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Pregnancy and Urolithiasis Workup

  • Author: Robert O Wayment, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Apr 17, 2015
 

Laboratory Studies

Laboratory studies in pregnant patients with possible urolithiasis include the following:

  • Urinalysis -To assess for microscopic hematuria
  • Serum chemistry studies, including a renal panel
  • Urine culture - To identify the offending bacteria and determine antibiotic sensitivities
  • Complete blood cell (CBC) count - To determine the presence or absence of systemic infection
  • Metabolic studies - To guide stone prevention

Urinalysis

Consider the following:

  • The presence of red blood cells may suggest a calculus
  • Using both dipstick and microscopic analysis can identify microscopic hematuria in 95% of patients with urinary stones
  • Pyuria, which can result from an inflammatory reaction to a stone or infection, mandates evaluation of a coexisting urinary tract infection. Urinary tract infection is present in approximately 31% [7]
  • Urine pH greater than 7 may signal the presence of infected stones (magnesium-ammonium-phosphate) with urea-splitting organisms (eg, Proteus and Klebsiella species)
  • Acidic urine (pH < 5) suggests the presence of a uric acid stone

Renal panel

Decreased serum bicarbonate and potassium levels suggest an underlying renal tubular acidosis that may result in the formation of calcium phosphate stones. Elevated serum calcium levels might suggest possible primary or secondary hyperparathyroidism. Hyperuricemia suggests possible gouty diathesis and hyperuricosuria, which can increase the risk for both uric acid and calcium stone formation.

Elevated serum creatinine levels suggest azotemia due to ureteral obstruction or chronic renal insufficiency. The physiologic increase in glomerular filtration rate (GFR) during pregnancy dictates that the serum creatinine and BUN levels should be nearly 25% less than levels in the nonpregnant patient.[17]

Metabolic studies

For patients with a sincere interest in reducing their risk of developing additional urinary stones, a 24-hour urine collection for stone prevention analysis is recommended. However, because of the physiologic and electrolytic changes associated with pregnancy, metabolic studies should be postponed until completion of pregnancy. Patients undergoing metabolic analysis studies should be willing to make long-term changes in their diet or lifestyle and take medications and/or supplements to help reduce their risk of new stone formation.

The metabolic evaluation should include, as a minimum, a 24-hour urine collection and determination of total volume and sodium, oxalate, citrate, uric acid, calcium, phosphate, and magnesium. Various commercial programs are available from laboratories such as Mission Pharmacal, LabCorp, Litholink, Dianon Systems, Nichols, and UroCor. All of these provide accurate and reliable results from the 24-hour urine collections.

The cornerstone of the metabolic evaluation is the stone analysis. All patients should be encouraged to strain urine until the stone passes or repeat imaging is performed.

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Imaging Studies

Radiologic diagnosis of urolithiasis in pregnant patients is complicated by the physiologic and hemodynamic changes of pregnancy, such as increased renal blood flow (RBF) and GFR, in addition to the concern for fetal radiation exposure. Delay in diagnosis or inappropriate therapy may risk maternal renal damage, premature labor, spontaneous abortion, pyonephrosis, and/or maternal hypertension. Tailor the diagnostic evaluation and management of the gravid patient to the individual.[18]

The use of ionizing radiation during pregnancy is a complicated and controversial issue. Radiographic studies should be used judiciously and avoided when possible, particularly during the first trimester. The guidelines available from the American College of Obstetricians and Gynecologists (ACOG) state, “concern about possible effects of high-dose ionizing radiation exposure should not prevent medically indicated diagnostic x-ray procedures from being performed on a pregnant woman. During pregnancy, other imaging procedures not associated with ionizing radiation (eg, ultrasonography, MRI) should be considered instead of x-rays when appropriate.” Concerning fetal dosages of radiation, ACOG states that “....less than 5 rads (5000 millirad [mrd]) has not been associated with an increase in fetal abnormalities or pregnancy loss.”[19]

Srirangam et al (2008) reported average fetal radiation doses for common diagnostic procedures used in the workup of urolithiasis in pregnancy, as follows:[20]

