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
- Editor-in-Chief emeritus
- 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).
- Stothers L, Lee LM. Renal colic in pregnancy. J Urol 1992; 148:1383.
- Butler EL, Cox SM, Eberts EG, Cunningham FG. Symptomatic nephrolithiasis complicating pregnancy. Obstet Gynecol 2000; 96:753.
- Curhan GC, Willett WC, Knight EL, Stampfer MJ. Dietary factors and the risk of incident kidney stones in younger women: Nurses' Health Study II. Arch Intern Med 2004; 164:885.
- Maikranz P, Holley JL, Parks JH, et al. Gestational hypercalciuria causes pathological urine calcium oxalate supersaturations. Kidney Int 1989; 36:108.
- Ross AE, Handa S, Lingeman JE, Matlaga BR. Kidney stones during pregnancy: an investigation into stone composition. Urol Res 2008; 36:99.
- Boridy IC, Maklad N, Sandler CM. Suspected urolithiasis in pregnant women: imaging algorithm and literature review. AJR Am J Roentgenol 1996; 167:869.
- Laing FC, Benson CB, DiSalvo DN, et al. Distal ureteral calculi: detection with vaginal US. Radiology 1994; 192:545.
- Elgamasy A, Elsherif A. Use of Doppler ultrasonography and rigid ureteroscopy for managing symptomatic ureteric stones during pregnancy. BJU Int 2010; 106:262.
- Shokeir AA, Mahran MR, Abdulmaaboud M. Renal colic in pregnant women: role of renal resistive index. Urology 2000; 55:344.
- White WM, Zite NB, Gash J, et al. Low-dose computed tomography for the evaluation of flank pain in the pregnant population. J Endourol 2007; 21:1255.
- White WM, Johnson EB, Zite NB, et al. Predictive value of current imaging modalities for the detection of urolithiasis during pregnancy: a multicenter, longitudinal study. J Urol 2013; 189:931.
- Fulgham PF, Assimos DG, Pearle MS, Preminger GM. Clinical effectiveness protocols for imaging in the management of ureteral calculous disease: AUA technology assessment. J Urol 2013; 189:1203.
- Bailey G, Vaughan L, Rose C, Krambeck A. Perinatal Outcomes with Tamsulosin Therapy for Symptomatic Urolithiasis. J Urol 2016; 195:99.
- Scarpa RM, De Lisa A, Usai E. Diagnosis and treatment of ureteral calculi during pregnancy with rigid ureteroscopes. J Urol 1996; 155:875.
- McAleer SJ, Loughlin KR. Nephrolithiasis and pregnancy. Curr Opin Urol 2004; 14:123.
- Parulkar BG, Hopkins TB, Wollin MR, et al. Renal colic during pregnancy: a case for conservative treatment. J Urol 1998; 159:365.
- Cocuzza M, Colombo JR Jr, Lopes RI, et al. Use of inverted fluoroscope's C-arm during endoscopic treatment of urinary tract obstruction in pregnancy: a practicable solution to cut radiation. Urology 2010; 75:1505.
- Asgari MA, Safarinejad MR, Hosseini SY, Dadkhah F. Extracorporeal shock wave lithotripsy of renal calculi during early pregnancy. BJU Int 1999; 84:615.
- Deliveliotis CH, Argyropoulos B, Chrisofos M, Dimopoulos CA. Shockwave lithotripsy in unrecognized pregnancy: interruption or continuation? J Endourol 2001; 15:787.
- Semins MJ, Trock BJ, Matlaga BR. The safety of ureteroscopy during pregnancy: a systematic review and meta-analysis. J Urol 2009; 181:139.
- Watterson JD, Girvan AR, Beiko DT, et al. Ureteroscopy and holmium:YAG laser lithotripsy: an emerging definitive management strategy for symptomatic ureteral calculi in pregnancy. Urology 2002; 60:383.