The Renal Colic During Pregnancy

Published Date: 02 Nov 2017

Objective: To determine the problems related to renal colic due to urinary stones during pregnancy, and the principles of management of those patients in our hospitals.

Material and Methods: It’s a retrospective analysis of a series of 21 cases of renal colic due to urinary stones during pregnancy from Mar. 2008 to Apr. 2010 at Prince Rashid Ben Al-Hassan Military Hospital, Jordan. Presenting symptoms, diagnostic studies and management of renal stone were evaluated.

Results: There were 15824 deliveries during this period in our study. 21 of them had renal colic due to urinary stones during pregnancy; with an overall incidence in this series was 0.13%. Most of them were in third trimester of pregnancy followed by the second trimester and the least were in the first trimester. The most common complaints were flank pain (95.2 %), urinary symptoms (hematuria, dysuria and urgency) in 80.9%, nausea and vomiting in 14.3% and fever in 28.6 %. Spontaneous passing of stones was noted in 19 cases (90.5%) with conservative treatment. Two patients unresponsive or relapsing after medical treatment were treated surgically in urological department by double J stents insertion, but no maternal or fetal loss was noted.

Conclusion: Majority of renal colic due to urinary stones during pregnancy can be safely managed conservatively. The commonest presenting symptoms in our study were flank pain, urinary symptoms (hematuria, dysuria and urgency), and early surgical intervention resulted in safe maternal and fetal outcome.

Key words: Renal colic, urinary stones, pregnancy.

Introduction:

Pregnancy has been described as a test of renal function. Major anatomical and physiological changes affecting the entire urinary tract occur during pregnancy. Renal function dramatically alters with a 50% increase in renal blood flow and glomerular filtration rate, also increased circulating hormone levels and the pressure effects of the gravid uterus on the collecting system result in dilatation of the ureter, renal pelvis and calyx. All these alternations in urinary tract physiology and anatomic changes during pregnancy may affect the interpretation of renal function tests during pregnancy and make diagnosis and treatment a more challenging issue(1).

Generally though, renal colic due to urinary stones during pregnancy is a relatively uncommon occurrence during pregnancy. The prevalence of renal stone in pregnancy has been estimated at approximately 1 per 1500 women similar to the nongravid woman, with vast majority being asymptomatic and a chance finding(2). Urinary stones complicates 0.026–0.531% of pregnancies and presents an interesting challenge to the obstetrician, radiologist and urologist(3).

Renal colic can occur at any time during gestation but is most common in the second and third trimester as seen in this study, because enlarging gravid uterus increasing the symptoms of the calculus, as gestation progresses(4). In a pregnant woman with symptoms suggestive of urinary calculi, it is imperative to confirm the diagnosis as quickly as possible with the minimum of risk to the developing fetus. Renal colic can precipitate premature labor and delayed diagnosis and intervention can result in permanent renal impairment(5).

Recurrent renal colic are common complications of renal stones and represent the most common non-gynecological conditions requiring hospitalization and intervention in pregnant woman(6). However, the differential diagnosis of appendicitis, pyelonephritis and premature labor should be considered with the latter two often associated with stones(7).

The use of ultrasound may confirm the diagnosis in the majority of non-gravid patients, but diagnostic accuracy is reduced during pregnancy. As the imaging diagnosis of urolithiasis in pregnancy is further complicated by the physiologic and hemodynamic alterations in the maternal urinary tract. Ultrasound also has limitation in detecting ureteral calculi. Recent use of trans-vaginal ultrasound has improved the detection rate of calculi at the ureterovesical junction(8).

Over three-quarters of renal calculi presenting during pregnancy will pass spontaneously with conservative management comprising bed rest, hydration, analgesia and antibiotics where indicated. In cases where there is calculus causing obstruction of the urinary tract, relief of the obstruction has required minimally invasive techniques as cystoscopic stent placement and percutaneous stent insertion(9).

Our aims in this study were to determine the problems related to renal colic due to urinary stones during pregnancy, to report our experience in its management and its effect on fetus outcome and to found out the overall morbidity and mortality of the disease in our hospitals.

Materials and Methods:

This is a retrospective study at Prince Rashid Ben Al-Hassan Military Hospital from Mar. 2008 to Apr. 2010. All patients with renal colic due to urinary stones during pregnancy who were admitted to the gynecology and obstetrics department were enrolled in treatment protocol.

All diagnoses were made with a combination of medical history and physical examination, laboratory tests (such as WBC, Serum urea, creatinine, also urine analysis and culture was requested) and ultrasonography. All patients were initially managed conservatively. Conservative management varied according with the admission diagnosis. Patients unresponsive or relapsing after medical treatment were considered conservative treatment failures and were referred to urological department. Also surgical measures are reserved for patients with sepsis, intractable pain, and acute renal failure.

We collect data from their medical records on age, gravidity, parity, trimester of pregnancy, symptoms, signs, laboratory and radiological tests, postoperative complication, duration of hospital stay and fetal and maternal outcome. Operative reports were also reviewed.

The local ethics committee approved the protocol and all patients signed an informed consent prior to their inclusion in the present study.

