used. Our routine is to (•atheterize undPr aseptic conditions all patients with urinary complicatioHs aml send the specimens to the laburatu1·y fur cultm·e, organism identification, awl sensitivity tests with the usual sul fonamiLles and antibiotics. One need not wait for the laboratory report to initiate therapy hut it is essential to haYe a specific weapon available if the patient does not respond to what is of necessity at the outset hlind therapy. Summary 1. Althoug-h renal nnd ureteral colie does not constitute a common complieation of pregnancy, it occurs in some repor·ted series more often than in the nonpregnant woman of a similm· age group. :.l. Urinary calculus can be a formidable complication requiring the most careful consideration on the part of the obstetrician and consulting Ul'olugist. ~L The elinical features are classical and the diagnosis will not ht>
Conclusions 1. 'l'he inciJence of urinary calculi in pregnancy at the Evanston Hospital, from 1940 to 1950, was 0.04 per cent, or 1 in every 2,247 obstetric admissions. 2. The treatment of obstructing ureteral stone during the first trimester of pregnancy is removal by cystoscopic manipulation or surgery. ;j_ Obstructing ureteral stone in late pregnancy may require termination of the pregnancy in order to permit spontaneous passage of the stone. "When this does not occur manipulative or surgical removal has been made possible and safe.

I"OLOMON

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References 1. Arnell, R E., and uetzofi, P. L.: AM .. f. ()g;;•r. & tlYNr;c. 44: ::l.t, 10±2. 3. Balch, <1. F.: .r. Frol. 47: 705, l!!.t3 . .•. Crabtree, K U.: Urological ]Jiseases of l'regnaney, Boston, HJ4:l, Little, Brown & (~outpa.l~Y, ehaps. 5 HJtd. :!7. -L Prather, U. l_:.: ..f. Indiana ;\f. A. 30: il71, w::1. 5. LaJLp-Roi>erts, l!. 1'4.: l'lin .. 1. 56: !J, 11!:!7. il. .Jol;·, .r. A.: Urol. & ( !utan. Rev. 38: 1, l!J:!+. 7. Heineck, A. P.: A~t. .1. 0BHT. & (h:---E('. 6: 1!11, UJ:J:l. s. Prather,<:. C., and (!ralltret.', E. H.: [Trol. & Cutan. Rev. 38: 17, Hl34. !J. Everett, Houston K: Oynecologieal arHl Ol>stPtrical Urology, ed. :l, Baltimore, lH4'i, Williams & \Yilkins Company. to. ::\Ienl.fl'l't, William 1•'., and LPe, Han:v P.: A:~r. .T. Onm'. & GYNEC. 24: 805, 1032 . .Y!Ell](';\1. AK'l':S lll'l],J>INU

Discussion JJH. E. K. BLBWE'l"l', Austin, Texas.-llr. 1'\olomon has presented an excellent review of tltis rather rare eomplication of urolithiasis in pregnaney. In the treatment of this ('Olllplication, it. is wist~ to follu\1' the genPml didum to "treat the disease and ignore the pl'l'g'!ltlll('_\".

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rPhe HtaHageHH.'Ht n1u~t be inilividnalized and ('lose cooperation hetvveen the urolog-i~t ruul oh~tetrician i~ essential. We agree with ])r. ~ulomon that if the complicating ureteral or renal stone is asymptomatic antaille
In the pre.sl'li<'C of hlol'lCessan·. In the prP~enee of a ureteral stone t•ausing completf' hlockage, y meam; of a ureteral catheter passe estahliAhe
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In the case that I mentioned, the stone had to be removed by cystotomy later on. The urologist found it impossible to crush it, and operation had to be resorted to. DR. SOLO.:\ION (Closing).-I agree that it is possible to make a cystoscopic approach to the ureters any time in pregnancy, even at term. All urologists say, "Of course we can do it." They are all very unhappy when they are faced with the problem. This procedure is most often a failure, besides subjecting the patient to an enormous amount of discomfort and the ureters to a fair amount of trauma. We do agree that the pregnancy is of secondary importance, and it is merely a difference in philosophy as to how we approach the end result that the pregnancy is of secondary importance. I happen to belong to a school that believes that labor can be induced in any patient, almost without exception, with a proper approach.