📃 Paper Title: Review on diagnosis and management of urolithiasis in pregnancy: an ESUT practical guide for urologists
🧍 Author: Bhaskar K Somani
🕒 Year: 2017
📚 Journal: World Journal of Urology
🌎 Country: UK
ㅤContext to the study:
Can you tell me about a study that reviews the current evidence on diagnosing and treating urinary stones in pregnancy?
ㅤ✅ Take-home message of study:
Urinary stones in pregnancy require careful multidisciplinary management to achieve good outcomes for both mother and baby.
ㅤ Non-systematic review of literature
ㅤ
Study participants:
Total included studies: 55
Inclusion criteria:
Studies reporting on diagnosis or management of pregnancy in humans
Studies published in English only
ㅤ
ㅤ
Key study outcomes:
Key messages on "Diagnosis":
The incidence and types of stones in pregnancy does not differ from the incidence and type of stones in non-pregnant women
75% pregnant women with stones are first time stone formers
The physiological dilatation of the urinary tract in pregnancy may make pregnant patients more likely to be symptomatic from stones compared to non-pregnant women
Increased eGFR in pregnancy may contribute to stone formation
Symptomatic stones in pregnancy are twice as likely to be in the ureter compared to the renal pelvis
Pain from urinary stones is one of the most common causes for abdominal pain requiring hospitalization in pregnancy, but can be misdiagnosed in 1/3rd of cases
Stone disease is associated with an increased risk of premature rupture of membranes (7 vs. 3%) and pre-term delivery (10.6 vs. 6.4%), but overall perinatal outcomes are not adversely affected
The use of ultrasound alone in diagnosis of stone disease in pregnancy can lead to high rates of negative ureteroscopy (up to 50%)
Low dose CT has a higher predictive value (96%) than MRI (80%) and USS (77%) for stone disease in pregnancy
Approximately 50% of pregnant patients with stones will suffer from UTI and will require antibiotics
Key messages on "Medical Management":
NSAIDS should be avoided in pregnancy due to increased risk of premature closure of ductus arteriosus in utero, oligohydramnios, early spontaneous abortion and cardiac malformations
Morphine sulphate can be used safely in small doses; codeine and oxycodone should be avoided in the first trimester due to possible teratogenic effects
First line antibiotic agents typically include penicillin and cephalosporins
Aminoglycosides (e.g. gentamicin), fluoroquinolones (e.g. ciprofloxacin) should be avoided in pregnancy due to adverse effects on the foetus
Nitrofurantoin - should be avoided in 3rd trimester due to risk of fetal anaemia
Trimethoprim - should be avoided in 1st trimester due to risk of neural tube defects (folate antagonist)
Conservative management is appropriate first line management for non-complicated cases of stone disease; spontaneous stone rate passages should not differ when compared to non-pregnant women
Key messages on "Surgical Management":
Clinical indications for urgent intervention relate to the same issues seen in non-pregnant patients: obstruction of solitary kidney; bilateral obstruction; impaired renal function; intractable symptoms; urinary sepsis
Eminent or established obstetric complications are further indications for intervention
Where decompression of urinary system is needed, the relative advantages and disadvantages of ureteric stenting and nephrostomy are not different in pregnant women compared to non-pregnant women
SWL is contraindicated in pregnancy due to associated risk of foetal death or malformations found in animal studies
Spontaneous miscarriage has been reported with SWL for lower ureteric stone
PCNL should be avoided in pregnancy because of need for general anaesthesia, fluoroscopy and specific positions of the patient making this more hazardous
Ureteroscopy is a safe and effective method of treatment for ureteral stones in pregnancy; previous studies have demonstrated no difference in stone free rates, complications, risk of UTI or ureteric injury when compared to non-pregnant patients
Non-urgent URS is best performed in the second trimester by an experienced endourologist at an institution with neonatal services and obstetrician oversight that can monitor the foetus and perform cesarean delivery
Fluoroscopy can be avoided in 80% of cases and passing a guidewire blindly is advocated in the majority of cases
If fluoroscopy is needed - use lowest possible dose settings, pulsed fluoroscopy, lead apron beneath patients' pelvis; use of lead shield directly over abdomen to shield foetus
Holmium laser appears safe in pregnancy, but ultrasonic lithotripsy should be avoided due to possible hearing damage to the embryo, lower stone free rates and risk of stone retropulsion
Ureteric stents have a high rate of encrustation in pregnancy, potentially due to hyper-excretion of calcium oxalate in the urine
Where no stent is left after URS or it was left for <48 hours, there may be an increased risk of ureteric colic or premature uterine contractions
Any ureteric stent should be left in situ for the minimum time required
In one study, the risk of pre-term labour with ureteroscopy has been estimated to be 4.3%, with no lost pregnancies (Johnson 2012; J Urology)
ㅤ
ㅤ
Study Limitations:
Included studies are typically based on small, retrospective series
ㅤ