Gross hematuria is less common than in afected nonpregnant women. It was a presenting symptom in 23 percent of women described by Butler and associates (2000). In another study, however, only 2 percent had gross hematuria (Lewis, 2003). Sonography is usually selected to visualize stones, but many are not detected because hydronephrosis may obscure indings (Iv1cAleer, 2004). Transabdominal color Doppler sonography to detect presence or absence of ureteral "jets" of urine into the bladder may exclude obstruction (As rat, 1998).
If the ureter is abnormally dilated but no stone is seen, then other imaging studies are indicated. While helical computed tomography (CT) scanning is the preferred imaging method for nonpregnant individuals, the associated x-ray exposure has led some to recommend MR imaging as a second-line test in pregnancy (Masselli, 2015). Thus CT scanning is usually avoided during pregnancy if possible (Curhan, 2015; Masselli, 2015). If it is used, the slices can be tailored as needed. White and colleagues (2007) recommend unenhanced helical CT and cite an average fetal radiation dose to be 7 mGy.
Treatment depends on symptoms and gestational age (Semins, 2014). Intravenous hydration and analgesics are given. In up to half of women with symptomatic stones, infection will be identiied, and this is treated vigorously as described earlier (p. 1029). Although stones infrequently cause symptomatic obstruction during pregnancy, persistent pyelonephritis should prompt a search for obstruction due to nephrolithiasis. Urinary obstruction with concomitant infection is an emergency-"pus under pressure" (Curhan, 2015).
Approximately 65 to 80 percent of symptomatic women will improve with conservative therapy, and the stone usually passes spontaneously (Tan, 2013). Others require an invasive procedure such as ureteral stenting, ureteroscopy, percutaneous nephrostomy, transurethral laser lithotripsy, or basket extraction (Butler, 2000; Johnson, 2012; Semins, 2014). Removal by a flexible basket via cystoscopy, although used less often than in the past, is still a reasonable consideration for pregnant women. In one study, 623 various procedures were performed in 2239 symptomatic pregnant women, but less than 2 percent required surgical exploration (Swartz, 200*). Of other treatments, the need for fluoroscopy limits the utility of percutaneous nephrolithotomy (Toth, 2005). Extracorporeal shock-wave lithotripsy is contraindicated in pregnancy.
Following transplantation, the I-year graft survival rate is 95 percent for grafts from living donors and 89 percent for those from deceased donors. Survival rates approximately doubled between 1988 and 1996, due in large part to the introduction of cyclosporine and muromonab-CD3 (OKT3 monoclonal antibody) to prevent and treat organ rejection. Since then, mycophenolate mofetil and tacrolimus have further reduced acute rejection episodes, however, the former is considered teratogenic (Briggs, 2014). he National Transplant Pregnancy Registry reports that 23 percent of fetuses exposed to mycophenolate had birth defects (Coscia, 2010). Importantly, resumption of renal function after transplantation promptly restores fertility in reproductive-aged women (Hladunewich, 2011; Rao, 2016). But, more than half of transplant recipients in one study reported that they were not counseled regarding contraception (French, 2013).