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Suspected renal colic in pregnancy — MSRA MCQ

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HardUrologySuspected renal colic in pregnancyMSRA

A 34-year-old woman who is 33+4 weeks pregnant presents to an urgent GP assessment service with 6 hours of severe right-sided colicky flank pain radiating to the groin and repeated vomiting. She has had renal stones previously. She is afebrile, haemodynamically stable and has no uterine tenderness or vaginal bleeding. Urine dipstick is positive for blood but negative for nitrites and leucocytes. Serum creatinine is 72 micromol/L, consistent with her booking baseline. She has been unable to retain oral paracetamol. She had an upper gastrointestinal bleed from a peptic ulcer after diclofenac 2 years ago. What is the most appropriate immediate management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Arrange same-day hospital assessment for urgent renal ultrasonography and intravenous paracetamol

This is probable renal colic: abrupt unilateral colicky flank-to-groin pain, vomiting, haematuria and a previous stone history support the diagnosis, while the absence of fever, pyuria, hypotension or acute kidney injury makes infected obstructed ureter less likely. In an adult with suspected renal colic, CT is normally first-line imaging, but NICE specifies ultrasonography instead of CT during pregnancy because of fetal radiation exposure. Imaging should be urgent, within 24 hours; given severe pain and vomiting, same-day hospital assessment is appropriate. An NSAID would ordinarily be first-line analgesia for renal colic, but it is unsuitable here because she is in the third trimester and has a previous NSAID-associated upper gastrointestinal bleed. NICE recommends intravenous paracetamol when NSAIDs are contraindicated or insufficient. Opioids are considered only when both NSAIDs and intravenous paracetamol are contraindicated or have not provided adequate analgesia. A and D incorrectly use CT in pregnancy. B correctly selects ultrasound but incorrectly gives diclofenac. C uses an analgesic reserved for failure or contraindication of intravenous paracetamol and does not select NICE first-line imaging in pregnancy.

Reference: NICE NG118: Renal and ureteric stones: assessment and management, Diagnostic imaging (2019) — https://www.nice.org.uk/guidance/ng118/chapter/recommendations NICE NG118: Renal and ureteric stones: assessment and management, Pain management (2019) — https://www.nice.org.uk/guidance/ng118/chapter/recommendations NICE QS195: Renal and ureteric stones, Quality statement 2: Pain management (2020) — https://www.nice.org.uk/guidance/qs195/chapter/Quality-statement-2-Pain-management