Case Study - November 2010

A 34 year old lady who was 26 weeks pregnant presented to the maternity unit with a 5 day history of gradual onset right loin pain. Her right loin pain worsened over a period of a few hours and an urgent ultrasound of the kidneys was arranged.

  1. What does the above ultrasound images show?
  2. What are the causes of this condition?
  3. What is the pathophysiology of pregnancy associated hydronephrosis?
  4. How would you manage this patient?

Reveal Answer

Open answer There is no fixed answer to this question, however your response should be similar to the one below:

  1. The ultrasound shows bilateral hydronephrosis. There is evidence of partial decompression of the right kidney with a large hypoechoic area seen around the right kidney and ureter. The appearances are suggestive of fluid around the right kidney and ureter and given the partial decompression of the right kidney, the appearances are likely to be that of an urinoma.
  2. Causes of acute hydronephrosis during pregnancy include physiological pregnancy associated hydronephrosis, urolithiasis or obstruction along the urinary tract. This patient was noted to have a large intrauterine fibroid which is causing mechanical blockage of both her ureters.
  3. May be due to ureteral smooth muscle relaxation in response to high levels of circulating progesterone during pregnancy. May also be due to mechanical compression of the ureters by the enlarging uterus at the level of the pelvis brim where the ureters cross the iliac vessels. Note that hydronephrosis during pregnancy is often worse on the right side because of pressure due to physiologic engorgement of the right ovarian vein and dextrorotation of the uterus.
  4. Primary management should be to relieve pressure and allow temporary diversion of urine by insertion of bilateral nephrostomy tubes or bilateral retrograde JJ stents. Nephrostomy insertion in this patient would be difficult as the right kidney is already partially decompressed, therefore cystoscopy and bilateral retrograde JJ stent insertion would be the preferred management choice. Careful consideration needs to be given to the risk to the unborn baby due to the use of anaesthetic agents and radiation exposure during JJ stent insertion.

Ultrasound image of left ureteric stent placement performed under U/S guidance alone.

illustrative image for answer to question $n

The cookie setting on this website is set to ‘allow cookies’ to give you the very best experience.

If you continue without changing this setting, you consent to this - but if you want, you can change your setting at any time using the ‘change cookie setting’ link at the bottom of this page.

Cookie Setting

Our Cookies

Cookie NamePurpose
eu_ask This is used to store the cookie setting you set in the form above.
If you choose 'Do Not Allow Cookies' we will need to store this information as a cookie with the value N.
If you choose 'Allow Cookies' or do not make a choice, we will store this information as a cookie with the value Y.

The value is kept for one year.

3rd Party Cookies

Cookie NamePurpose
Google Analytics This website uses Google Analytics, a web analytics service provided by Google, Inc.
Google Analytics sets a cookie in order to evaluate your use of the website and compile reports for us on activity on the website.
Google stores the information collected by the cookie on servers in the United States.
Google may also transfer this information to third parties where required to do so by law,
or where such third parties process the information on Google's behalf.
Google will not associate your IP address with any other data held by Google
By using this website, you consent to the processing of data about you by Google in the manner and for the purposes set out above.

How to reject or delete this cookie