Re: Etiology of right sided hydronephrosis in pregnancy
From: Latha Natarajan (nattu@vsnl.com)
Sun May 1 05:38:37 2005
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ORIGINAL ARTICLES
--------------------------------------------------------------------------------
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-------------------------------------------------------------------------Urologic Issues During Pregnancy
Jeffrey P. Weiss, MD, FACS
Clinical Adjunct Assistant Professor of Urology
New York Hospital-Cornell Medical Center
Urojock@aol.com
Abstract
Pregnancy induces a variety of physiologic changes in the urinary tract. When such changes become accentuated the physiologic becomes the pathologic and symptoms arise, at times of significance enough to threaten the well being of mother and/or fetus. This article intends to describe the basis for urinary physiology and its pathologic counterparts during pregnancy. Such a background may then facilitate a rational management protocol for various urologic problems in the gravid state.
Key Words: Pregnancy, physiology, hydronephrosis, calculi, infection, renal failure, transplantation
Urinary Tract Symptoms During Pregnancy
Frequency of voiding and stress incontinence are the most common urinary symptoms experienced by the gravid patient. Additional symptoms include urinary urgency, urge incontinence, incomplete emptying, and slow stream (1,2). Hematuria is a physiologic change of pregnancy owing to microanatomic alterations in venous fragility of the collecting tubules (3). Flank pain may be due to accompanying processes such as calculi, hydronephrosis, pyelonephritis or spontaneous renal rupture, a phenomenon peculiar to pregnancy.
Pregnancy-induced Changes in Renal Physiology
Hydroureteronephrosis is the most significant renal functional alteration of pregnancy, accounted for by both hormonal and mechanical factors. Increases in circulating estrogenic, progestational and prostaglandin-like agents are known to cause ureterectasis in the absence of obstruction during pregnancy (4,5).
Stasis caused by dextrorotation of the expanding uterus is the principal mechanical factor leading to hydroureteronephrosis of pregnancy and explains its tendency to occur on the right.
Hydronephrosis of Pregnancy
Gestational upper urinary tract dilatation results from evolution of a physiologic process, namely, ureteral compression by the expanding uterus (22). Because hydroureteronephrosis of pregnancy occurs as an outcome of dextrorotation of the uterus at mid-term, it usually happens on the right (23,24). Ureterectasis is also thought to have a non-obstructive component, related to hormonal changes induced by a functioning placenta (25,26).
References
1. Stanton, S.L., Kerr-Wilson, R. and Grant Harris, V.: The incidence of urological symptoms in normal pregnancy, Br J Obstet Gynecol 87:897-900, 1980.
2. Cutner, A., Cardozo, L.D. and Benness, C.J.: Assessment of urinary symptoms in early pregnancy, Br J Obstet Gynaecol 98:1283-1286, 1991.
3. Waltzer, W.C.: The urinary tract in pregnancy, J Urol 125:271-276, 1981.
4. Van Wagenen,G., Newton, W.H.: Pregnancy in the monkey after removal of the fetus, Surg Gynec Obst 77:539, 1943.
5. Rasmussen, P.E., Nielsen, F.R.: Hydronephrosis during pregnancy: A literature survey, Eur J Obstet Gynecol Reprod Biol 27:249, 1988.
6. Dunlop, W., Davison, J.M.: Renal haemodynamics and tubular function in human pregnancy, Clin Obstet Gynaecol 1:769, 1987.
7. Lindheimer, M.D., Katz, AI: The kidney and hypertension in pregnancy. In Brenner BM, Rector FC, editors: The kidney vol II, Philadelphia, 1991, WB Saunders Co.
