A 31-year-old woman, gravida 2, para 1, at 26 weeks gestation is evaluated in the clinic f… — USMLE Step 2 CK

A $31$ -year-old woman, gravida $2$ , para $1$ , at $26$ weeks gestation is evaluated in the clinic for right-sided flank discomfort that began $5$ days ago. The pain is described as a dull, constant ache and is not exacerbated by movement. She denies dysuria, hematuria, fever, chills, or vaginal bleeding. Fetal movement is active. Her prior pregnancy was uncomplicated. Temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $112/72\text{ mm Hg}$ , and pulse is $82/\text{min}$ . Physical examination shows a gravid uterus consistent with gestational age. There is mild right costovertebral angle tenderness, but no abdominal guarding or rebound. Urinalysis reveals no leukocytes, nitrites, or erythrocytes. A right upper quadrant and renal ultrasound demonstrates mild dilation of the right renal pelvis and proximal ureter without evidence of shadowing calculi. The left kidney and ureter are unremarkable. Which of the following is the most appropriate next step in management of this patient?

Observation and standard prenatal follow-upCevap
B
Prescription for oral cephalexin therapy
C
Magnetic resonance urography without contrast
D
Urology consultation for ureteral stent placement
E
24-hour urine collection for total protein

Cevap

Observation and standard prenatal follow-up

The correct management is observation and standard prenatal follow-up. This patient is experiencing physiologic hydronephrosis of pregnancy. During pregnancy, high levels of progesterone cause smooth muscle relaxation, leading to decreased ureteral peristalsis and dilation of the renal pelvis and ureters. Additionally, as the uterus enlarges, it naturally dextrorotates (turns to the right) due to the presence of the sigmoid colon on the left. This dextrorotation causes the uterus to compress the right ureter at the pelvic brim, resulting in right-sided hydroureter and hydronephrosis. This is a normal physiologic adaptation that occurs in up to

80\%

of pregnancies, is typically asymptomatic but can cause mild flank ache, and requires no intervention as long as there is no evidence of infection (e.g., negative urinalysis, afebrile) or intractable pain suggesting nephrolithiasis.

Adım Adım Çözüm

Evaluate the clinical presentation and diagnostic findings.

The patient is a pregnant woman in her second trimester with mild right-sided flank pain, normal vital signs, a benign urinalysis, and ultrasound findings of isolated right-sided hydronephrosis and hydroureter.

Synthesizing the data helps differentiate between a pathologic process (like infection or stones) and a normal physiologic adaptation.

Identify the etiology of the right-sided urinary tract dilation.

The dilation is a normal physiologic change of pregnancy caused by progesterone-induced smooth muscle relaxation and mechanical compression of the right ureter by the dextrorotated gravid uterus.

Recognizing physiologic hydronephrosis prevents unnecessary testing and potentially harmful interventions.

Determine the appropriate management.

Since the findings represent a normal physiological state without evidence of infection or pathological obstruction, expectant management is indicated.

Standard prenatal care is the correct approach for normal adaptations to pregnancy.

Anahtar Kavram

Physiologic hydronephrosis of pregnancy

Tahmini Süre:1m 15s

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Cevap

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