Along with this, the rate of stone disease among women and children is also on the rise. The management of stone disease in specific populations, such as in children and during pregnancy can present unique challenges to the urologist. In both populations, a multi-disciplinary approach is strongly recommended given the complexities of the patients. Prompt and accurate diagnosis requires a high degree of suspicion and judicious use of diagnostic imaging given the higher risks of radiation exposure. In general, management proceeds from conservative to more invasive approaches and must be individualized to the patient with careful consideration of the potential adverse effects.
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In case of excessive vomiting, bloody urine, and increasing infection, active surgical intervention may be required with the involvement of urologist, obstetrician, neonatologist, anesthetist, and radiologist. I am 39 wks pregnant with my 7th child and have been having flank pain on both right and left sides with nausea and vomiting. Lorelei Fray has been a medical writer since Some medications have been tested and are Kidney stone for pregnant women safe to continue throughout most of a pregnancy, while others are not. The normal population has Kidney stone for pregnant women greater percentage of calcium oxalate stones whereas pregnant women have calcium phosphate stones. Once the baby has been delivered and the mother has reverted to normal habits, further investigations can be carried out to assess her risk for another stone. Percutaneous axillary artery access for fenestrated… An upper extremity access UEA Womans vagina hymen necessary for complex endovascular aortic repairs, especially for branched and fenestrated endografts to successfully catheterize target vessels with a caudal orientation. Journal of General Internal Medicine. Russian babe escort Am Soc Nephrol. Please enter a valid email address. Best of luck, A nurse somewhere. There are a variety of factors that contribute to kidney stones, including: Fluid Intake Not consuming enough water will tend to promote urine that is highly concentrated with nutrients like calcium or phosphorus, dramatically increasing the risk for developing kidney stones. The most important thing for your daughter to do is to consult a high-risk pregnancy expert immediately developing a medication plan prior to conceiving is best, but since she's already pregnant she needs a consultation as soon as possibleas well as a psychiatrist who has experience with medications in pregnancy. Only the professional approach and the right therapy will help to support your health state and minimize danger.
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- Kidney stones are a painful condition for a relatively normal person.
- Along with the other challenges faced by women while they are pregnant, you can add the risk of developing a kidney stone.
- Lorelei Fray has been a medical writer since
Along with this, the rate of stone disease among women and children is also on the rise. The management of stone disease in specific populations, such as in children and during pregnancy can present unique challenges to the urologist.
In both populations, a multi-disciplinary approach is strongly recommended given the complexities of the patients. Prompt and accurate diagnosis requires a high degree of suspicion and judicious use of diagnostic imaging given the higher risks of radiation exposure. In general, management proceeds from conservative to more invasive approaches and must be individualized to the patient with careful consideration of the potential adverse effects.
However, innovations in endourologic equipment and techniques have allowed for the wider application of surgical stone treatment in these patients, and significant advancement in the field. This review covers the history and current advances in the diagnosis and management of stone disease in pregnant and pediatric populations. It is paramount for the urologist to understand the complexities of properly managing stones in these patients in order to maximize treatment efficacy, while minimizing complications and morbidity.
The incidence of kidney stone disease has been increasing worldwide over the past few decades. In Japan, the annual incidence of first-episode upper urinary tract stones increased from A similar increase has been shown in the United States, where the overall prevalence of kidney stones rose 3.
With stone disease becoming increasingly more common, it is important to understand the subtleties and implications of treating urolithiasis in special populations; this review will focus on the specific management of stone disease in pediatric and pregnant populations.
Recent evidence suggests that the incidence and prevalence of urinary stone disease are increasing substantially in the female population. In the United States, the overall prevalence of nephrolithiasis in women has increased at a rate of 1.
Overall, pregnant women are not at a higher risk of stone formation compared with non-pregnant women of similar age and demographics . However, the true incidence of urolithiasis during pregnancy remains largely unknown and reports in the literature vary widely from one out of every to 3 pregnancies  , . Literature reports that there has been no change in the incidence of stone disease among pregnant women over the past 2 decades . Although not common, urolithiasis during pregnancy represents a difficult clinical situation, which poses potential serious risks to both the mother and fetus, and requires careful diagnostic and management strategies.
