What is the initial treatment for moderate hematuria (blood in urine) in early pregnancy?

Initial Treatment for Moderate Hematuria in Early Pregnancy

Ultrasound of the kidneys and bladder is the initial treatment approach for moderate hematuria in early pregnancy, followed by evaluation for infection and other benign causes before considering more invasive testing after delivery. 1

Diagnostic Approach

First Steps

• Renal and bladder ultrasound: The American College of Radiology recommends ultrasound as the first-line imaging modality for pregnant women with hematuria 1
• Urinalysis and urine culture: To rule out urinary tract infection, which is the most common infection among pregnant women 2
• Blood pressure measurement: To evaluate for preeclampsia, especially if hematuria occurs later in pregnancy

Avoid in Pregnancy

• CT scans and CTU: Not recommended due to radiation exposure risks to the fetus 1
• MRI with gadolinium contrast: Should be avoided due to uncertain effects on the fetus 1
• Intravenous urography (IVU): No longer used as a first-line imaging modality 1

Treatment Algorithm

1. Rule out and treat infection

• If urinalysis/culture positive for UTI:
  • Treatment options: Short course of β-lactams, nitrofurantoin, or fosfomycin 2
  • Avoid: Tetracyclines, fluoroquinolones, and sulfonamides in late pregnancy

2. If no infection is found:

• Conservative management with hydration and rest
• Monitor for worsening symptoms: Flank pain, fever, or increasing hematuria
• Follow-up ultrasound: To monitor for changes in urinary tract

3. For persistent or severe hematuria:

• Consider MRU without contrast: Reasonable alternative if detailed imaging is necessary 1
• Defer complete workup: Full evaluation can be completed after delivery 1

Special Considerations

Potential Causes of Hematuria in Pregnancy

• Physiological changes: Increased renal blood flow and glomerular filtration rate
• Urinary tract infection: Most common infectious cause 2, 3
• Renal calculi: More common during pregnancy due to urinary stasis
• Nutcracker phenomenon: Compression of renal veins by gravid uterus 4
• Glomerular diseases: May be exacerbated during pregnancy
• Acute kidney injury: Can present with hematuria in severe cases 5

Monitoring

• Regular follow-up throughout pregnancy
• Repeat urinalysis to monitor resolution
• Assess for development of proteinuria, which may indicate preeclampsia

Important Caveats

• Malignancy risk is low: The incidence of asymptomatic hematuria in pregnant women is similar to non-pregnant women, with a low rate of malignancy 1
• Avoid unnecessary radiation: Radiation exposure should be minimized during pregnancy
• Defer complete workup: A full evaluation can be completed after delivery once gynecologic bleeding and other benign causes have been excluded 1
• Watch for signs of acute kidney injury: Hematuria with rising creatinine requires urgent evaluation 5

Remember that the primary goal is to rule out serious pathology while minimizing risk to both mother and fetus. Most cases of hematuria in pregnancy are benign and can be managed conservatively until after delivery.