Results:

There were 15824 deliveries during this period in our study. The age these patients ranged from 16 to 40 years. Of those, 21 women were admitted following diagnosis of renal colic due to urinary stones during pregnancy. The overall incidence of renal colic during pregnancy in this series was 0.13%. Most of them were in third trimester of pregnancy 57.1% (no=12) followed by the second trimester 28.6% (no=6) and the least were in the first trimester 14.3% (no=3).

The most common complaints were flank pain in 20 patients (95.2 %), urinary symptoms (hematuria, dysuria and urgency) in 17 women (80.9%), nausea and vomiting in 3 women (14.3%) and fever in 6 women (28.6 %) as shown in Table I. Physical examination of patients revealed that costovertebral angle tenderness was present in 12 patients (57.1%). Only 6 patients were febrile (28.6%) whereas leukocytosis more than 15.000/mm3 were found in 5 patients (23.8%), while abnormal kidney function tests was found in 2 patients (9.5%) and microscopic hematuria in 17 patients (80.9%). Sterile urine culture was seen in 5 patients (23.8%). Also all of these patients underwent renal ultrasound on admission and it was confirmed the diagnosis and visualized stones were obtained in 85.7 per cent of the cases (18 patients). Plain KUB film was done in 3 cases and stones could be seen in 2 cases (66.7%). Limited IVP was done in one case and the diagnosis could be done in all of them (100%). These are shown in table II.

The treatment of such patients requires a multidisciplinary team approach involving the urologist, obstetrician, and radiologist. The initial management should be conservative, consisting primarily of bed rest, adequate hydration with intravenous fluids, correction of electrolytes, and pain management with analgesia when required. Combining opioids with non-steroidal anti-inflammatory drugs (NSAIDs) is the optimal evidence-based regimen to treat severe symptoms.

Conservative medical management is recommended initially, especially during the first and third trimesters, in which surgical intervention may confer risk of abortion or premature labor, respectively. Conservative management varied according with the admission diagnosis, so patients with urinary tract infection also received broad spectrum antibiotics.

Spontaneous passing of stones was noted in 19 cases (90.5%) with conservative treatment. The remaining two patients (9.5%) unresponsive or relapsing after medical treatment were considered conservative treatment failures and were treated surgically during pregnancy in urological department by double J stents insertion. Mean hospitalization time was 4 days. Fetal distress was not evident in any of the patients, also there were no maternal and fetal losses noted.

Discussion

Our incidence of renal colic during pregnancy in this series was 0.13%, which is comparable to other studies(10,11). The most presenting symptoms include flank pain, urinary symptoms (hematuria, dysuria, and urgency), nausea, vomiting, but fever and tachycardia may not present during pregnancy, and also flank pain was the commonest symptoms (95.2%) in the present study, the classic presentation of acute renal colic is the sudden onset of very severe pain in the flank primarily caused by the acute ureteral obstruction as seen by study of Thomas A et al(12).

Recent studies have shown preponderance in the third trimester, with approximately 11.1 % of cases occurring during the first trimester, 33.3% during the second trimester, and 55.5 % during the third trimester(13). Also in our study 57.1 % of cases were seen during the third trimester, and rest during first and third trimester. This finding is probably explained by dilatation of the upper urinary tract start at 6 to 10 weeks of gestation and is present at about 90% of women by the third trimester. Also the alterations appear to be caused chiefly by hormonal and, to a lesser degree, by mechanical factors incidental to the pregnancy.

Conservative management is the first-line treatment for noncomplicated urolithiasis in pregnancy. A conservative approach is recommended if there is no hydronephrosis, sepsis or abnormal renal function, but in 9.5% of patients this form of treatment may prove to be inadequate and further intervention is required in the form of double J stents insertion(14). Also surgical measures are reserved for patients with sepsis, intractable pain, and acute renal failure or for patients who fail to respond to conservative management. In our study sixty sex patients (90.5%) completely recovered on conservative treatment, while two patients (9.5%) needed further intervention in the form of double J stents insertion. This result is quite comparable to other studies(15,16).

Glowacki et al.(17)reviewed 107 asymptomatic patients with renal calculi who received no treatment at the time of diagnosis, with a mean follow-up of 31.6 months; 31.8% became symptomatic during this period, 15% passed their stones spontaneously, whilst 8.4%, 5.6% and 2.8% required SWL, ureteroscopic extraction and percutaneous nephrolithotomy, respectively. These results support the prophylactic treatment of asymptomatic stones, to prevent later disabling episodes of pain and obstruction.

However, if the calculus does not pass, it may initiate premature labor, produce intractable pain, cause urosepsis in the setting of urinary tract infection, or interfere with the progression of normal labor(18). Management of renal colic in pregnancy poses a significant problem because premature labor may be induced, and invasive therapeutic procedures are potentially harmful to the fetus. Conservative temporal treatments are therefore usually recommended(19). In present study, there was no fetal loss and or premature delivery. Admittedly, the number of patients in the present study was too small to draw conclusions.

Conclusions:

Majority of renal colic due to urinary stones during pregnancy can be safely managed conservatively. Few patients who needed surgery can be managed safely during pregnancy. The commonest presenting symptoms in our study were flank pain, urinary symptoms (hematuria, dysuria and urgency), and early surgical intervention resulted in safe maternal and fetal outcome.