Case Western Reserve University School of Medicine
Introduction: Nephrolithiasis in pregnant patients is rare but has been linked to obstetric complications including preterm labor, premature rupture of membranes, and loss of pregnancy. For pregnant patients with renal colic who fail conservative management, the American Urological Association (AUA) guidelines recommend primary ureteroscopy (URS), double-J stent (DJS), or percutaneous nephrostomy (PCN). To our knowledge, this is the first study to examine neonatal outcomes following 3 different interventions in pregnant women presenting with an acute stone event.
Methods: After IRB approval, women undergoing a procedure for renal colic during pregnancy at a large multi-center, high-volume institution were retrospectively identified and categorized by initial intervention into 3 groups: DJS, PCN, and URS. Procedural and obstetric outcomes were recorded; neonatal outcomes were linked to maternal data. Intervention groups were compared by a Kruskal-Wallis or Fisher’s Exact Test, as appropriate. If statistical significance was reached at a=0.05, pairwise post-hoc significance testing was performed with a Wilcoxon rank-sum test (a=0.05).
Results: Eighty-one patients met inclusion criteria and were analyzed. Of these, 25 patients were managed with PCN, 45 with DJS, and 11 with URS. Maternal age at presentation, BMI, and maternal comorbidities including diabetes, hypertension, and chronic kidney disease were similar between groups. Gestational age at delivery did not significantly differ between groups (p=0.17). Neonatal Intensive Care Unit (NICU) admission and neonatal abstinence syndrome (NAS) rates were higher in mothers managed with PCN versus DJS (p=0.003 and p=0.01, respectively). No NAS was noted in the URS group. Although not statistically significant, hospital length of stay and respiratory distress syndrome trended higher in the PCN group (p=0.07 and p=0.08, respectively). Rates of other neonatal complications, including pre-term labor and APGAR scores at 1 and 5 minutes did not differ between groups.
Conclusions: Current AUA guidelines list DJS and PCN as safe alternative interventions to URS for managing nephrolithiasis in pregnancy, but our study demonstrates for the first time a higher rate of NAS and NICU admissions for babies born to mothers managed with PCN. All cases of NAS observed in our study occurred in the PCN group, with narcotic use directly linked to management of pain due to PCN. Larger multi-institutional studies are warranted to further explore these possible associations.