Nephrolithiasis during pregnancy
- Glenn M Preminger, MD
Glenn M Preminger, MD
- Section Editor — Renal Ureteral Stones
- Professor of Urologic Surgery
- Duke University Medical Center
- Director of Education
- Endourological Society
- Gary C Curhan, MD, ScD
Gary C Curhan, MD, ScD
- Section Editor — Chronic Kidney Disease
- Professor of Medicine
- Harvard Medical School
- Section Editors
- Stanley Goldfarb, MD
Stanley Goldfarb, MD
- Editor-in-Chief — Nephrology
- Section Editor — Mineral and Bone Metabolism; Renal Ureteral Stones
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
The development of a symptomatic stone during pregnancy is a rare event, occurring in about one in every 1500 to 3000 pregnancies [1,2]. This rate is similar to nonpregnant women of child-bearing age .
Affected patients usually present in the second or third trimester (approximately 20 percent in the first trimester) with acute flank pain (90 percent), which often radiates to the groin or lower abdomen. Hematuria is present in 75 to 95 percent, one-third of whom have gross hematuria, and approximately 40 percent will have pyuria [1,2].
Most of these women do not have a prior history of stone disease . However, it is not clear whether such women have a preexisting stone, an underlying tendency to stone formation, or whether factors related to pregnancy are responsible. Normal pregnancy is associated with a mild increase in urine calcium excretion (243 versus 194 mg/day in one series), lesser increases in urine citrate and magnesium excretion (which protect against stone formation), and a rise in urine pH but not urine volume . The urine supersaturation for calcium oxalate is similar to that in nonpregnant women with calcium stones. Additional factors that contribute to stone formation during pregnancy may include urinary stasis, secondary to increased progesterone levels and diminished fluid intake during late pregnancy, as a result of decreasing bladder capacity from the gravid uterus. Most stones appear to be predominantly composed of calcium phosphate .
Renal and pelvic ultrasound should be performed when an obstructing calculus is suspected . This modality avoids exposure to radiation and is useful for detecting secondary signs of obstruction, such as hydronephrosis or hydroureter (image 1). However, physiological hydronephrosis of pregnancy must be distinguished from pathological hydronephrosis from obstruction (image 2). (See "Renal and urinary tract physiology in normal pregnancy".) Rarely, pelvic ultrasound may identify a stone obstructing the distal ureter (image 3) .
The ability of ultrasonography and other imaging modalities to detect nephrolithiasis was retrospectively evaluated in a study of 57 pregnant women with 73 admissions for symptomatic nephrolithiasis . When performed as the initial examination, renal ultrasonography detected calculi in 21 of 35 cases (60 percent sensitivity).
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