Haematuria in Pregnancy

HAEMATURIA IN PREGNANCY

Pratima H Anjaria*, Pravin N Mhatre**, Vandana R Walvekar***
*Associate Professor; **Asstt. Honorary Professor and Consultant; ***Dean, Honorary Professor and Consultant, Nowrosjee Wadia Maternity Hospital, Parel, Mumbai 400 012.

Spontaneous, gross or microscopic haematuria occasionally complicates an otherwise uneventful gestation. The differential diagnosis refers to all causes causing haematuria in non-gravid patients. In the absence of such causes, the haematuria is labelled as "ldiopathic" and is explained by the peculiar changes in the urinary tract induced by hormonal and mechanical factors of pregnancy. Such a pregnancy-induced haematuria is associated with spontaneous and complete resolution of haematuria in the post-partum period and may or may not recur in subsequent pregnancies.

INTRODUCTION

Spontaneous, idiopathic haematuria in pregnancy resolving post-natally is explained by changes in the urinary tract by pregnancy. Haematuria in pregnancy would be labelled as "Idiopathic", only after organic causes of haematuria have been ruled out using non-invasive diagnostic techniques which include blood and urine tests, sonography and sometimes, magnetic resonance imaging.

Mechanical and hormonal factors of pregnancy result in renal vein varicosities (dilatation and tortuosity) in the region of the renal pelvis and upper ureter causing haematuria.[1] The fact that hormones alone can cause haematuria is proven by the observation that oral contraceptive pills (pseudopregnancy) are known to be associated with haematuria.[1] Oestrogen and progesterone promote atonia, relaxation and dilatation of the smooth muscles of the urinary tract leading to stasis and infection. Stasis causes undue pressure on the fornix of the renal calyces resulting in formation of abnormal communications between the renal calyces and submucosal venous sinuses with resultant haematuria.

CASE REPORT

Mrs. R, a 21 yr old primigravida presented at 38 wks gestation with history of haematuria, burning micturition and increased frequency of micturition for 2 days. There was no history of fever with chills, back pain or loin to groin pain. There was no past history of haematuria or repeated urinary tract infection. Also, there was no history of trauma, tuberculosis, drug intake or a bleeding disorder.

She had an uneventful antenatal period except for the diagnosis of idiopathic polyhydramnios (blood sugars and foetal anomaly scan were normal). Clinically, she had mild hypogastric tenderness but no renal angle tenderness. There was no evidence of bleeding from any other source (per vaginal examination revealed a closed, tubular cervix with no vaginal bleeding). Urine sample showed frank, macroscopic haematuria. She was empirically started no norfloxacin, urispas, mist alkali, ethamsyl and stadren tablets in view of haematuria with mild hypogastric tenderness (?cystitis) and while awaiting urine reports.

Hb was 9.5 gm%, CBC 6000/cmm and ESR 10 mm at 1 hr. Blood urea nitrogen, serum creatitine, bleeding time, clotting time, prothrombin time, platelet count and plasma fibrinogen were normal. Urine routine and microscopic picture was reddish yellow urine, acidic pH, albumin 4+, sugar and ketones absent, bile pigments absent, RBC 40-45/hpf, WBC 2-4/hpf, no casts or crystals or micro-organisms. Urine culture was sterile at the end of 48 hrs. USG kidneys showed normal renal echotexture with bilateral, moderate hydronephrosis. There was no evidence of calculi and urinary bladder was not distended. The moderate hydronephrosis was explained by backpressure from the enlarged full-term uterus with polyhydramnios.

Haematuria persisted for 2 days though the burning micturition and frequency of micturition subsided after antibiotics. In view of the continuing haematuria, labour was induced by intracervical PGE2 gel instillation. Twelve hrs later, the patient had an uneventful vaginal delivery, female baby 2.94 kg with an Apgar of 9/10. The haematuria resolved completely and spontaneously in the immediate post-partum period.

