Symptomatic Hydronephrosis and Ureteral Calculi in Pregnancy: A Narrative Review with a Proposed Management Protocol.

Introduction: Approximately 3% of pregnancies are complicated by symptomatic hydronephrosis and up to 0.8% with urolithiasis. Pain, coupled with the possibility of superimposed infection, increases the risks of premature labor and delivery, fetal loss, and caesarian sections. Surgical intervention as well as standard ionizing radiation imaging modalities are typically avoided making this a difficult, high-risk patient cohort to manage. In this study we propose a standardized contemporaneous approach to investigations and management in the pregnant population with acute upper tract pathology analysis. Methods: A literature search of PubMed, Cochrane, and EMBASE databases was performed to identify original, peer-reviewed articles from 2010 onward on the management of ureteral calculi and symptomatic hydronephrosis occurring during pregnancy. Search yielded 5636 articles and after exclusions, 24 full-text articles met inclusion criteria for analysis. Evidence Synthesis: Ultrasound remains the cornerstone of initial investigation with MRI in reserve if the diagnosis remains uncertain. Low-dose CT imaging can be used in limited cases. Conservative approaches for symptomatic hydronephrosis as well ureteral calculi is the preferred initial management option in the well patient. If intervention is required, ureteral stent and nephrostomy can be used with informed consent on the risks and benefits of each. Primary ureteroscopy with definitive stone management in centers with the appropriate expertise can safely deliver excellent stone-free rates and symptomatic improvement. Conclusions: Individualized investigation and management plans following a structured approach in pregnant women with symptomatic hydronephrosis or calculi are discussed. At all stages, the patient, obstetrician, anesthetist, and surgeon should be involved in a shared decision-making approach.