102 SAMJ VOL 77 20 JAN 1990

UrolithiasisA case report

A. D. SCHAMROTH

•In pregnancy

Summary

Urolithiasis in pregnancy is relatively rare and managementrequires slight modification. A case is presented and treat­ment discussed.

S Air Med J 1990; n: 102-104.

Case report

A 31-year-old woman, para 2, gravida 3, presented to hospitalat 26 weeks' gestation complaining of acute onset rIght-sidedloin pain associated with nausea and vomiting. She had hadtwo similar attacks in the preceding days, which resolved spon­taneously. The pregnancy had, until that time, been uneventfulapart from. the persistent severe haematuria and pyuria. Thepast obstetric and medical history was non-contributory.

Physical examination revealed a moderate' pyrexia (38,4°C),tachycardia of 120/min, dehydration and severe back tender­ness on the right side. The fetal heart beat was normal. Urinemicroscopy showed 450000 white cells, 95000 red cells and alarge bacterial count. The white cell count was)8,0 X 109/1.The serum urea and creatinine values were normal.

Ultrasonography of the right kidney showed a large hydro­nephrosis and a hydro-ureter (Fig. 1), and abdominal radio-

Fig. 1. Ultrasonograph of right kidney showing hydronephrosisand hydro-ureter.

Department of Obstetrics and Gynaecology, JohannesburgHospital and University of the Witwatersrand, Johannes­burgA. D. SCHAMROTH, M.B. B.CH. (Present Address; Depr ofObstetrics and Gynaecology, University ofMaryland, Baltimore, Md,USA)

Accepted 19 June 1989.

Fig. 2. Anteroposterior radiograph of the abdomen showingureteric calculus lodged at the level of the pelvic brim on theright side (arrow).

graphy showed a large ureteric stone on the right at the levelof the pelvic brim measuring 3 X 1,5 cm (Fig. 2).

Opiate analgesia and intravenous antibiotics were adminis­tered, and rehydration started. Mter the pain had persisted for24 hours, a percutaneous nephrostomy was performed andfrank pus was drained. Percutaneous insertion of a Frenchdouble T stent proved technically difficult. This catheter wassubsequendy successfully inserted using a retrograde cysto­scope.

I=ediate relief was obtained. The patient made an unevent­ful recovery and was discharged from hospital. Thereafterweekly ultrasonographic assessments of the kidney and ureterwere performed, and also estimations of the serum urea andcreatinine levels, and urine microscopy. No further deteriora­tion of renal structure or function was noted, but there waspersistence of both red and white cells on urine microscopy.

The patient went into spontaneous labour at 38 weeks'gestation and delivered a healthy infant vaginally.

Owing to the patient temporarily defaulting, definitive treat­ment was only provided 12 weeks later. A ureterolithotomy

was performed, and the double T stent removed. At surgery adilated and thickened ureter was found.

Lithotripsy was considered inappropriate, since the stonelay in close proximity to the bony pelvis. Ureteroscopic removalwas felt to be contraindicated because the condition waschronic and there was a risk of injury to the ureter.

Discussion

The incidence of urolithiasis in pregnancy (0,03 - 0,53%),1,2the rate of recurrence, and the relative incidence of the varioustypes of stones are similar to that in the non-pregnant popu­lation.1,3 In pregnancy, however, a greater percentage of stonesmigrate down the ureter and often cause obstruction at thelevel of the pelvic brim.2 As in the non-pregnant condition,left- and right-sided stones occur with equal frequency.l,2,4Multiparous women are more commonly affected than primi­parous women (ratio 3:1).1,2,4 The initial presentation morecommonly occurs in the second and third trimester - up to90% may occur during this time. l,2,4

While there are various factors in pregnancy that may bothincrease and decrease the likelihood of stone formation, the neteffect is negligible. 1,3

With the exception of premature labour (incidence as higha.s 66~t5 and an ~crease~ incidence of urinary tract infec­tIons,' pregnancy IS essentIally unaffected by the presence ofrenal stones.3 A single case of mechanically obstructed labouras a direct result of a ureteric calculus has been reponed.7 Theincidence of abortion as a result of renal stones remainsunknown.3,8

The presentation of urolithiasis in pregnancy is much thesame as in the non-pregnant state, with pain commonly beingthe presenting complaint.6 Fever, nausea, emesis, dysuria andurgency may also be present. Signs commonly present arepyrexia, pyuria, crystaluria, haematuria and costovenebralangle tenderness.