Retrospectively, this appears to be a case of pregnancy-induced, frank, macroscopic haematuria with spontaneous andcomplete post-partum resolution.

DISCUSSION

The various causes to be considered in the differential diagnosis of haematuria are - infections, calculi, trauma, tumours, renal parenchymal disease, bleeding and coagulation disorders, drugs, renal vein thrombosis and emboli, endometriosis.[2,3] There will still be many cases for which a definite cause of bleeding cannot be determined by routine urologic and clinical examination and would be called idiopathic.

De Schepper in 1972 attempted to explain the phenomenon of idiopathic haematuria by way of the "Nutcracker theory".[4] The left renal vein is subject to compression between the abdominal aorta and superior mesenteric artery resulting in resistance to venous outflow in the left renal vein. This results in the development of an extensive collateral venous drainage system involving the gonadal, capsular, suprarenal, lumbar, azygous and periureteral veins.[4] The extensive renal varicosities formed by these collaterals gives rise to haematuria following their rupture into the renal calyces. This is diagnosed on renal angiography and venography and can be corrected by medial fixation of the kidney (to decrease stretch on the renal vein) and excision of renal varicosities.[4]

There are some clinical points which must be considered while investigating a case of haematuria.

1.Upper limit for RBC in mid-stream urine is 1-2 RBC/hpf by semi-quantitative technique and 8000 RBC/ml using a counting chamber.[3]

2.Localise the source of bleeding - urinary or genital tract - by pelvic examination and sometimes, if in doubt, by obtaining a catheter urine specimen.[5]

3.Check for urinary tract infection and treat the same adequately.

4.Non-invasive techniques such as sonography and MRI should be applied to arrive at a diagnosis of idiopathic haematuria.

5.Cystoscopy would help to find organic causes of haematuria and would also localise the source of bleeding whether bladder or ureter and which ureter.[6]

CONCLUSION

In most cases of haematuria in pregnancy, no demonstrable cause can be found and the bleeding subsides postpartum. These events are explained by the rupture of small veins around the dilated renal pelvis in pregnancy causing haematuria. In any event, investigations of haematuria can often be deferred until delivery. Non-invasive investigations like USG and MRI are helpful in arriving at such decisions.[7]

Thus, in the absence of a demonstrable cause, haematuria in pregnancy is classified as idiopathic and recurrence is said to be unlikely in the current or subsequent pregnancy.[2]

REFERENCES

1.Danielli L, Korchazak D, Beyar H, Lotan M. Recurrent hematurias during pregnancies. Obs and Gyn 1987; 69 : 446.

2.Lindheimer MD, Davison JM. Hematuria in pregnancy. In : Principles and Practice of Medical Therapy in pregnancy. Ed-Gleicher N, 3rd edition, Appleton and Lange, Connecticut. 1998; 1074-75.

3.Levey AS, Madaio MP, Perrone RD. Laboratory assessment of renal disease : Clearance, urinalysis and renal biopsy. In : The Kidney. Ed-Brenner BM, Rector FC. 4th edition. WB Saunders Company, Jovanovich. 1991; 2 : 948.

4.Wendel RG, Crawford DE, Hehman KN. The Nutcracker phenomenon : An unusual cause for renal varicosities with hematuria. Journal of Urology 1980; 123 : 761.

5.Harty JI. Neoplasms of urinary tract. In Principles and Practice of Medical Therapy in pregnancy. Ed-Gleicher N, 3rd edition. Appleton and Lange, Connecticut. 1998; 1304-5.

6.Bullock N, Sibley G, Whitaker R. Hematuria. In : Essential Urology. 1st edition. Churchill Livingstone, New York. 1989; 196-201.

7.Lindheimer MD, Katz AI. The kidney and hypertension in pregnancy. In : The Kidney. Ed-Brenner BM, Rector FC. 4th edition. WB Saunders Company, Jovanovich. 1991; 2 : 1577.

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