Multiple changes occur in genitourinary anatomy and physiology throughout the course of pregnancy that may impact potential stone formation, including urinary stasis and changes to urinary lithogenic factors. The cause of collecting system dilatation during pregnancy is multi-factorial and includes elevated renal filtration, hormonal changes, and extrinsic compression from the gravid uterus.
However, extrinsic compression of the ureters by the uterus or ovarian vein plexus at the level of the pelvic brim is thought to be the most important contributing factor to gestational hydronephrosis . Typically, hydroureteronephrosis is greater on the right-side due to dextrorotation of the uterus and shielding of the left ureter by the sigmoid colon . In the majority of cases gestational hydronephrosis is asymptomatic and not associated with significant obstruction, however, in certain cases it can result in flank pain and even forniceal rupture.
Hydronephrosis during pregnancy results in urinary stasis and increases contact time with urinary lithogenic factors, which may increase the potential for crystallization and stone formation. Dilatation of the urinary tract may also allow for easier migration of stones from the kidney into the ureter, potentially explaining the observation that ureteric calculi are twice as common as renal calculi during pregnancy . Significant changes also occur to the urinary milieu during pregnancy.
Renal filtration increases along with the GFR, and results in a corresponding increase of multiple lithogenic constituents of the urine including calcium, oxalate, uric acid and sodium  , . In addition, hypercalciuria also results from the placental production of 1,dihydroxycholecalciferol 1,vit D , which causes increased gastrointestinal absorption and bone resorption of calcium, and suppresses parathyroid hormone levels  , .
All of these effects of placental 1,vit D act to increase filtration and decrease resorption of calcium by the kidney, thereby causing hypercalciuria.
In addition, many pregnant women may be taking additional calcium supplementation based on evidence that it significantly reduces the risk of pre-eclampsia, maternal morbidity and mortality, and preterm birth . While investigators have found a trend towards an increased risk of urolithiasis with calcium supplementation during pregnancy, it was not statistically significant . The benefits of calcium supplementation in pregnancy must be carefully balanced against the potential risks, especially in women at high risk of urolithiasis.
The increase in lithogenic factors during pregnancy is balanced by a similar increase in the excretion of urinary stone inhibitors such as citrate, magnesium, glycosaminoglycans, nephrocalcin, uromodulin and thiosulfate, all which inhibit crystal growth and aggregation .
Elevation of citrate levels in the urine not only directly inhibits stone formation, but also increases urinary pH thereby reducing the risk of calcium oxalate and uric acid stone formation . However, this alkalinization of the urine increases the likelihood of calcium phosphate stone formation.
Studies have demonstrated an increased incidence of calcium phosphate stones among pregnant women . The elevated GFR also increases urine volume, which further serves to decrease the risk of stone formation . The sum effect of these changes to urinary factors ultimately results in no overall difference to the risk of stone disease during pregnancy compared to non-pregnant women. The diagnosis of acute renal colic can be difficult during pregnancy due to the high prevalence of non-specific flank and abdominal pain, nausea and vomiting, lower urinary tract symptoms, and hematuria .
Elevated levels of progesterone can lead to nausea and vomiting, most commonly within the first trimester, but can be present throughout the entire pregnancy .
Patients less frequently present with complications of urolithiasis including urosepsis, premature labor, premature rupture of membranes, pregnancy loss, hypertension, or pre-eclampsia . All patients who present with symptoms suggestive of urinary stone disease should undergo a thorough history and physical exam. Initial laboratory investigations include a complete blood count, electrolytes, urea, creatinine, uric acid and calcium level, as well as a urinalysis and urine culture.
If a metabolic evaluation including 24 h urine studies is indicated based on the clinical presentation, then this should be delayed until completion of the pregnancy and weaning of breastfeeding, as the associated hormonal changes may significantly alter urine chemistries .
Diagnostic imaging is the cornerstone of investigating renal colic in pregnancy given the difficulty of making an accurate diagnosis based on history and physical examination alone.