  • Ultrasonography - None
  • MRI (< 1.5 T) - None
  • KUB, 1.4 milligray (mGy) - 140 mrd
  • Intravenous urography, 1.7 mGy - 170 mrd
  • Renal tract CT scanning, 80 mGy - 800 mrd
  • Technetium Tc 99m renal scan (mercaptoacetyltriglycine [MAG-3] or diethylenetriaminepentaacetic acid [DTPA]), 0.2 mGy - 20 mrd

Renal ultrasonography, with or without Doppler studies, is recommended as the primary imaging modality in pregnant women. In the event that ultrasonography findings are equivocal and clinical symptoms strongly suggest renal calculi, a limited IVP with reduced films and radiation exposure may be performed. If the ultrasonography and limited IVP test findings are unclear, additional tests or procedures may be indicated, depending on the clinical scenario. However, when indicated, many suggest proceeding directly to ureteroscopy for diagnosis and treatment, especially in the first and second trimesters.[21, 22, 23] Radiation exposure in the third trimester is less of a risk to the fetus.

Ultrasonography

Renal ultrasonography is the first-line screening tool for urolithiasis in pregnant patients. Stothers and Lee (1992) found that renal ultrasonography provided a sensitivity of 34% and specificity of 86%,[7] yet Parulkar et al (1998) reported 95% and 87%,[6] respectively. The sonogram may not actually show the stone.

However, false-positive results may occur in the setting of extrarenal pelvis, vesicoureteral reflux, a high urine-flow rate, parapelvic cysts, and crossing vessels within the renal sinus. Up to 35% of patients with documented acute ureteral obstruction may not demonstrate any significant hydronephrosis, which makes standard ultrasonography less useful. Furthermore, differentiating hydronephrosis caused by an obstructing calculus due to physiologic dilation of pregnancy may be difficult.

Advantages of renal ultrasonography include avoidance of radiation exposure to the fetus, no pain, avoidance of proallergenic intravenous contrast material, and the ability to examine coexisting abdominal or pelvic disease etiologies.

Vaginal ultrasonography

This has been found valuable in revealing stones in the distal ureter that are not visualized with renal ultrasonography. Laing et al (1994) reported that distal ureteral stones were identified in 13 of 13 patients; renal ultrasonography revealed the distal stones in only 15% of the 13 patients. Laing et al also observed that patients tolerated the procedure well.[24] Loughlin and Ker (2002) endorse the use of a transrectal ultrasonography probe if a vaginal transducer is unavailable.[25]

Renal ultrasonography with Doppler sonography

In contrast to standard renal ultrasonography, ultrasonography with Doppler studies enables recording of waveform tracings of the renal vasculature. Ureteric obstruction increases renal vascular resistance, resulting in a reduction of diastolic blood flow and a rise in renal resistance. Based on waveform tracings, a resistive index (RI) value is calculated (RI = peak systolic velocity - peak diastolic velocity / peak systolic velocity), providing improved sensitivity and specificity for differentiating obstructed from nonobstructed dilated collecting systems. An elevated RI value of greater than 0.70 is specific for ureteral obstruction. Alternatively, a difference in the RI of 0.04 or more between the affected and contralateral kidney also suggests an obstruction in the side with the higher RI value.

Shokeir and Abdulmaaboud (1999) also evaluated the change in RI, which showed increased sensitivity (88%) and specificity (98%) in diagnosing ureteral obstruction.[26]

Color Doppler renal sonography is a new addition to sonographic visualization of calculi, with a reported sensitivity of 100% and a specificity of 91% for diagnosing ureteral obstruction. This important study demonstrates the presence of ureteral jets (streams of densely opacified urine) flowing into the bladder (containing dilute nonopacified urine). The absence of these jets may suggest ureteral obstruction, while symmetric jets indicate the absence of obstruction. In addition, color Doppler studies also aid in differentiating iliac vessels from a dilated ureter.

Equivocal sonographic results that do not suggest either physiologic hydronephrosis of pregnancy or urolithiasis require further imaging with limited excretory urography.

