Re: Ob: Suspected nephrolithiasis
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Wed Dec 27 14:46:03 2006
Hi Ashley:
Great to hear from you.
I've not heard of the stone cocktail before; there's no way she would
take any drugs, knowing the patient well.
I've heard from urologists that you can have stones without hematuria;
she has had dipstick hematuria earlier in the pregnancy, and her urine
culture was negative.
Anyway, expectant management is the game plan here--thanks to all.
Garry
At Tue, 26 Dec 2006, D. Ashley Hill wrote:
>
>Garry-
>
>If I'm reading this right, it sounds like a patient at 7 weeks with
>unilateral flank pain but no diagnosis yet with a normal urinalysis and
>renal sonography. I agree with others that radiography is not indicated
>(since
>the renal sono showed no hydronephrosis). I'm not sure that an IVP
>would even show a stone, since the UA revealed no hematuria. If it's
>not a stone it could be something very unusual like ovarian vein
>syndrome, where the gonadal veins compress the ureter, but I suspect
>that would cause some hydronephrosis.
>
>We see a lot of stone patients for some reason. I recall that about 85%
>of stones <5mm pass on their own within 3 weeks of presentation. If you
>want to try things to speed the process, one trick the urologists taught
>us is the "stone cocktail" of procardia (to dilate the ureter), oral
>prednisone (to decrease ureteral inflammation and pain) and narcotics or
>NSAIDs as needed. We've used these later in pregnancy with good
>results. I'm not sure if there are RCTs to support this. Good luck.
>Happy Holidays and I hope you have a great 2007.
>
>Ashley
>
>At Mon, 25 Dec 2006, Garry E. Siegel, M.D. wrote:
>>
>>31 YO P0000 at 8 weeks. She is a CNM.
>>
>>She has a history of hematuria (dipstick and micro, not gross) predating
>>pregnancy, and saw a urologist who suspected a small, asymptomatic
>>stone, but no imaging done.
>>
>>Now, she is having daily unilateral flank pain radiating to her groin,
>>and was in enough pain/nausea last night to be admitted for IVF. She is
>>fearful of any meds for pain, and didn't require an anti-emetic. Her
>>hope is that IVF over time will help with passage of the suspected
>>stone.
>>
>>Her exam is benign, CBC and metabolic panels normal, and normal u/a with
>>a culture pending.
>>
>>Today's renal ultrasound is totally negative, and she has a viable 7w5d
>>gestation. The radiologist says that any stone big enough to warrant
>>consideration for extraction would result in hydronephrosis, and there
>>is none.
>>
>>In speaking with the urologist, we kicked around a limited IVP (scout,
>>and one or two post injection shots) versus simply using pain
>>meds/anti-emetics; the patient is torn and really wants to do nothing. I
>>have advised taking meds as needed and delaying imaging until later (12
>>weeks, and only if symptomatic) for her peace of mind.
>>
>>I'm really not too worried about a limited IVP here--and I believe
>>Ashley had a nice paper from around 1995 regarding radiation in
>>pregnancy. Both the urologist and radiologist are hesitant, and the
>>urologist was worried about a cystoscopy (if needed for extraction)
>>causing an abortion.
>>
>>I've really not ever seen problems with indicated imaging studies such
>>as a limited IVP, or cystoscopy--realizing that the numbers of bad
>>outcomes would be exceedingly small, and the number of cases I've seen
>>isn't huge.
>>
>>My gut says take meds prn and image at some point--as per above.
>>
>>Any thoughs?
>>
>>Garry
>>
>>--
>>Garry E. Siegel, M.D.
>>Private Practice
>>Roswell, GA
>>
>--
>D. Ashley Hill, MD
>Associate Director
>Department of Obstetrics and Gynecology
>Florida Hospital Family Practice Residency
>Medical Director, Loch Haven Ob/Gyn Group
>Division Director, Dept. of Ob/Gyn, Florida Hospital Orlando
>Orlando, Florida
>
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
