Symptomatic hydronephrosis during pregnancy presents a challenging clinical dilemma as management must balance maternal symptom control with fetal safety while avoiding ionizing radiation and unnecessary surgical intervention. We report the case of a 21-year-old primigravida at 27 1/7 weeks of gestation, who presented with severe bilateral flank pain, despite sonography showing only bilateral grade 2 hydronephrosis. Conservative management, including hydration, antibiotics, and analgesics, was initiated; however, her symptoms progressively worsened. Following multidisciplinary consultation, diagnostic ureteroscopy with bilateral double-J ureteral stent placement was performed. The patient experienced rapid pain relief after stent placement, and the pregnancy progressed uneventfully to term delivery. This case highlights that clinical severity, rather than imaging prediction, should guide escalation to intervention in pregnancy-associated hydronephrosis. Clinical severity, infection status, and obstetric context should guide intervention decisions when conservative management fails.
Chen et al. (2026) studied this question.