Stones During Pregnancy: Difference between revisions

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== Management ==

* '''First-line: observation in pregnant patients and well controlled symptoms'''

=== Options ===

*'''First-line: observation'''

*'''Second-line: intervention'''

**'''Pharmacological (1):'''

**#'''Medical expulsive therapy (MET)'''

**'''Surgical (2):'''

**#'''Ureteral stent or percutaneous nephrostomy tube'''

**#'''Ureteroscopy'''

==== Observation (first-line) ====

*'''Observation is the first-line management strategy in pregnant patients and well controlled symptoms'''

**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.

*'''Second~~-line~~:'''

**'''Pharmacological and surgical intervention should be coordinated with the obstetrician'''

==== Intervention (second-line) ====

***'''~~Pharmacological~~'''

*'''Pharmacological and surgical intervention should be coordinated with the obstetrician'''

~~***~~*'''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.'''

~~***~~*'''NSAIDs (e.g., ketorolac) are contraindicated in pregnancy'''

===== Pharmacological =====

***'''~~Surgical~~'''

*'''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.'''

~~***~~* '''Ureteral stent or percutaneous nephrostomy tube'''

*'''NSAIDs (e.g., ketorolac) are contraindicated in pregnancy'''

~~***~~** '''Disadvantages''':

~~***~~**# '''Increased risk of stent encrustation/migration'''

===== Surgical =====

~~***~~**#* '''Ureteral stents placed in pregnant women should be exchanged every 4 to 6 weeks.'''

* '''Ureteral stent or percutaneous nephrostomy tube'''

~~***~~**#** For a woman in an early gestational stage, multiple stent changes will be required over the course of the pregnancy.

** '''Disadvantages''':

~~***~~**# Increased risk for bacteriuria and UTI

**# '''Increased risk of stent encrustation/migration'''

~~***~~**# Stent pain, which can have a negative impact on a patient’s quality of life

**#* '''Ureteral stents placed in pregnant women should be exchanged every 4 to 6 weeks.'''

~~***~~*** 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

**#** For a woman in an early gestational stage, multiple stent changes will be required over the course of the pregnancy.

~~***~~* '''Ureteroscopy'''

**# '''Increased risk for bacteriuria and UTI'''

~~***~~** '''Methods to minimize radiation exposure in a pregnant patient (4):'''

**# '''Stent pain, which can have a negative impact on a patient’s quality of life'''

~~***~~**# '''Low dosed and pulsed fluoroscopy'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]

*** 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

~~***~~**# '''Collimating to the minimum required visual fluoroscopy field'''

* '''Ureteroscopy'''

~~***~~**# '''Using the last image hold feature'''

** '''Methods to minimize radiation exposure in a pregnant patient (4):'''

~~***~~**#* Has been shown to reduce radiation exposure by reducing the number of repetitive images.

**# '''Low dosed and pulsed fluoroscopy'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]

~~***~~**# '''Below-table x-ray source'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]

**# '''Collimating to the minimum required visual fluoroscopy field'''

~~***~~**#* The uterus is located superior and anterior aspect of the pelvis during the pregnancy

**# '''Using the last image hold feature'''

~~***~~**#* 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

**#* Has been shown to reduce radiation exposure by reducing the number of repetitive images.

~~***~~**#** 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.'''

**# '''Below-table x-ray source'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]

~~***~~**#*** '''Scattering of the primary beam from the patient is the primary source of radiation exposure to the operator during endourologic procedures.'''

**#* The uterus is located superior and anterior aspect of the pelvis during the pregnancy

~~***~~**#**** Maximizing the distance between the operator and the patient during fluoroscopy is a very effective method of reducing exposure.

**#* 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

~~***~~**# '''X-ray source further away from patient'''

**#** 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.'''

~~***~~**#* '''Reduces exposure to fetus but increases scatter to physician'''

**#*** '''Scattering of the primary beam from the patient is the primary source of radiation exposure to the operator during endourologic procedures.'''

~~***~~**# '''Lead apron placed below the patient's pelvis to shield the fetus'''§

**#**** Maximizing the distance between the operator and the patient during fluoroscopy is a very effective method of reducing exposure.

