Urinalysis in pregnancy

The role of urinalysis in suspected hepatitis

When assessing the condition of a pregnant woman, urinalysis acts as a basic yet highly informative tool. In the context of infectious liver diseases such as acute viral hepatitis E (HEV), changes in urine often become the first visual marker of the disease progressing to a severe stage.

When the icteric form of the pathology develops, bile pigments appear in the urine—a condition known as bilirubinuria. Visually, this manifests as a pronounced darkening of the urine output. This symptom typically manifests on the fifth day of the disease, simultaneously with the appearance of acholic (clay-colored) stools. These changes precede visible icterus (jaundice) of the skin, mucous membranes, and sclera, which develops slightly later—on the sixth day.

Associated clinical picture (red flags)

Darkening of urine in pregnant women rarely occurs in isolation. The chronology of the disease (Anamnesis morbi) shows that it is preceded by a pre-icteric period (about 4 days) proceeding in a mixed variant:

• Dyspeptic syndrome: persistent, constant heartburn and belching completely resistant to antacids, escalating nausea, vomiting after meals, anorexia.
• Asthenovegetative syndrome: pronounced weakness, fatigue, malaise, headache, and dizziness.

With the onset of bilirubinuria, cholestasis syndrome joins. Patients complain of intense pruritus that painfully intensifies at night, leading to multiple excoriations (scratch marks). Objective status (Status praesens) reveals moderate hepatomegaly: the liver projects 1–2 cm below the costal margin, has an elastic consistency, and palpation is accompanied by tenderness in the right upper quadrant. At the same time, signs of peritoneal irritation are absent, which rules out acute surgical pathology.

Syndromic blood panel alongside changes in urine

Changes in the urinalysis require immediate advanced laboratory investigation. A complete blood count in an uncomplicated course is often uninformative (leukocytes normal or reduced, ESR normal), but in severe cases, marked leukocytosis (up to 26 × 10^9/L) with a sharp left shift (band neutrophils up to 12%) and accelerated ESR are possible.

A key role is played by biochemical blood analysis, confirming hepatic syndromes:

1. Cholestasis syndrome: marked hyperbilirubinemia (e.g., up to 142 µmol/L) predominantly due to the direct fraction, sharp elevation of alkaline phosphatase (ALP).
2. Cytolysis syndrome: multiple excess of reference values for ALT and AST with a De Ritis ratio < 1, which is typical for viral damage.
3. Renal syndrome: elevated creatinine (up to 138 µmol/L) and urea (up to 14.6 mmol/L), indicating concomitant renal dysfunction.
4. Impairment of protein-synthesizing function: marked hypoproteinemia (total protein drops to 43 g/L) and hypoalbuminemia.

It is also critically important to evaluate the coagulogram: a decrease in the prothrombin index (PTI down to 40%) indicates pronounced hypocoagulation.

3rd trimester risks and formulation of diagnosis

Detection of bilirubinuria and cholestasis syndrome in pregnant women is an absolute red flag. This is especially true for women in the third trimester (e.g., at 34 weeks gestation), as this group is characterized by a fulminant (malignant) course of viral hepatitis E with an extremely high risk of life-threatening complications.

Progression of hepatic dysfunction can lead to acute liver failure (ALF) and acute hepatic encephalopathy (AHE). A critical drop in PTI triggers hemorrhagic syndrome, up to profuse gastrointestinal bleeding (single or recurrent "coffee ground" vomiting).

To verify the diagnosis, specific diagnostics are prescribed: ELISA to detect early antibodies (anti-HEV IgM) and PCR to detect the pathogen's genetic material (HEV RNA). When formulating an expanded clinical diagnosis, it is mandatory to indicate the nosology, form of the course (icteric or anicteric), severity grade, presence of complications, the fact and exact gestational age, as well as laboratory rationale.

Class and exam questions

What else to study on this topic

• Differential diagnosis of viral hepatitis by serological markers (ELISA and PCR).
• Assessment of hepatocellular insufficiency syndrome and the risk of hemorrhagic complications.
• Stages of the course of acute viral hepatitis: from dyspepsia to full-blown jaundice.
• Algorithm for formulating an expanded clinical diagnosis taking into account obstetric status.
• Analysis of the biochemical profile: cytolysis, cholestasis, and renal dysfunction syndromes.

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.