8. Wright, A., et al: The urinary excretion of albumin in normal pregnancy, Br J Obstet Gynaecol 94:408, 1987.
9. Boler, L., et al: Quantitation of proteinuria in pregnancy by the use of single voided urine samples,
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> ----- Original Message -----
From: Allen Worrall
To: Multiple recipients of list ULTRASOUND
Sent: Thursday, April 28, 2005 9:29 PM
Subject: Re: Etiology of right sided hydronephrosis in pregnancy
I forget the details, but it has to do with the course of the right ureter at the brim of the pelvis, compared to the left ureter. The right ureter is more easily compressed by the enlarged uterus. This difference probably is due to the arteries as you say. I do know that the right ureter is much easier to find at surgery than the left.
Allen
> ----- Original Message -----
From: DuBose, Terry
To: Multiple recipients of list ULTRASOUND
Sent: Thursday, April 28, 2005 7:14 AM
Subject: Etiology of right sided hydronephrosis in pregnancy
I need some help finding an explanation of why maternal hydronephrosis is more common on the right side than the left.
Seems I read somewhere, years ago, that it has to do with the left iliac artery protecting the left ureter from compression, while the right iliac is more midline and the uterus can compress the right ureter. I found the following abstract, but unfortunately do not have access to the electronic version. and will not be able to get to the library this week. I doubt it will explain the etiology anyway.
Anyone have a reference or good explanation for this phenomenon?
Thanks, Terry
Terry J. DuBose, M.S., RDMS, FSDMS, FAIUM
Associate Professor & Director
Diagnostic Medical Sonography Program
University of Arkansas for Medical Sciences, CHRP
4301 West Markham St. Mail Slot #563
Little Rock, Arkansas, 72205 USA
501-686-6510
DuBoseTerryJ@UAMS.edu
http://www.io.com/~dubose/
http://www.uams.edu/chrp/dms/default.asp
http://www.obgyn.net/us/panel/panel.htm
---------------------------------------------------------------
Authors
---------------------------------------------------------------
---------------------------------------------------------------
Eckford SD. Gingell JC.
Institution
Department of Obstetrics, Southmead Hospital, Bristol.
Title
Ureteric obstruction in pregnancy--diagnosis and management.
Source
British Journal of Obstetrics & Gynaecology. 98(11):1137-40, 1991 Nov.
Local Messages
All @ UAMS
Abstract
OBJECTIVE--To discuss the aetiology, diagnosis and management of ureteric obstruction in pregnancy and to describe the use of double-pigtail ureteric stents in a series of 10 patients. DESIGN--Retrospective study of women presenting to a maternity unit in whom the diagnosis of ureteric obstruction is reached. SETTING--Southmead Hospital in Bristol; a large district general hospital with a throughput of around 6000 maternity patients per year. SUBJECTS--10 women (8 in their first pregnancy, 1 in her second and 1 in her third; mean age 29.2 years (range 18-31 years). INTERVENTIONS--Double-pigtail ureteric stents were electively passed after a diagnosis of ureteric obstruction. Stents remained in situ for a mean 15.5 weeks (range 8-25 weeks) and were electively removed 4-6 weeks post partum. RESULTS--Nine women progressed uneventfully through the remainder of their pregnancy. One developed strangury, haematuria and discomfort after stent insertion. Seven women had normal vaginal deliveries, two assisted vaginal deliveries and one was delivered by caesarean section. None required to have external urinary drainage. CONCLUSIONS--Double-pigtail ureteric stents are easy to place and remove and are well tolerated. They provide a simple, safe and effective method of internal upper urinary tract drainage in ureteric obstruction in pregnancy.