Urine microscopy will usually reveal microscopic haematuriawith or without the presence of white cells and bacteria. Thepersistence of fever after 48 hours of antibiotic therapy shouldalen the clinician to the possibility of calculus over and abovethe presence or absence of a urinary tract infection.

Ultrasonography is of use as a screening test when there issuspicion of urolithiasis, and assists percutaneous nephrostomy.Limitations of ultrasonography are that ureteric calculi may becompletely missed and there may be difficulty in distinguishingbetween pathological hydronephrosis and the physiologicaldilatation of the ureter in pregnancy.1

To minimise fetal exposure to radiation, the following radio­diagnostic protocols are suggested: 1,5,9 (i) a single anteropos­terior abdominal radiograph; and (il) while the necessity forurography must be assessed in each case, the following situa­tions may indicate a need for a limited-exposure intravenouspyelogram: (a) persistent fever after 48 hours of antibioticcover; (b) rising serum urea nitrogen and creatinine levels; (c)ultrasonographic demonstration of significant hydronephrosis;and (d) persistent vomiting resulting in dehydration. A 'limitedintravenous pyelogram' means that the first exposure is taken30 - 60 minutes after the injection of contrast. A second andthird fIlm, if required, may be taken at 9O-minute intervals. Ifstill inadequate, a fourth fIlm may be taken 3 hours later.s

Nuclear imaging techniques, such as the radionucleotiderenogram and renal scan, do not offer much additional infor­mationl and are consequently not routinely used.

Several different treatment modalities are available andshould be individualised for each patient. They are: (I) conser­vative management;' and (il) intervention - percutaneousdrainage or surgical intervention (bypassing or removing theobstruction).

SAMT VOL 77 20 JAN 1990 103

Extracorporeal shock wave lithotripsy is contraindicated inpregnancy.6

Considerations to be borne in mind when deciding on whatmode of therapy to use are: (I) location of the stone; (il) degreeof obstruction; (iil) presence or absence of infection; (iv)general condition of the patient; and (v) gestational age of thefetus.

As a general rule, the more aggressive modes of 'therapyshould, where possible, be delared until after pregnancy.6

Conservative management l ,2, ,6,10 comprises analgesia, hydra­tion and, where applicable, antibiotics. Following this regimen,more than 50% of all stones will be passed spontaneously. 1,2,4,6,10Promotion of a diuresis and increased urine alkalinity may alsobe advantageous.6

Interventional therapy is indicated in the following situa­tions:1,1O (I) calculus pyelonephritis/pyonephrosis; (il) persistenthydronephrosis; (iil) protracted and unremining pain; and (iv)documented impairment of renal.function. Such' interventionis associated with minimal risk to both fetus and niother,2 andmay take one of the following forms:

1. Percutaneous nephrostomy drainage is indicated whenendoscopic manipulation is technically impossible, and whenopen surgery is contraindicated because the risk. of prematurelabour in the early third trimester would significantly com­promise the fetus.s

2. Obstruction bypass is accomplished by means of a doubleT stent. It is panicularly useful for the relief of pain andsepsis in the first and second trimester. At this gestational age,the enlarging uterus has not yet significantly distoned thepelvic and ureteric anatomys making the procedure technicallydifficult. The stent may be left in sicu for up to 9 months withfew urological complications.s

3. Removal of the obstruction is more commonly performedby percutaneous or endoscopic means than by open surgery,which was previously routinely practised.

With regard to fetal outcome, it should be emphasised thatthere are no significantly increased risks to the fetus for any ofthe recently developed techniques. Normal babies with appro­priately distributed Apgar scores and normal birth-weightdistributions can be expected. ll If, however, the stone is dueto maternal hypercalcaemia, the infant's parathyroid glandmay have been suppressed in utero. In such a case, neonatalhypoparathyroidism may occur.

Conclusion

Urolithiasis has a minimal effect on, and is linle altered by,pregnancy. Suspicion should, however, be alened in cases ofurinary tract infection that fail to respond to routine medica­tion, and in those patients presenting with atypical abdominalpain.

