Editing Stones During Pregnancy (section)

== Management ==

=== Options ===
*'''<span style="color:#ff0000">First-line: observation</span>'''
*'''<span style="color:#ff0000">Second-line: intervention</span>'''
**'''<span style="color:#ff0000">Pharmacological (1):</span>''' 
**#'''<span style="color:#ff0000">Medical expulsive therapy (MET)</span>'''
**'''<span style="color:#ff0000">Surgical (2):</span>''' 
**#'''<span style="color:#ff0000">Ureteral stent or percutaneous nephrostomy tube</span>'''
**#'''<span style="color:#ff0000">Ureteroscopy</span>'''

==== Observation (first-line) ====
*'''<span style="color:#ff0000">Observation is the first-line management strategy in pregnant patients and well controlled symptoms</span>'''
**50-80% of pregnant patients with symptomatic calculi will pass their stones spontaneously
**A stone event in pregnancy is associated with an increased risk of maternal and fetal morbidity, so patients should be followed closely for recurrent or persistent symptoms.

==== Intervention (second-line) ====
*'''<span style="color:#ff0000">Pharmacological and surgical intervention should be coordinated with the obstetrician</span>'''

===== Pharmacological</span> =====
*'''<span style="color:#ff0000">Should MET be considered for the pregnant patient, patient should be counseled that MET has not been investigated in the pregnant population, and the medication is being used for an “off-label” purpose.</span>'''
*'''<span style="color:#ff0000">NSAIDs (e.g., ketorolac) are contraindicated in pregnancy</span>'''

===== Surgical</span> =====
* '''<span style="color:#ff0000">Ureteral stent or percutaneous nephrostomy tube</span>'''
** <span style="color:#ff0000">'''Disadvantages''':</span>
**# '''<span style="color:#ff0000">Increased risk of stent encrustation/migration</span>'''
**#* '''<span style="color:#ff0000">Ureteral stents placed in pregnant women should be exchanged every 4 to 6 weeks.</span>'''
**#** For a woman in an early gestational stage, multiple stent changes will be required over the course of the pregnancy.
**# '''Increased risk for bacteriuria and UTI'''
**# '''Stent pain, which can have a negative impact on a patient’s quality of life'''
*** Many of the same limitations that apply to ureteral stents also apply to nephrostomy tubes in that ≈50% of patients will require exchanges, replacements, or flushing because of dislodgement or obstruction
* '''<span style="color:#ff0000">Ureteroscopy</span>'''
** '''<span style="color:#ff0000">Methods to minimize radiation exposure in a pregnant patient (4):</span>'''
**# '''<span style="color:#ff0000">Low dosed and pulsed fluoroscopy</span>'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]
**# '''<span style="color:#ff0000">Collimating to the minimum required visual fluoroscopy field'''
**# '''<span style="color:#ff0000">Using the last image hold feature</span>'''
**#* Has been shown to reduce radiation exposure by reducing the number of repetitive images.
**# '''<span style="color:#ff0000">Below-table x-ray source</span>'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]
**#* The uterus is located superior and anterior aspect of the pelvis during the pregnancy
**#* X-ray beams that project in a posterior to anterior (PA) direction contribute to less radiation than the beam projected in anterior to posterior (AP) direction because, in PA projection, the X-ray gets attenuated before reaching anteriorly located uterus
**#** In the unpregnant- patient, '''positioning the radiation source of the C-arm under the operating table reduces exposure to the surgeon by reducing scatter radiation but does not change patient exposure.'''
**#*** '''Scattering of the primary beam from the patient is the primary source of radiation exposure to the operator during endourologic procedures.'''
**#**** Maximizing the distance between the operator and the patient during fluoroscopy is a very effective method of reducing exposure.
**# '''<span style="color:#ff0000">X-ray source further away from patient</span>'''
**#* '''Reduces exposure to fetus but increases scatter to physician'''
**# '''<span style="color:#ff0000">Lead apron placed below the patient's pelvis to shield the fetus</span>'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]
** '''American College of Obstetricians and Gynecologists (ACOG) guidelines recommend that <span style="color:#ff0000">any nonurgent surgeries, such as URS, should be performed in the second trimester of pregnancy</span> to minimize the risk of preterm contractions and spontaneous abortion[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]'''