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<TD><A href="http://www.duj.com/index.html"><IMG height4
src="http://www.duj.com/Article/Weiss/smallduj.gif" width$6 align=top
border=0></A></TD>
<TD><FONT size=7><B>ORIGINAL ARTICLES</B></FONT></TD></TR></TBODY></TABLE>
<HR>
<CENTER><FONT size=6><B>Urologic Issues During Pregnancy</B></FONT></CENTER>
<CENTER> </CENTER>
<CENTER><FONT size=5>Jeffrey P. Weiss, MD, FACS</FONT></CENTER>
<CENTER><FONT size=4>Clinical Adjunct Assistant Professor of
Urology</FONT></CENTER>
<CENTER><FONT size=4>New York Hospital-Cornell Medical Center</FONT></CENTER>
<CENTER><FONT size=4>Urojock@aol.com</FONT></CENTER>
<P><FONT size=4></FONT> </P>
<P><FONT size=5><B>Abstract</B></FONT></P>
<P><FONT size=4>Pregnancy induces a variety of physiologic changes in the
urinary tract. When such changes become accentuated the physiologic becomes the
pathologic and symptoms arise, at times of significance enough to threaten the
well being of mother and/or fetus. This article intends to describe the basis
for urinary physiology and its pathologic counterparts during pregnancy. Such a
background may then facilitate a rational management protocol for various
urologic problems in the gravid state.</FONT></P>
<P><FONT size=4><B>Key Words</B>: Pregnancy, physiology, hydronephrosis,
calculi, infection, renal failure, transplantation</FONT></P>
<P><FONT size=4></FONT> <BR> <BR> </P>
<P><FONT size=5><B>Urinary Tract Symptoms During Pregnancy</B></FONT></P>
<P><FONT size=4>Frequency of voiding and stress incontinence are the most common
urinary symptoms experienced by the gravid patient. Additional symptoms include
urinary urgency, urge incontinence, incomplete emptying, and slow stream (1,2).
Hematuria is a physiologic change of pregnancy owing to microanatomic
alterations in venous fragility of the collecting tubules (3). Flank pain may be
due to accompanying processes such as calculi, hydronephrosis, pyelonephritis or
spontaneous renal rupture, a phenomenon peculiar to pregnancy.</FONT></P>
<P><FONT size=4><B>Pregnancy-induced Changes in Renal Physiology</B></FONT></P>
<P><FONT size=4>Hydroureteronephrosis is the most significant renal functional
alteration of pregnancy, accounted for by both hormonal and mechanical factors.
Increases in circulating estrogenic, progestational and prostaglandin-like
agents are known to cause ureterectasis in the absence of obstruction during
pregnancy (4,5). </FONT></P>
<P><FONT color=#ff0000 size=4>Stasis caused by dextrorotation of the expanding
uterus is the principal mechanical factor leading to hydroureteronephrosis of
pregnancy and explains its tendency to occur on the right.</FONT></P>
<P><FONT color=#ff0000 size=4><STRONG><FONT color=#000000 size=5>Hydronephrosis
of Pregnancy</FONT></STRONG></P>
<P><FONT size=4><FONT color=#000000>Gestational upper urinary tract dilatation
results from evolution of a physiologic process, namely, ureteral compression by
the expanding uterus (22).</FONT> Because hydroureteronephrosis of pregnancy
occurs as an outcome of dextrorotation of the uterus at mid-term, it usually
happens on the right (23,24). <FONT color=#000000>Ureterectasis is also thought
to have a non-obstructive component, related to hormonal changes induced by a
functioning placenta (25,26).</FONT></FONT></P>
<P><FONT size=5><I><B>References</B></I></FONT></P>
<P><FONT color=#000000 size=4>1. Stanton, S.L., Kerr-Wilson, R. and Grant
Harris, V.: The incidence of urological symptoms in normal pregnancy, Br J
Obstet Gynecol 87:897-900, 1980.</FONT></P>
