| BackgroundPregnant women with symptomatic urinary tract stones are not common in clinical settings, reported incidence rate is between 1:200 to 1:2000, the vast majority of which is ureteral calculus.Ureteral stones can cause renal colic, infection and obstruction, and may have adverse effects on pregnant women and the fetus. The incidence of premature labor and premature rupture of membranes in this particular group of patients was higher than that of normal pregnant women. The diagnosis and treatment for this condition has a certain degree of difficulty and limitation because of maternal and child safety considerations, the choice of safe and effective treatment measures are of great significance for this special population. It is generally believed that for ureteral calculi in pregnancy, conservative treatment should be the first choice, mainly to relieve pain. Although in non pregnant patients, 95% of the ureteral stones with diameter below 4mm could pass out spontaneously with the help of the drugs, but the average time required for passage is up to 40 days, it is reported that 60% to 80% of pregnant women with urinary calculi could spontaneously pass the stone, but some author stated that because pregnant patients with physiological hydronephrosis and urinary tract infection can also present renal colic and ureteral obstruction, and were misdiagnosed as urinary tract stones, so that the stone expulsion rate maybe overstated, and the actual pregnancy urinary stone spontaneous passage rate could be as low as 48%. For this special group of pregnant women, medications of expulsive therapy such as alpha receptor antagonist, calcium channel blockers and traditional Chinese medicine have limits on usage. And the gravid uterine and gorged ovary blood vessel could cause pression on the ureter, the spontaneous passage rate of ureteral calculi during pregnancy may be even lower, and longer time may be needed. Thus the symptom of renal colic may be recurrent, leading to increased incidence of miscarriage, premature birth and other obstetric complications. Current literature views are not the same for surgical treatment. Some authors consider that the simplest surgical treatment measures such as placement of ureteral stent, percutaneous renal drainage should be applied during pregnancy, further definite treatment of the should not be used until the pregnancy ended. But these temporary measures need repeated replacement of ureteral stents or drainage tube, especially for pregnant women in the 1st and 2nd trimester, with poor tolerability, and affecting the quality of life of the patients. With the development of ureteroscopy technique and stone fragmentation equipment refinement, reports on using ureteroscopy for the treatment of ureteral calculi during pregnancy has been increasing. Some authors believe that ureteroscopy has high stone clearance rate, and definite efficacy. It also has little impact on the fetus and pregnant women and does not increase the incidence of obstetric complication; it can be used as the first-line treatment measures for this disease. There are also some authors believe that surgical intervention will cause fetal anesthetic drug exposure which may have teratogenic effect and increase the risk of miscarriage, and thus skeptical about its safety. There is also no clear understanding on indications for surgery. It is generally believed that when conservative treatment fails, and renal colic can not eased, surgical intervention then be considered. However, if the stone is not discharged, renal colic may be recurrent, and brings physiological and psychological adverse effects on these pregnant women, affecting the quality of life during pregnancy and jeopardizing maternal and child safety. Ureteroscopic lithotomy with its exact clearance of stones, as the initial approach for the treatment of ureteral calculi in pregnancy can avoid the uncertainty of calculi clearance, and reduce the recurrence of renal colic.MethodsTo collect 108 cases of pregnant wowen with ureteral calculi who was hospitalised for treatment from January 2005 to December 2015 in our hospital. All the available medical record was carefully reviewed. Patients were divided into two groups according to whether stone clearance was achieved. The patient’s general condition,clinical syptoms,laboratory and auxiliary examination results as well as treatment options was reviewed to summarize the clinical feature. The risk factor for treatment options was analysed and safty issue was also discussed. The related factors affecting therapeutic efficacy was analysed.Results1. The average age was 27.16±4.36 years.21 (19.44%) patients were in the first trimester,67(62.04%) were in the second trimester, and 20 (18.52%) in the third.33(30.56%) patients had ureteral calculi in the upper segment,12 (11.11%) had ureteral calculi in the middle segment,and 63(58.33%) in the lower segment. The mean stone size was 8.47±3.58mm,and 65 patients had stone smaller than 8mm, while the other 43 had stone larger than 8 mm.51 patients received