What is the management for acute urinary retention in a pregnant woman at 13 weeks gestation?

Management of Acute Urinary Retention in Pregnancy at 13 Weeks

Immediate bladder decompression via urethral catheterization is the first-line management for acute urinary retention in a pregnant woman at 13 weeks gestation, followed by identification and treatment of the underlying cause.

Etiology and Assessment

Acute urinary retention (AUR) during early pregnancy is rare but requires prompt intervention to prevent complications. The most common causes at 13 weeks include:

• Retroverted (tilted) uterus - most common cause 1, 2
• Pelvic adhesions from previous surgeries or infections 1
• Uterine fibroids impacting the bladder neck 3
• Urinary tract infection 1, 4

Key assessment findings to identify:

• Duration of inability to void
• Lower abdominal pain and distension
• History of previous pelvic surgeries or infections
• Presence of fever or urinary symptoms suggesting infection

Management Algorithm

Step 1: Immediate Management

• Perform urethral catheterization to decompress the bladder 5, 6
• Document residual urine volume
• Obtain urine sample for culture if infection is suspected 7

Step 2: Diagnostic Evaluation

• Renal ultrasonography with color Doppler as first-line imaging to:
  • Evaluate for hydronephrosis
  • Assess uterine position (retroverted vs. anteverted)
  • Rule out obstructive uropathy from stones 5, 7

Step 3: Treatment Based on Underlying Cause

1. For retroverted uterus:

   • Manual disimpaction and repositioning of the uterus into anterior position 1, 3
   • Knee-chest position to help reposition the uterus 1
   • Consider vaginal pessary as a temporizing measure if manual repositioning fails 3

2. For urinary tract infection:

   • Obtain urine culture before starting antibiotics 7
   • Initiate appropriate antimicrobial therapy for 4-7 days 7
   • Choose antibiotics safe in pregnancy (e.g., nitrofurantoin, β-lactams) 7

3. For obstructive uropathy (e.g., stones):

   • Conservative management with hydration and appropriate pain control as first-line approach 5
   • If conservative management fails, consider retrograde ureteral stenting 7, 5
   • Percutaneous nephrostomy only if retrograde stenting fails or in cases of severe infection 7, 5

Step 4: Follow-up Management

• Trial without catheter after 1-3 days if cause has been addressed 6
• Consider alpha-1 adrenergic blockers before catheter removal to improve chances of successful voiding 6
• Regular ultrasound monitoring every 2-4 weeks if conservative management is chosen 5

Complications and Precautions

• Untreated AUR can lead to bladder rupture, miscarriage, or uterine rupture 2
• Interventional procedures carry risks of ureteral injury, perforation, or sepsis that could lead to preterm labor 7
• Avoid NSAIDs for pain management during pregnancy 5
• Coordinate care with obstetrician for any interventional management 5

Special Considerations

• For patients with recurrent episodes, clean intermittent catheterization may be necessary until the uterus ascends into the abdominal cavity (typically by 16-20 weeks) 3
• Definitive treatment of any underlying cause (e.g., stones) should generally be deferred until postpartum unless absolutely necessary 5
• Screening for and treating asymptomatic bacteriuria is recommended during pregnancy to prevent complications 7

Prompt recognition and appropriate management of AUR in early pregnancy are essential to prevent complications and ensure the safety of both mother and fetus.