Urolithiasis during gestation is an infrequent status, with an incidence of 0.026 to 0.531 per centum in the medical literature ( 1 ) . Nephritic gripes is the most common presentation of urolithiasis, every bit good as the most common nonobstetric cause of hospitalization during gestation and a predetermining factor of premature labour particularly if accompanied by urinary piece of land infection ( 2,3 ) . In about 70 per centum of the instances the rock is passed spontaneously with the usage of anodynes and hydration. ( 4-7 ) In other instances the oncoming of infection, febrility and stubborn ureteral gripes require a assortment of endourologic actions such as stent arrangement intervention ( 8 ) .
The diagnosing of ureteral concretions in pregnant adult females is frequently hard because of the serious hazards presented by radiation exposure, particularly during the first trimester. As such, the diagnosing is best based on clinical informations, uranalysis and ultrasound scrutinies ; nevertheless, ultrasound does non ever supply a clear diagnostic image, even though at times color flow Doppler ultrasound may be utile ( 9 ) . Further diagnostic attempts are indicated when the patient has intractable hurting or upper urinary piece of land infection, or if nephritic map is diminishing for which a more precise diagnosing purposes at specific intervention. In this state of affairs ureteroscopy was considered a utile option, since it combines the diagnostic process with unequivocal intervention ( 10 ) .
Because of the recent progresss in the techniques and engineering in the field of ureteroscopy, the new and thinner semirigid and flexible ureteroscopes have allowed easy entree to the ureter without any demand for dilation and with minimum use. ( 11 ) Ureteroscopy can be performed successfully for ureteral concretions in pregnant adult females and rocks can be removed with the rock basket or fragmented with supersonic ballistic or optical maser lithotriptors under sedation-analgesia ( 12-14 ) . Ureteroscopy can be performed with greater attention when the patient is under sedation-analgesia than if spinal or general anaesthesia is used, since the patient can join forces during the process. Therefore, sedation-analgesia may be preferred when ureteroscopy is performed in pregnant patients ( 15,16 ) . For grounds mentioned above, we have started usage of minureteroscopes for pull offing pregnant patients with complicated rock disease non reacting to medical steps and herein we present our experience with 15 patients.
Patients AND METHODS
Between 2000 and 2005 we performed ureteroscopy and ureterolithotripsy on 15 pregnant patients 21 to 32 old ages old. All patients underwent extended diagnostic rating including uranalysis, urine civilization and antibiogram, complete blood image, hemorrhage and curdling times, nephritic and liver map trials every bit good as, complete abdomino-pelvic ultrasound, and an accurate obstetrical scrutiny to measure the foetal status.
The adult females were placed on the operating tabular array in an oblique place with the left side down when necessary to diminish the force per unit area of the pregnant womb on the inferior vein cava. Sedation-analgesia with 2.5mg Verseds and 50 milligrams pethidine intravenously was used in the first 7 patients. In the undermentioned 8 instances 10 mg nalbuphine HCL was used in add-on to midazolam. Contraceptive therapy with ampicillin/ sulbactum 1.5gm was administered before the process. Ureteroscopy was performed with ultrasound monitoring. The usage of ionising radiation was avoided earlier, during and after the processs. Changeless obstetrical monitoring was available throughout the processs.
All patients underwent ureteroscopy with thin stiff 7.0F ureteroscopes without dilation of the ureteral meatus. We used either the micro-six ACMI ureteroscope or Karl-Storz 6.9 F semirigid ureteroscope. Floppy tip usher wire 0.035 was inserted over a 6 F unfastened tip ureteric catheter through the 22 F cystoscopy. The wire was advanced foremost to the collection system where it has been fixed. In instances with hard usher wire interpolation through the cystoscope, direct ureteroscopy was so performed and a safety wire was inserted through the ureteroscope. Then the ureteroscope was advanced alongside the wire and visual image of the whole ureter was done. Once a rock is visualized a determination was made in respect to the best agencies of extraction. Factors, such as size, sum of guess, grade of impaction, location within the ureter and status of the distal ureter, were considered. Our method of pick was the usage of the rock basket under direct vision. If the size of the rock precluded the usage of the basket technique, we elected to disintegrate the rock utilizing pneumatic intracorporeal lithotripsy. At the terminal of the process, a dual pigtail ureteral stent or external ureteral catheter was placed in the ureter to avoid partial urinary obstructor and wing hurting due to mucosal edema. If external stent was used, it is tied to a Foley catheter. The Foley and ureteral catheters were removed within 1 to 2 yearss.