Multiple imaging modalities including ultrasonography, X-ray examination of the kidneys, ureters, and bladder KUB , intravenous pyelogram IVP , computed tomography CT , and magnetic resonance urography MRU have been utilized. However, the need for an accurate and timely diagnosis must be carefully balanced with the potential risks of radiation exposure to the mother and fetus.
The risk of teratogenicity from radiation exposure to the fetus is dependent on gestational age at the time of exposure. Estimated fetal doses of radiation associated with maternal radiologic procedures . Ultrasound is the preferred initial diagnostic modality for evaluating pregnant patients with potential renal colic given that there is no ionizing radiation, it is safe to both the mother and fetus, and is easily obtained. A definitive diagnosis with ultrasound can be difficult secondary to the patient's body habitus, position of the fetus, or location of the calculi within the ureter.
In attempts to improve the diagnostic accuracy of ultrasonography a number of adjunct measurements have been utilized including urinary jets, endovaginal ultrasound, and resistive indices RI. The location of hydroureteronephrosis can be suggestive of acute obstruction; for instance, hydroureter distal to the iliac vessels or severe left hydroureteronephrosis can be indicative of pathologic obstruction .
The use of endovaginal ultrasound can assist in the detection of distal ureteric calculi and urinary jets, but is contraindicated in the presence of ruptured or prolapsed membranes . Doppler ultrasound with the measurement of RI has also been utilized to distinguish physiologic hydronephrosis from pathologic obstruction. An elevated RI of 0. Low-dose and ultra-low-dose CT protocols have been developed in order to minimize radiation exposure while maintaining a high sensitivity and specificity for the detection of urolithiasis.
A previous series examining low-dose CT scans in pregnancy confirmed very low radiation exposure of 7. Newer software may allow for further reductions in radiation dose and are currently under investigation. MRU, using a T2-weighted half-Fourier single-shot turbo-spin echo HASTE protocol, has emerged as a promising option for the diagnostic imaging of urolithiasis in pregnancy.
However, its utilization is limited by cost, availability, and the inability to be used in patients with metallic implants. Despite significant advances in diagnostic imaging, the accurate and safe diagnosis of urolithiasis in pregnancy remains challenging. The AUA recently released recommendations for imaging of renal colic in pregnancy based on the available published evidence .
While their recommendations are based mostly on lower-strength observational studies, ultrasound is recommended as the initial investigation of all pregnant women suspected of renal colic .
As a result of the complexities and potential complications associated with treating urolithiasis in pregnancy, a multidisciplinary approach with involvement of a urologist, obstetrician, radiologist, neonatologist, and possibly an anesthesiologist is highly recommended. In general, first line treatment for renal colic in pregnancy is expectant management. However, indications for acute intervention include active infection, obstructed solitary kidney or bilateral obstruction, unremitting pain or emesis, progressive renal obstruction, or signs of impending obstetrical complications such as pre-term labor and pre-eclampsia.
Ideally, surgical intervention is best preformed in the second trimester when the risk of miscarriage and pre-term labor is minimized . Options for acute intervention include temporizing measures with placement of an indwelling ureteral stent or external nephrostomy tube, or ureteroscopy.
Expectant management with a trial of spontaneous passage is the general first line treatment for ureteric calculi in the pregnant population. The higher rate of successful spontaneous passage has been attributed to the effects of progesterone, which result in smooth muscle relaxation and ureteral dilatation . Observation with serial ultrasounds is recommended throughout the duration of the pregnancy and once the patient has delivered routine management of the stone can be undertaken.
An important component of expectant management is aggressive fluid resuscitation and symptom control with analgesia and anti-emetics. Potential maternal or fetal adverse effects of medications administered during pregnancy must be carefully considered when managing this population.
While nonsteroidal anti-inflammatories are classically used for analgesia in renal colic, they are contraindicated in pregnancy due to the risk of premature closure of the patent ductus arteriosus and the association with fetal pulmonary hypertension .
Codeine has been shown to have teratogenic effects if administered in the first trimester . These medications are currently classed as a category B medication in pregnancy and thought to be safe with no harmful effects having been demonstrated in humans .