conservative treatment and 57 patients underwent surgical interventions total of 47 patients had their stones removed by surgery or passed out spontaneously. In the 51 patients in the conservative treatment group,6 patients readmitted into the hospital because of renal colic recurrence. In the surgical treatment group,1 patient readmitted for double J stent prolapsed. There was no miscarriage or preterm labor occurred, no fetal loss either.2. The incidence of pyuria was found higher in the surgical treatment group than in the conservative treatment group, indicating that urinary infection was a risk factor for the need of surgical intervention.3. The stone passage rate in the conservative treatment group was associated with the location and size of the calculi. Compared with the stones located in the lower segment of the ureter, the passage rate upper and middle segment was significantly lowered. The passage rate of stone that larger than 8mm was also lowered. (OR=0.172,95%CI:0.029～1.010)。4. Stone location was an associate factor of stone free rate of surgical treatment. Compared with the lower segment stones, the stone free rate of surgical treatment for the upper segment stones were significantly lowered. (OR=0.116,95%CI: 0.028～0.474) It was also found that the stone free rate of surgical treatment would be significantly elevated if the stone was larger than 8mm.Conclusions:1. The major symptom of ureter stones during pregnancy was acute lumbar pain, and sometimes accompanied by fever and urinary frequency, urgency and other lower urinary tract symptoms, most patients had microscopic hematuria.ultrasonography was the first line imaging diagnositic modality of pregnancy complicated with ureteral calculi. More than half of the patients had infection manifestations such as microscopic pyuria, elevated white blood cell counts. and positive rate of urine culture was low, priority was given to drug treatment in order to relieve renal colic, antibiotic treatment was needed in Most patients, surgical intervention was indicated in more than half of these patient.2. Urinary infection was a risk factor for the option of conservative or surgical treatment. Ureter obstruction can cause infection, and infections in its turn enhance urinary infection. If urinary infection could not be controlled by antibiotics, surgical intervention may be indicated.3. The location of stones and choice of treatment methods were the related factors that affect the rate of stone clearance in pregnanct women complicated with ureteral calculi. The stone clearance rate was higher in patient with lower ureteral calculi. And surgical treatment can improve the stone free rate of this kind of patients.4. The size and location of stone were the two related factors that afect stone passage rate in the medical treatment group. Stones that located in upper ureter or larger than 8mm in size had lower passage rate.so it is indicated that for calculi in upper ureter or larger than 8mm in size, active surgical intervention should be considered.5. Although compared with drug therapy, surgical treatment can improve the upper ureteral calculi stone clearance rate, but compared to lower ureteral calculi, the stone clearance rate is low, so for upper ureteral calculi, ureter stent placement drainage might be an optimal treatment.6. Surgcal treatment can achieve a high stone clearance rate in lower ureter. For lower ureter calculi which size is less than 8mm,the spontaneous passage rate was also high,so that conservative treatment might be the first choice.while for those stones larger than 8mm. When conservertive treatment attempt failed,surgical intervention should be applied quickly.7. Ureteroscopy was a safe procedure during all period of pregnancy, the premise is that the operator shold be skillful. Keep close cooperation with the Anesthesiologist and obstetricians.8. Perioperative management such as infection control and preterm labor prevention should be applied. Phloroglucinl, magnesium sulfate and progesterone can relieve renal colic. They also can be as an effective tocolytic agent, when preoperatively administered, they could prevent preterm labor in the pregnant underwent surgical procedures. Epidural or spinal anesthesia would be preferable for pregnant patient underwent uretercoscopy. Patients must be kept oxygenated and avoided from hypotention. Uterine contraction and fetal heart rate should be monitored during operation. Fetal hypoxia should be avoided. Treatment options such as ureteral stent placement or uerterscope lithotripsy should be carefully chosen according to the conditions of the patients. Intraoperative manipulation should be gentle, and ureteroscopy going in and out of the lumen too often should be avoided. Perfusion pressure could be avoided appropriately, when ureteroscopic access was difficult, ureter drainage can be applied instead. Try to shorten the operation time if possible. These measures can improve the safety of ureteroscopy in the pregnant patient. |
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