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Suspected renal colic in third-trimester pregnancy — MSRA MCQ

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HardNephrolithiasisSuspected renal colic in third-trimester pregnancyMSRA

A 30-year-old woman who is 31+4 weeks pregnant presents to an urgent treatment centre with 6 hours of severe, intermittent right flank pain radiating to the groin and vomiting. She is afebrile, haemodynamically stable and has right costovertebral-angle tenderness. Urine dipstick is positive for blood but negative for nitrites and leucocytes. Her creatinine is normal. She has not taken analgesia. There is no vaginal bleeding, uterine tenderness or contraction pattern. What is the most appropriate immediate management?

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

Reveal the answer and explanation

Correct answer: E — Arrange urgent renal tract ultrasound and administer intravenous paracetamol

Explanation lettering: E = shown as B · B = shown as C · C = shown as E

This presentation is consistent with suspected renal colic without features of infected obstruction or haemodynamic instability. In pregnancy, NICE recommends urgent ultrasound rather than CT as first-line imaging for suspected renal colic. At 31+4 weeks, diclofenac is contraindicated because this is the third trimester. NICE recommends intravenous paracetamol when NSAIDs are contraindicated or ineffective; opioids are reserved for when both NSAIDs and intravenous paracetamol cannot be used or have failed. A is inappropriate because both CT and diclofenac are unsuitable in this setting. B selects the correct imaging modality but oral paracetamol is not the recommended second-line acute analgesic route when an NSAID cannot be used. D is plausible given severe pain and vomiting, but morphine is premature before intravenous paracetamol has been tried, provided there is no immediate need for resuscitation or urgent intervention. E uses appropriate analgesia but magnetic resonance urography is not the recommended initial investigation; it may have a later specialist role if ultrasound is non-diagnostic and diagnostic uncertainty persists.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — Recommendations (8 January 2019; last reviewed 26 February 2021) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations Diclofenac sodium Dexcel SR 75 mg Prolonged-release Tablets — Summary of Product Characteristics (May 2026) — https://www.medicines.org.uk/emc/product/2661/smpc