<P><FONT color=#000000 size=4>2. Cutner, A., Cardozo, L.D. and Benness, C.J.:
Assessment of urinary symptoms in early pregnancy, Br J Obstet Gynaecol
98:1283-1286, 1991.</FONT></P>
<P><FONT size=4></FONT><FONT color=#000000> <BR><FONT size=4>3. Waltzer, W.C.:
The urinary tract in pregnancy, J Urol 125:271-276, 1981.</FONT>
<BR> </FONT></P>
<P><FONT color=#000000><FONT size=4>4. Van Wagenen,G., Newton, W.H.: Pregnancy
in the monkey after removal of the fetus, Surg Gynec Obst 77:539, 1943.</FONT>
</FONT></P>
<P></FONT><FONT size=4><FONT size=4>5. Rasmussen, P.E., Nielsen, F.R.:
Hydronephrosis during pregnancy: A literature survey, Eur J Obstet Gynecol
Reprod Biol 27:249, 1988.</FONT> <BR> </P>
<P><FONT size=4>6. Dunlop, W., Davison, J.M.: Renal haemodynamics and tubular
function in human pregnancy, Clin Obstet Gynaecol 1:769, 1987.</FONT></P>
<P><FONT size=4> 7. Lindheimer, M.D., Katz, AI: The kidney and hypertension
in pregnancy. In Brenner BM, Rector FC, editors: The kidney vol II,
Philadelphia, 1991, WB Saunders Co.</FONT> <BR> </P>
<P><FONT size=4>8. Wright, A., et al: The urinary excretion of albumin in normal
pregnancy, Br J Obstet Gynaecol 94:408, 1987.</FONT></P>
<P><FONT size=4> 9. Boler, L., et al: Quantitation of proteinuria in
pregnancy by the use of single voided urine samples, </FONT></P></FONT>
<P><FONT size=4>
<HR>
</FONT></P>
<P><FONT size=4></FONT> </P></DIV>
<BLOCKQUOTE dir=ltr
style="PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
> <DIV style="FONT: 10pt arial">----- Original Message ----- </DIV>
<DIV
style="BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: black"><B>From:</B>
<A title=jworrall@alaska.net href="mailto:jworrall@alaska.net">Allen
Worrall</A> </DIV>
<DIV style="FONT: 10pt arial"><B>To:</B> <A title=ultrasound@dns.obgyn.net
href="mailto:ultrasound@dns.obgyn.net">Multiple recipients of list
ULTRASOUND</A> </DIV>
<DIV style="FONT: 10pt arial"><B>Sent:</B> Thursday, April 28, 2005 9:29
PM</DIV>
<DIV style="FONT: 10pt arial"><B>Subject:</B> Re: Etiology of right sided
hydronephrosis in pregnancy</DIV>
<DIV><BR></DIV>
<DIV><FONT face="Comic Sans MS">I forget the details, but it has to do with
the course of the right ureter at the brim of the pelvis, compared to the left
ureter. The right ureter is more easily compressed by the enlarged uterus.
This difference probably is due to the arteries as you say. I do know that the
right ureter is much easier to find at surgery than the left. </FONT></DIV>
<DIV><FONT face="Comic Sans MS"></FONT> </DIV>
<DIV><FONT face="Comic Sans MS">Allen</FONT></DIV>
<BLOCKQUOTE dir=ltr
style="PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
> <DIV style="FONT: 10pt arial">----- Original Message ----- </DIV>
<DIV
style="BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: black"><B>From:</B>
<A title=DuboseTerryJ@uams.edu href="mailto:DuboseTerryJ@uams.edu">DuBose,
Terry</A> </DIV>
<DIV style="FONT: 10pt arial"><B>To:</B> <A title=ultrasound@dns.obgyn.net
href="mailto:ultrasound@dns.obgyn.net">Multiple recipients of list
ULTRASOUND</A> </DIV>
<DIV style="FONT: 10pt arial"><B>Sent:</B> Thursday, April 28, 2005 7:14
AM</DIV>
<DIV style="FONT: 10pt arial"><B>Subject:</B> Etiology of right sided
hydronephrosis in pregnancy</DIV>
<DIV><BR></DIV>
<DIV class=Section1>
<P class=MsoNormal><FONT face=Arial color=green size=3><SPAN
style="FONT-SIZE: 12pt; COLOR: green">I need some help finding an
explanation of why maternal hydronephrosis is more common on the right side
than the left. <o:p></o:p></SPAN></FONT></P>
<P class=MsoNormal><FONT face=Arial color=green size=3><SPAN