The development of new techniques for the treatment ofurolithiasis have reduced the acute phase protlem. This allowsthe physician to treat the patient conservatively and delaydefinitive therapy until the pregnancy is over.

REFERENCES

1. Horowitz E, Joseph JD. Renal calculi in pregnancy. Clin Obs/tl Gynecol1985; 28: 324-338.

2. Lattanzi OR, Cook WA. Urinary calculi in pregnancy. Obm! GynecoI1980;56: 462-466.

3. Coe FL, Parks JH, Lindheimer MD. Nephrolithiasis during pregnancy. NEnglJ Med 1978; 298: 324-326.

4. Hedegaard CK, WalIace D. Percutaneous nephrostomy: current indicationsand potenoaJ uses m obsretncs and gyneco1ogy - literature review andrepon of a case. Obs/tl Gynecol SUTV 1987; 42: 671-675.

5. Drago J, Rohner TJ, Chez RA. Management of urinary calculi in pregnancy.Urology 1982; 20: 578-581.

104 SAMJ VOL 77 20 JAN 1990

6. Maikranz P, Coe FL, Parks JH, Lindheimer MD. The urinary tract inpregnancy. Baillieres elin Obsrer Gynaecol 1987; 1: 909-919.

7. Armon PI. Obstructed labour due to a vesical calculus. Br Med] 1977; 2:498.

8. Honore LH. The increased incidence of renal stones in women withspontaneous abortion: a retrospective study. Am] Obsrer Gynecol 1980; 137:145-146.

9. Miller RD, Ka1<I<is J. Prognosis, management and outcome of obstructiverenal disease in pregnancy.] Reprod Med 1982; 27: I99-20I.

10. Cass AS, Smith CS, Gleich P. Management of urinary calculi in pregnancy.Urology 1986; 28: 370-372.

II. Cumming DC, Taylor PJ. Urologic and obstetric significance of urinarycalculi in pregnancy. Obscec Gynecol 1979; 53: 505-508.

Summer-type hypersensitivitysouthern AfricaA report of 5 cases in one family

G. H. SWINGLER

• •pneumonItIs •In

Summary

Five patients, from a family of 8 who all lived in the samehouse, developed chronic hypersensitivity pneumonitis. The4 patients followed up showed features strikingly similar tosummer-type hypersensitivity pneumonitis, previously thoughtunique to Japan. The clinical setting and limited immuno­logical investigations suggest the cause to be a bacterial orfungal groW1h in the roof of the house.

S Atr Med J 1990; 77: 104-107.

Hypersensitivity pneumonitis, an immunological lung diseaseresulting from exposure to a wide range of inhaled organicdusts, may take either an acute or a chronic form.! A form ofchronic hypersensitivity pneumonitis that detetiorates duringsummer and early autumn has been described in Japan andhas been thought to be unique to that country.2 Five patients,from one family in Ciskei, with chronic hypersensitivitypneumonitis and deterioration during summer are reported.

Case reports

Results of laboratory investigations are shown in Table I.

Case IA lO-year-old girl presented to hospital with a 3-month

history of dyspnoea and cough. No preceding problems werereported. The mass was 50% of that expected for age and thepatient was cyanosed, with clear-cut finger clubbing. Fineinspiratory crackles were audible at both lung bases. Chestradiography (Fig. 1) showed diffuse soft infiltrative consolida-

Department of Paediatrics, Cecilia Makiwane Hospital,Mdantsane, CiskeiG. H. SWINGLER, F.C.P. (S.A.)

Accepted 24 Mar 1989.

Fig. 1. Chest radiograph of case 1 showing diffuse interstitialconsolidation and nodular shadows.

tion with nodularity. Partial arterial oxygen pressure (P02)while breathing room air was 6,5 kPa and partial carbondioxide pressure (PC02) was 5,6 kPa. The forced vital capacity(FVC) was 0,55 1 (33% of the predicted value for height) andforced expiratory volume in 1 second (FEV1) was 0,41 (29% ofpredicted value). The FEV1/FVC ratio was 73%. Open lungbiopsy showed several small inflammatory granulomas withoutcentral necrosis, with one multinuclea~ed giant cell present.While in hospital on antibiotic and anti tuberculosistreatment, the patient showed marked clinical improvementand the FVC improved from 33% to 45% of predicted value.Treatment with prednisone resulted in further improvementof the FVC to 67% of predicted value.