The operating clip, infirmary stay, perioperative and postoperative complications, result of the gestations and bringings, and status of the newborns postpartum were all recorded. All adult females underwent PUT and abdomino-pelvic ultrasound 6weeks after bringing.
Consequence
The average age of our patients was 25.3 old ages ( run 21-32 old ages ) and the average gestation clip was 28 hebdomads ( range16-32 hebdomads ) . The chief presenting symptoms and indicant of surgical intercession were perennial ureteric gripes non reacting to anodynes, febrility, recurrent UTIs, and haematuria ( table1 ) .
Table 1: Demographic informations: Clinical presentation and research lab findings
Presentation
No. Pregnancies
Percentage ( % )
Gestation at presentation:
16-24 hebdomads
24-34 hebdomads
6
9
40
60
Nephritic gripes:
Right sided
Left sided
10
5
66.7
33.3
Microscopic haematuria
2
13.3
Macroscopic haematuria
3
20
Asymptomatic bacteriuria
4
26.7
Pyelonephritis
2
13.3
Urine civilization was positive for ampicillin-sensitive strains of E-coli and proteus vulgaris in 3 patients. Macroscopic haematuria was found in 3 patients while microscopic haematuria was present in in 2 patients. Leukocytosis was found in 2 patients. Ultrasonography showed dilation of the nephritic pelvic girdle in all instances and rocks were identified in 8 instances. Upper ureteral rocks were found in 3 patients while lower ureteric rocks were diagnosed in 5 patients. The average rock size diagnosed with ultrasound was 0.6cm ( scope from 0.5-1.2 centimeter ) . Ureteroscopy was done for all instances with the full ureter examined without the demand for ureteric opening distension. Rocks were extracted from the lower ureter by Dormia basket in 7 patients. Stone atomization with the pneumatic lithotriptor was used for rocks above the iliac vass in 6 instances and no rocks have been found in 2 patients ( table 2 ) .
A dual pigtail ureteral catheter was inserted in 8 instances ( 6 patients with disconnected concretion and the 2 instances with no confirmed rock ) and ensured to be in the proper place by watching its distal terminal in the vesica and monitoring of the upper terminal curling in the nephritic pelvic girdle through ultrasound scrutiny. In the 7 patients with extracted concretion, a 6 F ureteric catheter was inserted for one or two yearss postoperatively.
Table 2: Consequences of 15 ureteroscopic processs during gestation.
Presentation
No. Pregnancies
Percentage ( % )
Ureteroscopic findings:
Rocks in the upper ureter
Rocks in the lower ureter
No rocks
6
7
2
40
46.7
13.3
Endoscopic direction:
Dormia basket extraction
Pneumatic lithotripsy
Doble J stenting
7
6
8
46.7
40
53.3
Duration of the process ranged from 15-30 proceedingss and obstetric monitoring showed no marks of foetal hurt or pre-term bringing. No complications encountered and recuperation was uneventful. Patients who had hurting were improved unusually and fever disappeared within the following 24 hours after the process. Patients were discharged place 72 yearss after the process and the external ureteric catheter was removed. Patients with dual J stenting had their stent removed after labour in the two patients with negative ureteroscopic happening while patients underwent stone atomization had stent backdown after 3 hebdomads. All gestations progressed to full term bringing. Five patients had an elected Cesarean subdivision as they had a history of old subdivision and no foetal abnormalcies were detected. The follow up PUT and U/S performed 6 hebdomads postpartum revealed disappearing of nephritic pelvic girdle distension and no concretion were found in all patients.
Discussion
The first publications on ureteroscopic diagnosing and direction of ureteral concretion during gestation appeared in 1988.12 The differential diagnosing of ureteral concretions versus physiological distension in gestation was rendered possible by this process with great aid in direction. Using ureteroscopy and stent arrangement, under ultrasound monitoring, was an of import measure frontward in rock use during gestation ( 12,13 ) . It was supposed that anatomic deformations caused by the foetal presence would non let the debut of the stiff ureteroscope and this process could be of high hazard to the gestation. However, it was proved that the natural ureteral dilation in gestation facilitates the debut of the ureteroscope and the process could be performed easy by following the usual regulations, except for the usage of fluoroscopy ( 17 ) .