style="FONT-SIZE: 12pt; COLOR: green"><o:p> </o:p></SPAN></FONT></P>
<P class=MsoNormal><FONT face=Arial color=green size=3><SPAN
style="FONT-SIZE: 12pt; COLOR: green">Seems I read somewhere, years ago,
that it has to do with the left iliac artery protecting the left ureter from
compression, while the right iliac is more midline and the uterus can
compress the right ureter. I found the following abstract, but
unfortunately do not have access to the electronic version… and will not be
able to get to the library this week. I doubt it will explain the
etiology anyway. <o:p></o:p></SPAN></FONT></P>
<P class=MsoNormal><FONT face=Arial color=green size=3><SPAN
style="FONT-SIZE: 12pt; COLOR: green"><o:p> </o:p></SPAN></FONT></P>
<P class=MsoNormal><FONT face=Arial color=green size=3><SPAN
style="FONT-SIZE: 12pt; COLOR: green">Anyone have a reference or good
explanation for this phenomenon? <o:p></o:p></SPAN></FONT></P>
<P class=MsoNormal><FONT face=Arial color=green size=3><SPAN
style="FONT-SIZE: 12pt; COLOR: green"><o:p> </o:p></SPAN></FONT></P>
<P class=MsoNormal><FONT face=Arial color=green size=3><SPAN
style="FONT-SIZE: 12pt; COLOR: green">Thanks, Terry
<o:p></o:p></SPAN></FONT></P>
<P class=MsoNormal><FONT face=Arial color=green size=3><SPAN
style="FONT-SIZE: 12pt; COLOR: green"><o:p> </o:p></SPAN></FONT></P>
<P><FONT face="Arial Black" color=green size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: green; FONT-FAMILY: 'Arial Black'">Terry J.
DuBose, M.S., RDMS, FSDMS, FAIUM</SPAN></FONT><FONT color=green><SPAN
style="COLOR: green"> <o:p></o:p></SPAN></FONT></P>
<P><FONT face="Arial Black" color=green size=1><SPAN
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Professor & Director</SPAN></FONT><FONT color=green><SPAN
style="COLOR: green"> <BR></SPAN></FONT><FONT face="Arial Black" color=green
size=1><SPAN
style="FONT-SIZE: 7.5pt; COLOR: green; FONT-FAMILY: 'Arial Black'">Diagnostic
Medical Sonography Program</SPAN></FONT><FONT color=green><SPAN
style="COLOR: green"><BR></SPAN></FONT><FONT face="Arial Black" color=green
size=1><SPAN
style="FONT-SIZE: 7.5pt; COLOR: green; FONT-FAMILY: 'Arial Black'">University
of Arkansas for Medical Sciences, CHRP</SPAN></FONT><FONT color=green><SPAN
style="COLOR: green"> <BR></SPAN></FONT><FONT face="Arial Black" color=green
size=1><SPAN
style="FONT-SIZE: 7.5pt; COLOR: green; FONT-FAMILY: 'Arial Black'">4301 West
Markham St. Mail Slot #563 </SPAN></FONT><FONT color=green><SPAN
style="COLOR: green"><BR></SPAN></FONT><FONT face="Arial Black" color=green
size=1><SPAN
style="FONT-SIZE: 7.5pt; COLOR: green; FONT-FAMILY: 'Arial Black'">Little
Rock, Arkansas, 72205 USA </SPAN></FONT><FONT color=green><SPAN
style="COLOR: green"><BR></SPAN></FONT><FONT face="Arial Black" color=green
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style="FONT-SIZE: 7.5pt; COLOR: green; FONT-FAMILY: 'Arial Black'">DuBoseTerryJ@UAMS.edu</SPAN></FONT><FONT
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face="Arial Black" color=green size=1><SPAN
style="FONT-SIZE: 7.5pt; COLOR: green; FONT-FAMILY: 'Arial Black'"><A
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href="http://www.uams.edu/chrp/dms/default.asp">http://www.uams.edu/chrp/dms/default.asp</A></SPAN></FONT><FONT
color=green><SPAN style="COLOR: green"> <BR></SPAN></FONT><FONT
face="Arial Black" color=green size=1><SPAN
style="FONT-SIZE: 7.5pt; COLOR: green; FONT-FAMILY: 'Arial Black'"><A
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style="FONT-SIZE: 7.5pt; COLOR: green; FONT-FAMILY: 'Arial Black'">---------------------------------------------------------------</SPAN></FONT><FONT=20
