How does treating constipation help in a pregnant patient with severe right hydronephrosis and a likely forniceal rupture?

From the Guidelines

Treating constipation in a pregnant patient with severe right hydronephrosis and likely forniceal rupture is crucial to reduce mechanical pressure on the already compromised urinary tract, and this can be achieved by increasing fluid intake, consuming fiber-rich foods, and using pregnancy-safe laxatives such as polyethylene glycol or lactulose, as recommended by the AGA clinical practice update on pregnancy-related gastrointestinal and liver disease 1.

Key Considerations

• The treatment of constipation in pregnant patients with severe right hydronephrosis and likely forniceal rupture should prioritize the use of dietary fiber, lactulose, and polyethylene glycol–based laxatives, as these are considered safe and effective options during pregnancy 1.
• Increasing fluid intake to 2-3 liters daily and consuming fiber-rich foods can help promote regular bowel movements and prevent constipation, which is essential in reducing mechanical pressure on the urinary tract 1.
• Physical activity within pregnancy limitations should also be encouraged to help relieve constipation and improve overall health outcomes.

Physiological Basis

The physiological basis for this approach is that a distended bowel filled with hardened stool can directly compress the ureter, especially on the right side where the ascending colon lies adjacent to the urinary tract, exacerbating existing hydronephrosis and increasing pressure in the collecting system 1.

Clinical Implications

By relieving constipation, the additional mechanical obstruction is removed, potentially improving urine drainage, reducing renal pelvic pressure, and allowing the forniceal rupture to heal more effectively while preventing further complications like urinary tract infections or worsening renal function, as supported by the AGA clinical practice update on pregnancy-related gastrointestinal and liver disease 1.

Additional Considerations

In settings where ureteral catheterization is not technically possible, percutaneous nephrostomy (PCN) can safely provide temporary urinary tract decompression, although the data are from small observational series, and the procedure should be performed with caution and consideration of the potential risks and benefits 1.

From the Research

Treating Constipation in Pregnant Patients with Severe Right Hydronephrosis and Likely Forniceal Rupture

• Treating constipation in pregnant patients with severe right hydronephrosis and a likely forniceal rupture can help alleviate symptoms and prevent further complications 2.
• Constipation can exacerbate the condition by increasing intra-abdominal pressure, which can worsen hydronephrosis and potentially lead to more severe consequences such as forniceal rupture 2.
• The use of laxatives such as macrogol and lactulose is recommended as first-line therapy for treating chronic constipation during pregnancy, as they are considered safe and effective 2.
• In cases where constipation is severe, treating it promptly can help reduce the risk of premature labor and delivery, fetal loss, and caesarian sections associated with symptomatic hydronephrosis and ureteral calculi 3.

Management of Hydronephrosis and Forniceal Rupture

• The management of symptomatic hydronephrosis during pregnancy typically involves conservative treatment, with ureteral stenting or percutaneous nephrostomy reserved for refractory cases 4, 5.
• In cases of forniceal rupture, percutaneous nephrostomy may be considered as a treatment option to relieve obstruction and prevent further complications 5.
• The decision to intervene should be made on a case-by-case basis, taking into account the patient's overall health, the severity of the condition, and the potential risks and benefits of each treatment option 3, 6.

Importance of Individualized Care

• Pregnant patients with severe right hydronephrosis and a likely forniceal rupture require individualized care, with a multidisciplinary approach involving obstetricians, anesthetists, and surgeons 3.
• The patient should be involved in the decision-making process, and informed consent should be obtained before any intervention 3.
• Close monitoring and follow-up are essential to ensure the best possible outcomes for both the mother and the fetus 4, 3, 5, 6.