What are the management and treatment options for hematuria during pregnancy?

Management of Hematuria During Pregnancy

Ultrasound of the kidneys and bladder is the recommended first-line imaging for hematuria in pregnancy, with comprehensive workup deferred until after delivery once benign causes like urinary tract infection and gynecologic bleeding have been excluded. 1, 2

Initial Diagnostic Approach

History and Physical Examination

Begin by identifying specific features that distinguish serious from benign causes:

• Rule out urinary tract infection (UTI) through urinalysis with microscopic examination and urine culture, as UTI is one of the most common causes of hematuria in pregnancy and affects up to 25% of untreated bacteriuria cases progressing to pyelonephritis 3
• Exclude gynecologic bleeding as a source, which can be mistaken for true hematuria 1, 2
• Assess for nephrolithiasis by evaluating for flank pain, colic, fever, and irritative voiding symptoms, as stones present similarly in pregnant and non-pregnant women 4
• Screen for preeclampsia if hematuria is accompanied by hypertension (≥140/90 mmHg after 20 weeks gestation) or proteinuria (>300 mg/24h), as this represents a hypertensive emergency requiring hospitalization 1

Laboratory Evaluation

• Complete urinalysis with microscopic examination to confirm true hematuria and identify casts, crystals, or infection 2
• Urine culture to definitively rule out bacteriuria, as asymptomatic bacteriuria occurs in approximately 20% of pregnant women 2, 5
• Serologic testing to evaluate for intrinsic renal disease if proteinuria or cellular casts are present 2

Imaging Strategy

First-Line Imaging

Renal and bladder ultrasound is the only appropriate initial imaging modality because: 1, 2

• It avoids fetal radiation exposure
• It can identify most structural abnormalities including hydronephrosis, stones, and masses
• The incidence of asymptomatic microhematuria in pregnant women (approximately 20%) is similar to non-pregnant women, but malignancy risk is extremely low 1, 2, 5

Imaging to Avoid

• CT abdomen/pelvis and CTU are contraindicated due to fetal radiation exposure 1, 2
• MRI with gadolinium contrast should be avoided due to uncertain fetal effects 1, 2
• MRU without IV contrast may be considered only in select cases where ultrasound is inadequate and delivery cannot be awaited, but this is rarely necessary 1, 2
• Conventional radiographs and IVU are not recommended as first-line modalities 1

Treatment Based on Etiology

Urinary Tract Infection

• Treat all bacteriuria in pregnancy to prevent progression to pyelonephritis, which occurs in up to 25% of untreated cases 3
• Select antibiotics carefully given rising antimicrobial resistance; cefoperazone-sulbactam can be recommended for empirical treatment as it is safe in pregnancy and covers both gram-positive and gram-negative organisms 6
• Follow-up closely as one-third of pregnant women with UTI will experience recurrence 3

Nephrolithiasis

• Conservative management is appropriate for most cases, including hydration and analgesia 4
• Renal ultrasound is sufficient for diagnosis in most cases 4
• All treatment modalities except extracorporeal shock wave lithotripsy are appropriate if intervention is required 4
• Coordinate care between urology, obstetrics, pediatrics, anesthesiology, and radiology 4

Preeclampsia-Related Hematuria

If hematuria occurs with hypertension ≥170/110 mmHg: 1

• Hospitalize immediately as this represents a hypertensive emergency
• Reduce blood pressure with intravenous labetalol, oral methyldopa, or oral nifedipine
• Avoid intravenous hydralazine as it is associated with more perinatal adverse effects than other agents

Idiopathic Microscopic Hematuria

• Defer comprehensive workup until after delivery if benign causes are excluded and the patient is asymptomatic 1, 2
• Arrange postpartum follow-up at 3 months, as persistent hematuria may indicate underlying mild glomerulonephritis in approximately 50% of cases 5
• Reassure the patient that microscopic hematuria rarely signifies a disorder impacting pregnancy outcome 5

Critical Caveats

• Dipstick hematuria is very common (20% of pregnant women) and does not correlate with adverse pregnancy outcomes including preeclampsia, gestational hypertension, or small-for-gestational-age babies 5
• Physiologic hydronephrosis of pregnancy can complicate interpretation of imaging and should not be mistaken for pathology 4
• Radiation exposure from CT should be avoided entirely during pregnancy; ultrasound provides adequate diagnostic information for initial management 1, 2
• Pyelonephritis complications can be severe, including preterm labor, transient renal failure, ARDS, sepsis, and hematologic abnormalities, making UTI treatment essential 3