Summary

Disadvantages of renal sonography include the following:

  • Suboptimal determination of the level of obstruction
  • Difficulty in showing the ureters and intraureteral calculi
  • Possible difficulty differentiating physiologic hydronephrosis of pregnancy from acute obstructive hydronephrosis
  • Unable (in most cases) to determine the size or shape of the urinary calculi
  • Difficulty visualizing calculi obscured by overlying bony structures, fetal skeleton, or fecal material
  • Operator dependent

Disadvantages of renal sonography with color Doppler include the following:

  • Relies on elevated urine output and density differences between urine in the bladder and urine existing within the ureter
  • Degree of asymmetry of the ureteral jets unaltered from reference range because of calculi causing low-grade or no obstruction
  • Operator dependent

Normal findings on renal sonography are consistent with the following results:

  • Degree of renal and ureteral dilation consistent with pregnancy
  • RI value of less than 0.70 in both kidneys
  • Symmetric ureteral jets
  • No specific calculus identified

The following results indicate a high probability of urolithiasis during pregnancy:

  • Greater degree of dilatation disproportionate to hydronephrosis of pregnancy in collecting system
  • RI value greater than 0.70 in the symptomatic kidney or change in RI greater than 0.60 [26]
  • Dilated ureter extending below the level of the iliac arteries
  • Asymmetry of ureteral jets
  • Identification of calculus

Excretory urography

Excretory urography remains an important diagnostic modality for stone detection in nonpregnant women, allowing the investigator to accomplish the following:

  • Establish the presence of an obstruction
  • Locate and determine the size of the offending calculus
  • Estimate renal function
  • Identify anatomic abnormalities that may alter the treatment algorithm
  • Detect altered renal physiology secondary to obstruction

Intravenous urography (IVU or IVP) consists of initial abdominal radiography of the kidneys, ureters, and bladder (KUB) followed by a second radiograph obtained 20-30 minutes after the intravenous injection of a contrast medium. The initial KUB radiograph exposes the fetus to 0.002 Gy; however, because the standard IVU necessitates four or five films, the patient may be exposed to a total of 0.004-0.01 Gy. The dose of radiation during IVU has been reported to be safe to the fetus during the second and third trimesters.

Limited IVP, however, has been shown to successfully reveal calculi without the high radiation dose of full IVP. Stothers and Lee (1992) recommend a scout film, a 30-second film, and a 20-minute film. They report successful visualization of 16 of 17 stones in pregnant patients who presented with acute renal colic.[7] See the image below.

The arrow in this intravenous pyelogram of a gravi The arrow in this intravenous pyelogram of a gravid female indicates a filling defect at the ureterovesical junction. This finding is most likely consistent with a ureteral stone (distal).

Indications for excretory urography in a pregnant patient may include the following:

  • Sonography results that are equivocal for pregnancy dilatation or urolithiasis
  • Azotemia suggestive of postrenal obstruction
  • Persistent fever or persistent positive finding on urine culture despite 48 hours of parenteral antibiotic treatment
  • Massive hydronephrosis on abdominal ultrasonography

Disadvantages of IVU include the following:

  • Risk of intravenous contrast allergy in the mother and fetus
  • Risk of radiation exposure to the mother and fetus
  • Possible ambiguous differentiation between delayed excretion of contrast material from calculus obstruction and pathologic hydronephrosis, especially in the third trimester
  • Small ureteral calculi obscured by enlarged uterus during IVU studies, especially in the third trimester

Magnetic resonance imaging

MRI provides high-quality images of the kidneys and urinary tract with obstruction and is used by some as second line to ultrasonography. Considerations are as follows:

  • MRI visualizes stones poorly; it cannot demonstrate the actual stone, only the point of obstruction
  • MRI does provide a benefit in its ability to reveal non–urinary-tract pathology that may manifest with similar symptoms (ie, ovarian torsion, appendicitis) [20]
  • Using T2-weighted imaging, MRI urography can be used to differentiate a physiological upper tract dilatation from a pathologic ureterohydronephrosis during pregnancy and to ascertain whether the obstruction is intrinsic or extrinsic
  • MRI does not use ionizing radiation or iodinated contrast, but its use during the first trimester is not recommended because the effect of MRI on fetal development is not clear
  • MRI is expensive, uncomfortable for the pregnant patient, and often unavailable