~~***~~** '''American College of Obstetricians and Gynecologists (ACOG) guidelines recommend that any nonurgent surgeries, such as URS, should be performed in the second trimester of pregnancy to minimize the risk of preterm contractions and spontaneous abortion[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]'''

**# '''X-ray source further away from patient'''

**#* '''Reduces exposure to fetus but increases scatter to physician'''

**# '''Lead apron placed below the patient's pelvis to shield the fetus'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]

** '''American College of Obstetricians and Gynecologists (ACOG) guidelines recommend that any nonurgent surgeries, such as URS, should be performed in the second trimester of pregnancy to minimize the risk of preterm contractions and spontaneous abortion[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]'''

== Questions ==

@@ Line 68: / Line 68: @@
 == Management ==
-* '''<span style="color:#ff0000">First-line: observation in pregnant patients and well controlled symptoms</span>'''
+=== 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.
-*'''<span style="color:#ff0000">Second-line:</span>'''
-**'''<span style="color:#ff0000">Pharmacological and surgical intervention should be coordinated with the obstetrician</span>'''
+==== Intervention (second-line) ====
-***'''<span style="color:#ff0000">Pharmacological</span>'''
+*'''<span style="color:#ff0000">Pharmacological and surgical intervention should be coordinated with the obstetrician</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>'''
+===== Pharmacological</span> =====
-***'''<span style="color:#ff0000">Surgical</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">Ureteral stent or percutaneous nephrostomy tube</span>'''
+*'''<span style="color:#ff0000">NSAIDs (e.g., ketorolac) are contraindicated in pregnancy</span>'''
-***** <span style="color:#ff0000">'''Disadvantages''':</span>
-*****# '''<span style="color:#ff0000">Increased risk of stent encrustation/migration</span>'''
+===== Surgical</span> =====
-*****#* '''<span style="color:#ff0000">Ureteral stents placed in pregnant women should be exchanged every 4 to 6 weeks.</span>'''
+* '''<span style="color:#ff0000">Ureteral stent or percutaneous nephrostomy tube</span>'''
-*****#** For a woman in an early gestational stage, multiple stent changes will be required over the course of the pregnancy.
+** <span style="color:#ff0000">'''Disadvantages''':</span>
-*****# Increased risk for bacteriuria and UTI
+**# '''<span style="color:#ff0000">Increased risk of stent encrustation/migration</span>'''
-*****# Stent pain, which can have a negative impact on a patient’s quality of life
+**#* '''<span style="color:#ff0000">Ureteral stents placed in pregnant women should be exchanged every 4 to 6 weeks.</span>'''
-****** 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
+**#** For a woman in an early gestational stage, multiple stent changes will be required over the course of the pregnancy.
-**** '''<span style="color:#ff0000">Ureteroscopy</span>'''
+**# '''Increased risk for bacteriuria and UTI'''
-***** '''<span style="color:#ff0000">Methods to minimize radiation exposure in a pregnant patient (4):</span>'''
+**# '''Stent pain, which can have a negative impact on a patient’s quality of life'''
-*****# '''<span style="color:#ff0000">Low dosed and pulsed fluoroscopy</span>'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]
+*** 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">Collimating to the minimum required visual fluoroscopy field'''
+* '''<span style="color:#ff0000">Ureteroscopy</span>'''
-*****# '''<span style="color:#ff0000">Using the last image hold feature</span>'''
+** '''<span style="color:#ff0000">Methods to minimize radiation exposure in a pregnant patient (4):</span>'''
-*****#* Has been shown to reduce radiation exposure by reducing the number of repetitive images.
+**# '''<span style="color:#ff0000">Low dosed and pulsed fluoroscopy</span>'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]
-*****# '''<span style="color:#ff0000">Below-table x-ray source</span>'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]
+**# '''<span style="color:#ff0000">Collimating to the minimum required visual fluoroscopy field'''
-*****#* The uterus is located superior and anterior aspect of the pelvis during the pregnancy
+**# '''<span style="color:#ff0000">Using the last image hold feature</span>'''
-*****#* 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
+**#* Has been shown to reduce radiation exposure by reducing the number of repetitive images.
-*****#** 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.'''
+**# '''<span style="color:#ff0000">Below-table x-ray source</span>'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851105/ §]
-*****#*** '''Scattering of the primary beam from the patient is the primary source of radiation exposure to the operator during endourologic procedures.'''
+**#* The uterus is located superior and anterior aspect of the pelvis during the pregnancy
-*****#**** Maximizing the distance between the operator and the patient during fluoroscopy is a very effective method of reducing exposure.
+**#* 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
-*****# '''<span style="color:#ff0000">X-ray source further away from patient</span>'''
+**#** 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.'''
-*****#* '''Reduces exposure to fetus but increases scatter to physician'''
+**#*** '''Scattering of the primary beam from the patient is the primary source of radiation exposure to the operator during endourologic procedures.'''
-*****# '''<span style="color:#ff0000">Lead apron placed below the patient's pelvis to shield the fetus</span>'''§
+**#**** Maximizing the distance between the operator and the patient during fluoroscopy is a very effective method of reducing exposure.
-***** '''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/ §]'''
+**# '''<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/ §]'''
 == Questions ==