The diagnosing of ureteral concretions in pregnant adult females is frequently hard because of the serious hazards presented by radiation exposure, particularly during the first trimester ( 9 ) . Several research workers have highlighted the jobs related to the exposure of the pregnant patients to X raies in respect to the incidence of tumours in kids who were irradiated during foetal life ( 9,18 ) . Therefore, the usage of X ray for the diagnosing or direction of rocks during gestation remains controversial ( 19 ) .
Ultrasonography is the chief diagnostic method in these instances, because besides its non-invasive nature, it does non utilize radiation, and is universally available ( 3,8 ) . However, Ultrasound does non ever supply a clear diagnostic image, even though at times color flow Doppler ultrasound by utilizing resistive indices may be utile ( 10 ) . In our survey, we avoided the usage of X ray for the diagnosing of rocks during gestation and we depend chiefly on clinical diagnosing and ultrasound scrutiny. Nephritic pelvic distension entirely or combined with calycine distension was diagnosed by U/S in our patients and ureteral rocks were found in 8 ( 61.5 % ) out of 13 ureteroscopically confirmed rocks. Although U/S is safe under all fortunes of gestation, its use in naming obstructor is of limited value owing to its sub-optimal position of the ureter and presence of hydroureteronephrosis as a physiologic accompaniment of gestation.
Hematuria, both macro and microscopic, is a frequent mark, but is non specific ( 4, 8, 20 ) while urinary piece of land infection is present in 20 to 45 % of the instances of concretion during gestation ( 1,21-22 ) . Among our patients, haematuria was present in 5 ( 33.3 % ) patients and symptomless bacteriuria was detected in 4 ( 26.7 % ) patients while pyelonephritis complicated 2 ( 13.3 % ) pregnant adult females.
In the early protocols for rock direction in pregnant patients, the dual pigtail catheters were used to handle nephritic distension and in instances of failure, an ultrasound guided nephrostomy was preferred over the hazards built-in with ureteroscopy ( 19 ) . Stents and drains may hold many disadvantages including inadvertent dislodgement, obstructor or vesica crossness and unpleasant symptoms ( 1 ) . In add-on, encrustation on dual pigtail stents with attendant obstructor is frequent in pregnant adult females and it is advised that stents should be changed every few hebdomads during gestation. The perennial interpolations of tubings and stents may hold possible hazards that may be comparable to the hazard associated with ureteroscopy performed as a individual process. ( 11-14 ) . In the present series, we have used the 7F semirigid ureteroscope, without demand of distending the ureteral meatus in any of the instances. In fact, this process is simpler than it was supposed in the yesteryear.
It was suggested that pregnant patients with ureteral concretion and febrility should be treated with antibiotics and drainage by a double-J catheter. The advantage of this method is that it is an efficient and less invasive method. Ureteroscopy was non advised in these patients because ureteral use and liquid injection under force per unit area in the excretory system may take to bacteruria and airing of the infection ( 23 ) . However, stent should be left until the terminal of gestation, which can be a predisposing factor to infections and may do vesical uncomfortableness in most patients. We have used ureteroscopy in 2 pregnant patients with pyelonephritis and blockading ureteral concretions and rocks were removed and dual J stents were inserted for 3 hebdomads without complications. Those patients were given antibiotics harmonizing to civilization and sensitiveness trial prior to the process and during ureteroscopy unstable force per unit area was kept at minimal and non-refluxing dual J stents were used.
A farther advantage of ureteroscopy as a diagnostic and curative option is that general anaesthesia can be avoided during gestation. With the application of mini-ureteroscopes and little instruments, general anaesthesia was replaced by sedation analgesia among our patients. This facet has already been highlighted by others who reported on flexible ureteroscopy ( 12 ) .
In decision, ureteroscopy during gestation can be performed safely under sedation analgesia for diagnosing and remotion of ureteral concretions in instances of failure of conservative direction in experient centres with the usage of miniureteroscopes and without utilizing fluoroscopy.