While this recent study is promising, more rigorous evidence is required before the use of MET in pregnancy can be widely adopted. When temporizing drainage is required, either an indwelling ureteral stent, or an external nephrostomy tube may be used.
Both drainage types have distinct advantages and disadvantages and the selection of drainage device ultimately depends on the clinical scenario, availability of resources, and surgeon and patient preference. Either drainage device can become infected, dislodged, blocked, or encrusted .
Numerous reports have demonstrated the accelerated encrustation of foreign bodies in the urinary tract during pregnancy secondary to the metabolic changes that occur. This necessitates the frequent exchange of either ureteric stents or nephrostomy tubes every 4—6 weeks . External nephrostomy tubes may be associated with flank discomfort and require additional care as there is an external tube.
Indwelling ureteric stents can cause lower urinary tract voiding symptoms, suprapubic and flank discomfort. While both stents and nephrostomy tubes can be inserted with minimal anesthesia under ultrasound guidance, stent insertion is typically performed under limited fluoroscopic guidance and therefore not ideal during the first trimester . Nephrostomy tube insertion results in rapid decompression of the collecting system, avoids ureteric manipulation, has a high success rate, and may be preferred in the setting of sepsis .
Recent evidence suggests that drainage with ureteric stents and nephrostomy tubes is equivalent in terms of patient outcomes . Temporary drainage and delaying of definitive stone management until the postpartum period were the mainstay of treatments for urolithiasis in pregnancy until the mid s. However, this treatment strategy is associated with many drawbacks including frequent tube changes and significant discomfort from the drainage tube.
Definitive surgical management with ureteroscopy is now an accepted alternative for patients who fail expectant management. Contraindications include active infection, large stone burden, multiple calculi, abnormal anatomy, obstetrical complications, or inadequate obstetric, urological or anesthetic resources . Given the higher teratogenic risks of anesthesia in the first trimester, ureteroscopy is reserved for the second and third trimesters of pregnancy . Ureteroscopy has been shown to be both feasible and safe during the second and third trimesters of pregnancy, with comparable stone-free rates to non-pregnant patients.
A meta-analysis has demonstrated no difference in the incidence of ureteric injury or urinary tract infection UTI in pregnant patients compared with non-pregnant patients .
Finally, a recent retrospective review found that ureteroscopy was associated with the least number of complications, compared with ureteric stent or nephrostomy tube drainage, for the treatment of ureteric calculi in pregnancy . Ureteroscopy may be performed under general, spinal or local anesthetic. The patient should be positioned in the lithotomy position with the right side of the abdomen elevated to avoid uterine compression of the inferior vena cava. Fetal monitoring should be performed during and after the procedure .
Minimal or no anesthesia may be used, and this procedure is usually successful. The upper urinary tract including kidneys and ureters become dilated due to compression from the uterus and the effects of hormones. I am 5 months pregnant and l just have a kidney stone on my rights side,what can l do to protect my baby? Unfortunately, the chance of the embryos implanting is relatively small in a 53 year old. Shockwave lithotripsy is not performed because of risks from the shockwaves on the developing fetus and percutaneous nephrolithotripsy is avoided because of the belly down position necessary for surgery.
Kidney stone for pregnant women. Health Information You Can Trust
Definitive treatment of the stones can usually be delayed until after delivery. Open surgery with general anesthesia to remove the stone, and shockwave therapy which to break up the stone, can usually be used in patients who are not pregnant. However, they are not considered to be safe during pregnancy because of risks to the fetus. Health Kidney Conditions Kidney Stone. By Lorelei Fray. Pregnant woman sitting on a bench. Conservative "Watch and Wait" Therapy. Stent or Tube Placement. Contraindicated Treatments.
Management of urinary calculi in pregnancy. Dec ;20 6 Urolithiasis in pregnancy. Diagnosis, management and pregnancy outcome. J Reprod Med. Nephrolithiasis and pregnancy. Curr Opin Urol. Share this article. The main task of every pregnant woman is to be able to listen to her own body, so she can quickly understand what is happening at the moment.
