How to manage abdominal pain and dysuria in a pregnant woman?

Management of Abdominal Pain with Burning Micturition in Pregnancy

For pregnant women with abdominal pain and dysuria (burning during urination), a urinary tract infection (UTI) should be suspected and treated promptly with appropriate antibiotics to prevent complications such as pyelonephritis, preterm birth, and low birth weight. 1, 2

Initial Assessment and Diagnosis

• Urinary tract infections are the most common bacterial infection during pregnancy, affecting up to 10% of pregnant women 2
• Three clinical types of UTIs in pregnancy include asymptomatic bacteriuria (ASB), cystitis (lower UTI), and pyelonephritis (upper UTI) 2, 3
• Symptoms of cystitis include dysuria, frequency, urgency, and suprapubic pain without systemic symptoms 4
• Obtain a clean-catch midstream urine specimen for urinalysis and culture before starting antibiotics 1
• Significant bacteriuria is defined as ≥10^5 colony-forming units per mL of a single uropathogen 5
• Ultrasound should be the first imaging modality if additional imaging is needed to rule out other causes of abdominal pain 1

Treatment Approach

For Uncomplicated Lower UTI (Cystitis)

• Begin empiric antibiotic therapy while awaiting culture results 1, 6
• First-line options include:
  • Nitrofurantoin 100 mg PO twice daily for 5-7 days (avoid in G6PD deficiency and near term) 7, 8, 9
  • Amoxicillin-clavulanate 500/125 mg PO three times daily for 5-7 days 10, 6
  • Cephalexin 500 mg PO four times daily for 5-7 days 7, 9
• Avoid fluoroquinolones and tetracyclines during pregnancy due to potential adverse effects on fetal development 7, 8

For Suspected Pyelonephritis

• Hospitalization is often required for IV antibiotics and hydration 7, 9
• Initial IV therapy options include ceftriaxone, ampicillin plus an aminoglycoside, or an extended-spectrum cephalosporin 7
• After clinical improvement, transition to oral antibiotics based on culture sensitivity for a total 10-14 day course 7, 9

Special Considerations

• All pregnant women should be screened for asymptomatic bacteriuria at the first prenatal visit 1, 5
• Even asymptomatic bacteriuria requires treatment in pregnancy, as 20-35% of untreated cases can progress to pyelonephritis 1, 9
• Group B Streptococcus in urine at any colony count requires treatment during pregnancy 5
• Distinguish between contamination (e.g., Lactobacillus) and true bacteriuria requiring treatment 5
• Obtain follow-up urine culture after completing treatment to confirm clearance of infection 7

Imaging Considerations

• Ultrasound is the first-line imaging modality for pregnant women with abdominal pain 1
• For inconclusive ultrasound findings, MRI without contrast is preferred over CT to avoid radiation exposure 1
• CT with IV contrast should only be used when benefits outweigh risks, such as in cases requiring urgent intervention 1
• For urinary tract calculi evaluation, static-fluid MR urography without gadolinium can be performed 1

Prevention of Recurrence

• Ensure adequate hydration and frequent urination 9
• Urinate before and after sexual intercourse 6
• Consider antibiotic prophylaxis for recurrent UTIs during pregnancy 9
• Monitor for recurrence with periodic urine cultures throughout pregnancy 7

Common Pitfalls to Avoid

• Delaying treatment of confirmed bacteriuria in pregnant women 1, 5
• Using single-dose therapy, which has lower efficacy than short-course regimens 7
• Mistaking normal vaginal flora contamination for true bacteriuria requiring treatment 5
• Overlooking follow-up cultures after treatment, as recurrence is common 7
• Failing to consider other causes of abdominal pain in pregnancy such as appendicitis, cholecystitis, or urolithiasis 1