Nuclear renal scan

Nuclear renal scan using technetium Tc 99m DTPA is an excellent study for objectively establishing the differential renal function and the efficiency of drainage of the dilated collecting system (washout times). DTPA is cleared almost exclusively by glomerular filtration. The rate of clearance provides an excellent estimate of GFR. However, nuclear studies do not allow visualization of stones and provide very limited illustration of anatomy. Differing opinions exist on its utility in the diagnosis of urolithiasis in pregnancy.[4, 17]

Interpretation is as follows:

  • A drainage half-time of 20 minutes or more indicates obstruction, whereas a drainage half-time of 10 minutes or less indicates nonobstruction
  • Washout or drainage half-times of 10-20 minutes are considered indeterminate

Computed tomography

Unenhanced helical CT scanning is reported to be highly sensitive (96-97%) and specific (96-99%) and has become the criterion standard in the diagnosis of urinary calculi. It is also effective in differentiating calculi from tumors or blood clots.

Despite these benefits, this study has traditionally been avoided in pregnant patients. Recently, White et al (2007) reported on the use of low-dose CT scanning in pregnant patients with suspected urinary calculi, with an average radiation dose of only 705.5 mrd. They assert that this offers an acceptable degree of risk, and they advocate its use in the setting of refractory flank pain and inconclusive ultrasonographic results in pregnant patients.[27] However, the use of CT scanning, or any study that involves radiation, should be avoided when possible, and patients should be counseled appropriately.

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Procedures

Ureteroscopy has emerged as a safe and efficient way to treat urolithiasis during pregnancy.[21] Ulvik and associates (1995) have used ureteroscopy to successfully treat urolithiasis and consider it as a diagnostic procedure in difficult cases.[23] Rigid or flexible ureteroscopes may be used, but Ulvik et al feel that flexible scopes may be better suited in diagnosis during pregnancy.

Rittenberg and Bagley reported the use of ureteroscopy for diagnosis with local anesthesia alone in 1988.[28] Currently available ureteroscopes are small and may be used with minimal or no anesthesia.[21, 29] Lemos and coworkers (2002) feel that ureteroscopy used solely for diagnosis may be aggressive but agree that it can be used as a single modality for diagnosis and removal of ureteral calculi in pregnancy.[22] Ureteroscopy offers clear-cut diagnosis, with direct visualization, as well as definitive therapy in the same encounter.

Retrograde pyelography

This can successfully reveal ureteral stones in cases with ambiguous sonography and IVU results. However, this study is performed only during stent placement because of the invasiveness of the examination, possible introduction of bacteria and risk of sepsis, and the need for radiation, sedation, and cystoscopy. Routine retrograde pyelography is not recommended for documentation of ureteral calculi in pregnant patients.

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Contributor Information and Disclosures
Author

Robert O Wayment, MD Urologist, Ogden Clinic Urology

Robert O Wayment, MD is a member of the following medical societies: American Urological Association, Western Section of the American Urological Association, Utah Urological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN is a member of the following medical societies: American Association for the Advancement of Science, International Society of Nephrology, American Society for Biochemistry and Molecular Biology, American Federation for Medical Research, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, Kentucky Medical Association, National Kidney Foundation, Phi Beta Kappa

Disclosure: Received grant/research funds from Dept of Veterans Affairs for research; Received salary from American Society of Nephrology for asn council position; Received salary from University of Louisville for employment; Received salary from University of Louisville Physicians for employment; Received contract payment from American Physician Institute for Advanced Professional Studies, LLC for independent contractor; Received contract payment from Healthcare Quality Strategies, Inc for independent cont.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Acknowledgements

Jeffrey B Garris, MD Chief, Assistant Professor, Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Tulane University School of Medicine

Jeffrey B Garris, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, American Urological Association, Association of Professors of Gynecology and Obstetrics, Louisiana State Medical Society, Royal Society of Medicine, and Sigma Xi

Disclosure: Nothing to disclose.

Rajesh Prasad, MD Staff Physician, Department of Surgery, Division of Urology, University of Cincinnati Medical Center

Disclosure: Nothing to disclose.

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The arrow in this intravenous pyelogram of a gravid female indicates a filling defect at the ureterovesical junction. This finding is most likely consistent with a ureteral stone (distal).
 
 
 
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