Kidney stones are not an exception. The faster you identify the symptoms, the earlier you will get the time to improve your health and to neutralize the possible dangers. Things you need to know about the functioning of kidneys during pregnancy if there are stones in them :. If you have even minor pain in the kidneys, you should not ignore this symptom in any case. When you have kidney stones, the pain is distinguished by its progressive nature, which means a significant daily increase in pain and severe attack of fever and cramps.
Apart from the fact that the pain is severe, yet it can be described as cramping. It encircles the first lumbar region, then gradually moves to ureters and can shoot up the genitals. During pregnancy, kidney pain can signal other diseases. In order to accurately identify the stones, you need to know other features of the disease in order to avoid misdiagnosis. It is also a true symptom of the disease. Stones can move spontaneously, thus destroying the integrity of the surrounding tissues.
This is due to the increase in hormone levels in a woman's body during pregnancy, when the muscles of the abdominal cavity, the renal pelvis and ureters are relaxed. Thus, the movement of stones is eventually triggered. Sand in kidneys is not less dangerous phenomenon, it is also able to irritate the mucous membranes of the body and thus cause blood in urine.
The escape of stones is always accompanied by tenderness, especially when urinating. Every time you will be troubled by cutting and acute pain. Apart from the above symptoms, at the acute stage of disease or neglecting, the temperature often rises. There are also fever, nausea, vomiting and flatulence.
If you suddenly feel that you have kidney pain during pregnancy, call a doctor immediately.
Kidney Stones in Pregnancy: Causes, Symptoms & Treatment
Kidney or ureter stones in pregnancy are a major health concern and are one of the most common causes for abdominal pain in pregnant women. Stones may lead to a blocked kidney, kidney infection which may spread to the whole body, and early labour which needs immediate hospital attendance and treatment for the expecting mother.
Kidney Ultrassound showing an obstructive stone arrow. Painful stones occur in 1 of pregnancies. Women who had previously delivered another child are more commonly affected than those expecting their first child. Most women with stones experience problems in the 4 th to 6 th months of pregnancy.
Diagnosis Ultrasound US is recommended to look for the causes of pain in pregnancy since it has no radiation and is harmless for the mother and the baby Fig. Generally, a computer tomography CT is used to find stones. However, in pregnancy this is avoided due to radiation which can harm the development of the baby. In special cases, a CT with a lower radiation dose can be used if ultrasound cannot provide a diagnosis.
At first, the pain will be controlled and fluids will be given through a needle in the arm veins because stone pain goes often along with nausea and vomiting leading to dehydration. The doctors will carefully evaluate which pain killers can safely be given without harming the baby.
If there are signs of infection, it may be necessary to start antibiotic treatment. The doctors will choose carefully an antibiotic which is safe for the developing baby. Surgical treatment Other than in non-pregnant patients, the surgical treatment of stones in pregnancy will be evaluated very carefully and only suggested by doctors when unavoidable to prevent further complications potentially dangerous for mother and child.
Surgical treatment may become necessary when pain is uncontrollable, when ongoing vomiting and fever endanger the pregnancy, or when the pregnancy is threatened by an early onset of labor. Women with a single kidney, with stones blocking both kidneys, or stones not likely to pass out spontaneously may be another group of patients needing surgical intervention.
When a kidney is blocked by a stone, it is important to open the outflow again to allow the kidney to function and not to get infected. This is usually done by the insertion of a thin plastic tube into the ureter the pipe connecting the kidney with the bladder which may bypass the stone and drain the kidney. Dependent on the duration of the remaining pregnancy, this may have to be changed once or a few times until the baby is delivered.
Then the stone can be treated. Another option can be to insert a tube through a little puncture in the flank into the blocked kidney. Generally, this is however not preferred by patients because of its inconvenience.
Nowadays, in women with stones but without infection, and being beyond the 3 th month of pregnancy, stones may be treated there and then by passing a small optical instrument URS through natural openings onto the stone and breaking it up with a laser fiber.
The doctor will discuss with the patient which one is the most suitable option in a particular case keeping the health and safety of mother and child as a paramount concern in mind.
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