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Write prescription for a patient with complaints of abdominal pain radiating to back…with left side flank pain and burning micturation Patient is primigravida with 29weeks gestational age USG done suggestive of left side multiple renal calculus

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renal calculi nephrolithiasis pregnancy management

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Prescription

Dr. [Name], MBBS / MD (Obs & Gynae) [Hospital/Clinic Name, Address] Date: 31-May-2026 Reg. No.: ________
Patient Name: _________________ Age: _____ yrs IP/OP No.: _________ Wt.: _____ kg Diagnosis: Left renal calculi with ureteric colic + symptomatic UTI (burning micturition) in pregnancy Gestational Age: 29 weeks (G1P0 - Primigravida) USG finding: Multiple left renal calculi

Rx

1. IV / Oral Hydration
  • IV Normal Saline 1000 mL over 4 hours, then oral fluids 3-3.5 L/day
  • Rationale: Increases urine flow, promotes spontaneous stone passage. First-line measure. (Creasy & Resnik, p. 1383)
2. Analgesic - Pain Relief
Tab. Paracetamol (Acetaminophen) 500 mg - 1000 mg
  • 1 tab every 6 hours orally as needed for pain
  • First-line analgesic in pregnancy - safest option
If pain uncontrolled (severe colic): Inj. Tramadol 50 mg IV/IM (slow IV, diluted in 100 mL NS)
  • Every 8-12 hours as needed; use short duration only
  • Monitor fetal heart rate
  • Opioid analgesics are acceptable for uncontrolled renal colic in pregnancy when acetaminophen is insufficient. (Creasy & Resnik, p. 1383)
Note: NSAIDs (Diclofenac, Ketorolac, Ibuprofen) are CONTRAINDICATED at 29 weeks gestation - risk of premature closure of ductus arteriosus and oligohydramnios.
3. Antiemetic
Tab. Ondansetron 4 mg
  • 1 tab orally every 8 hours as needed for nausea/vomiting
  • Antiemetics are recommended as adjuncts in renal colic management during pregnancy. (Brenner & Rector's The Kidney, p. 2163)
4. Antibiotic (for UTI - burning micturition)
Tab. Cephalexin 500 mg
  • 1 tab orally twice daily (BID) for 7 days
  • Cephalosporins are first-line antibiotics for UTI in pregnancy - safe, active against common uropathogens. (Rosen's Emergency Medicine, p. 305)
OR (based on local antibiogram / culture sensitivity)
Tab. Amoxicillin-Clavulanate 625 mg
  • 1 tab orally every 8 hours for 7 days
Note: Trimethoprim-sulfamethoxazole is AVOIDED in third trimester (risk of neonatal hyperbilirubinemia/kernicterus). Fluoroquinolones (Ciprofloxacin, Norfloxacin) are CONTRAINDICATED in pregnancy (fetal cartilage toxicity). Nitrofurantoin AVOID at term (risk of neonatal hemolytic anemia).
5. Antispasmodic (ureteric smooth muscle relaxant)
Tab. Hyoscine Butylbromide (Buscopan) 10 mg
  • 1 tab orally every 8 hours as needed for colic
  • Smooth muscle antispasmodic for ureteric spasm relief
6. Urine Alkalinizer (supportive, for burning micturition)
Sachets Potassium Citrate (Alkasol / Uricool)
  • 1 sachet in 200 mL water, 3 times daily after meals for 5-7 days
  • Reduces burning micturition, alkalinizes urine; safe in pregnancy
7. Folic Acid (ongoing)
Tab. Folic Acid 5 mg
  • 1 tab orally once daily (continue routine supplementation)
8. Send Investigations:
TestPurpose
Urine Routine & MicroscopyConfirm hematuria, pyuria
Urine Culture & SensitivityGuide antibiotic choice
CBC (Complete Blood Count)Rule out sepsis/leukocytosis
Serum Creatinine + UreaAssess renal function
Serum Electrolytes (Na, K, Cl)Baseline
Serum Calcium, Uric AcidStone metabolic workup
Urine calcium:creatinine ratioHypercalciuria screening
Non-stress Test (NST)Fetal well-being (colic may trigger preterm labor)

Non-Pharmacological Advice

  • Lie on the right/non-affected side to reduce ureteric compression by gravid uterus on left ureter
  • Avoid calcium supplements unless dietarily necessary
  • Drink plenty of fluids throughout the day
  • Monitor for fever, rigors, decreased fetal movements - report immediately

Follow-up & Escalation Criteria

Refer to Urology / Nephrology / MFM if:
  • Fever persists or spikes (suspect pyelonephritis/urosepsis)
  • Uncontrollable pain despite analgesia
  • Rising serum creatinine (bilateral obstruction, AKI)
  • Stone >10 mm or solitary functioning kidney obstruction
  • Preterm labour contractions
Surgical options if conservative fails:
  • Ureteral stent (DJ stent) placement under local anesthesia - requires exchange every 4-6 weeks
  • Percutaneous nephrostomy tube (if stenting fails)
  • Ureteroscopy with laser lithotripsy (becoming primary surgical option in pregnancy)
  • Shock Wave Lithotripsy (ESWL) is CONTRAINDICATED in pregnancy
  • PCNL is CONTRAINDICATED in pregnancy
Prognosis: Up to 75-80% of ureteral stones pass spontaneously during pregnancy due to physiologic ureteral dilation. Conservative management is appropriate in most cases. (Creasy & Resnik's Maternal-Fetal Medicine, p. 1383; Brenner & Rector's The Kidney, p. 2163)
Signature: _________________ Stamp / Registration No.: ________________

Key Prescribing Safety Summary

Drug ClassSAFE in Pregnancy (29 wks)CONTRAINDICATED
AnalgesicsParacetamol, short-course Opioids (Tramadol/Morphine)NSAIDs (risk: ductus arteriosus closure, oligohydramnios)
AntibioticsCephalexin, Amoxicillin-ClavulanateFluoroquinolones, TMP-SMX (in 3rd trimester), Nitrofurantoin (near term)
Stone proceduresDJ Stent, Nephrostomy, UreteroscopyESWL, PCNL
Diuretics-Thiazides, Allopurinol
Sources: Creasy & Resnik's Maternal-Fetal Medicine (7th Ed.); Brenner & Rector's The Kidney; Smith & Tanagho's General Urology (19th Ed.); Rosen's Emergency Medicine
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