From the Guidelines
Management of hydronephrosis during pregnancy primarily involves conservative approaches unless complications arise, with most cases requiring only observation and regular monitoring with ultrasound, as the condition typically resolves after delivery 1. The goal of management is to prevent complications such as preterm labor, maternal and/or fetal death, and permanent nephron loss, while also alleviating symptoms and improving quality of life. Key aspects of management include:
- Conservative approaches, such as adequate hydration, pain control with acetaminophen (500-1000mg every 6 hours as needed), and position changes, for symptomatic patients 1
- Antibiotics, such as cephalexin (500mg four times daily for 7-14 days) or amoxicillin-clavulanate (875/125mg twice daily for 7-14 days), if urinary tract infection develops 1
- Temporary drainage with ureteral stent placement or percutaneous nephrostomy for severe cases with persistent pain, infection, or impaired renal function, typically performed after the first trimester when possible 1 The physiologic basis for pregnancy-related hydronephrosis includes mechanical compression of the ureters by the enlarging uterus (particularly on the right side) and hormonal effects of progesterone causing ureteral smooth muscle relaxation 1. Close collaboration between obstetricians and urologists is essential for optimal management of complicated cases, with ultrasound playing a crucial role in diagnosis and monitoring, including measurement of anteroposterior diameter of the renal pelvis and diagnosis of causative ureteral stone 1.
From the Research
Management of Hydronephrosis in Pregnancy
- Hydronephrosis in pregnancy can be managed conservatively in most cases, with treatment including analgesics, intravenous fluids, and antibiotics 2, 3.
- Conservative treatment has been shown to be successful in 92.9% to 94% of patients with symptomatic hydronephrosis in pregnancy 2, 3.
- In cases where conservative treatment fails, instrumental drainage of the affected kidney may be necessary, which can be achieved through the insertion of a double pigtail ureteric stent 2, 3 or percutaneous nephrostomy 4.
- The decision to treat hydronephrosis in pregnancy should be based on a multidisciplinary approach, taking into account the severity of symptoms, renal function, and the presence of complications such as pyonephrosis or urosepsis 5.
- Studies have shown that double pigtail stent insertion is an effective treatment for moderate or severe symptomatic hydronephrosis in pregnancy, with a lower failure rate compared to conservative treatment 6.
- However, double pigtail stent insertion may be associated with complications such as stent discomfort and flank pain, and therefore conservative treatment should still be considered as the first line of treatment 6.
Treatment Options
- Conservative treatment:
- Analgesics
- Intravenous fluids
- Antibiotics
- Instrumental drainage:
- Double pigtail ureteric stent insertion
- Percutaneous nephrostomy
- Multidisciplinary approach:
- Renal ultrasonography
- Renography
- Urinalysis
- Serum creatinine levels
- White blood cell counts
- Urine culture
Complications and Outcomes
- Complications of untreated hydronephrosis in pregnancy may include pyonephrosis, urosepsis, and kidney dysfunction 5, 4.
- Studies have shown that treatment of hydronephrosis in pregnancy can lead to good perinatal outcomes, with no increased risk of preterm labor or low birth weight 2, 6.
- However, patients with symptomatic hydronephrosis in pregnancy should be closely monitored for complications and outcomes, and treatment should be individualized based on the severity of symptoms and renal function 5, 6.