Black'">---------------------------------------------------------------</ color=3Dgreen><SPAN style=3D"COLOR: green"> =
Black'">---------------------------------------------------------------</</SPAN></FONT><o:p></o:p></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt">Authors<o:p></o:p></SPAN></FONT></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt"> <st1:place w:st="on"><st1:City
w:st="on">Eckford</st1:City> <st1:State
w:st="on">SD.</st1:State></st1:place> Gingell
JC.<o:p></o:p></SPAN></FONT></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt">Institution<o:p></o:p></SPAN></FONT></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt"> Department of Obstetrics, <st1:PlaceName
w:st="on">Southmead</st1:PlaceName> <st1:PlaceType
w:st="on">Hospital</st1:PlaceType>, <st1:place w:st="on"><st1:City
w:st="on">Bristol</st1:City></st1:place>.<o:p></o:p></SPAN></FONT></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt">Title<o:p></o:p></SPAN></FONT></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt"> Ureteric obstruction in pregnancy--diagnosis
and management.<o:p></o:p></SPAN></FONT></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt">Source<o:p></o:p></SPAN></FONT></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt"> British Journal of Obstetrics &
Gynaecology. 98(11):1137-40, 1991 Nov.<o:p></o:p></SPAN></FONT></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt">Local Messages<o:p></o:p></SPAN></FONT></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt"> All @ UAMS<o:p></o:p></SPAN></FONT></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt">Abstract<o:p></o:p></SPAN></FONT></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt"> OBJECTIVE--To discuss the aetiology,
diagnosis and management of ureteric obstruction in pregnancy and to
describe the use of double-pigtail ureteric stents in a series of 10
patients. DESIGN--Retrospective study of women presenting to a maternity
unit in whom the diagnosis of ureteric obstruction is reached.
SETTING--<st1:PlaceName w:st="on">Southmead</st1:PlaceName> <st1:PlaceType
w:st="on">Hospital</st1:PlaceType> in <st1:City w:st="on"><st1:place
w:st="on">Bristol</st1:place></st1:City>; a large district general hospital
with a throughput of around 6000 maternity patients per year. SUBJECTS--10
women (8 in their first pregnancy, 1 in her second and 1 in her third; mean
age 29.2 years (range 18-31 years). INTERVENTIONS--Double-pigtail ureteric
stents were electively passed after a diagnosis of ureteric obstruction.
Stents remained in situ for a mean 15.5 weeks (range 8-25 weeks) and were
electively removed 4-6 weeks post partum. RESULTS--Nine women progressed
uneventfully through the remainder of their pregnancy. One developed
strangury, haematuria and discomfort after stent insertion. Seven women had
normal vaginal deliveries, two assisted vaginal deliveries and one was
delivered by caesarean section. None required to have external urinary
drainage. CONCLUSIONS--Double-pigtail ureteric stents are easy to place and
remove and are well tolerated. They provide a simple, safe and effective
method of internal upper urinary tract drainage in ureteric obstruction in
pregnancy.<o:p></o:p></SPAN></FONT></P>
<P class=MsoPlainText><FONT face="Courier New" size=2><SPAN
style="FONT-SIZE: 10pt"><o:p> </o:p></SPAN></FONT></P>
<P class=MsoNormal><FONT face=Arial size=3><SPAN
style="FONT-SIZE: 12pt"><o:p> </o:p></SPAN></FONT></P></DIV><!--[object_id=#uams.edu#]-->
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