Urolithiasis in pregnancy remains a diagnostic and therapeutic challenge. Its presentation may mimic the normal findings of pregnancy and other retroperitoneal and intra-abdominal conditions. Ultrasonography remains the cornerstone of imaging; the role of MRI is continuing to evolve. Modifications of technique may allow safer use of EXU and ultra-low-dose CT as second-line studies when clinically indicated. As most stones will pass spontaneously, expectant management with supportive care should be attempted, but temporary urinary drainage and definitive ureteroscopic management are highly successful if required. Shock wave lithotripsy remains contraindicated in pregnancy. Although the expectant mother who has flank pain is often approached with trepidation, the combination of a high index of suspicion, careful regard for the mother and fetus, and use of well-established endourologic techniques maximizes the possibility of an excellent, stone free outcome.
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