Should urinalysis for proteinuria be routine?

[expert on call]

Dear Experts,
We received this question from a member today, and would like to better understand why a practice might make the decision to do this, and advice to our members on what to do if their provider chooses not to screen them for proteinuria, particularly if they have a past history of preeclampsia. Thanks! Laura

Hi, I'm writing because I found out at my OB checkup today that my maternal fetal group at a large university in NC has decided to no longer screen pregnant women for protein in their urine. I was told they will now only take urine samples of a woman's BP is extremely high. Today mine was 145/88 and I do believe that is high, but they would not screen me, even though I suffered eclampsia in my last pregnancy and am considered high risk this time around.

My concern for this decision is not only about myself. I will deliver my baby by c-section in less than 2 weeks and I do know the signs to watch out for. I am, however, extremely concerned for the other women who may be overlooked by not being screened or who may be diagnosed too late. Having had eclampsia myself and a pretty massive seizure that nearly killed me and my baby, I would hope that even if they only catch one or two women early enough to help them, it would be well worth the effort.

So, that being said, I am looking for ideas and suggestions for what I might be able to do to help reverse this very foolish decision.

[expert on call]

Expert Answer #1:

Before commenting I would need to see the actual policy as written. We continue to screen for protein, glucose and ketones at each prenatal visit though I must admit that the "scientific basis" for our approach is at best weak.

Information provided on this site is provided for informational purposes only and is not meant to substitute for the advice provided by your own physician or other medical professional. You should not use the information contained herein for diagnosing or treating a health problem or disorder, or prescribing any medication. The Preeclampsia Foundation presents all data as is, without any warranty of any kind, express or implied, and is not liable for its accuracy, for mistakes or omissions of any kind, nor for any loss or damage caused by a user's reliance on information obtained on the site. Professional opinions on this condition vary greatly. The Preeclampsia Foundation endorses no one course of treatment or "cure". Responses generated by our Experts to specific questions are based on information anonymously submitted to this site via email, are not based on a complete review of any patient’s medical records and should not be construed as the only reasonable expert response to the info submitted and/or the scenario described.

[expert on call]

Expert Answer #2:

There are two questions here. Should routine screening be performed at each visit, and should the patient asking the question have been screened. The simple answer is the second. Yes, a high risk patient near term with a blood pressure of 145/88 mm Hg should have her urine checked, and most would hospitalize her if proteinuria was detected. With a history of eclampsia she has a 20% chance of repeat preeclampsia/eclampsia, any many an eclamptic has convulsed with pressures at the levels noted here, and some times without the "classic" warning signs. Also we are not told of her earlier in gestation values, but if they were substantially lower it is hard to imagine why protein was not checked.

The first question is harder to answer for two reasons. Although the dipstick is considered the hallmark of a prenatal visit, and proteinuria is known to precede the blood pressure rise in preeclampsia, I am unaware of good outcome data in this area. We do know that qualitative dipstick testing has a high false positive and false negative incidence, especially for readings of 1+ but even for 2+, and that doing timed collections, or protein/creatinine ratios on single voided urines on all patients would be quite expensive in health care costs to yield terms, but quantitative dipstick apparatuses that will give albumin/creatinine ratios during a clinic visit and at low cost are not far away. In the meantime I would stay with the time honored dipstick.

Finally, urine glucose need not always be checked (as noted in one response) as many gravidas with normal glucose tolerance spill sugar in their urine, some to the tune of a few grams a day. But the ketone determination is very useful to the clinician, as a clue to adequate carbohydrate intake (I believe!)

Information provided on this site is provided for informational purposes only and is not meant to substitute for the advice provided by your own physician or other medical professional. You should not use the information contained herein for diagnosing or treating a health problem or disorder, or prescribing any medication. The Preeclampsia Foundation presents all data as is, without any warranty of any kind, express or implied, and is not liable for its accuracy, for mistakes or omissions of any kind, nor for any loss or damage caused by a user's reliance on information obtained on the site. Professional opinions on this condition vary greatly. The Preeclampsia Foundation endorses no one course of treatment or "cure". Responses generated by our Experts to specific questions are based on information anonymously submitted to this site via email, are not based on a complete review of any patient’s medical records and should not be construed as the only reasonable expert response to the info submitted and/or the scenario described.

[expert on call]

Expert Answer 3:
My comments echo Dr. ****. The woman described should have been tested in any setting. Whether urine proteins as routines are supported by evidence is open to question. However it would seem changing approaches that could be important for identifying risk without evidence they are not useful is not a rational approach.

Information provided on this site is provided for informational purposes only and is not meant to substitute for the advice provided by your own physician or other medical professional. You should not use the information contained herein for diagnosing or treating a health problem or disorder, or prescribing any medication. The Preeclampsia Foundation presents all data as is, without any warranty of any kind, express or implied, and is not liable for its accuracy, for mistakes or omissions of any kind, nor for any loss or damage caused by a user's reliance on information obtained on the site. Professional opinions on this condition vary greatly. The Preeclampsia Foundation endorses no one course of treatment or "cure". Responses generated by our Experts to specific questions are based on information anonymously submitted to this site via email, are not based on a complete review of any patient’s medical records and should not be construed as the only reasonable expert response to the info submitted and/or the scenario described.

[expert on call]

Expert Answer 4
Laura, I just checked the email before heading out the door on a trip. My thoughts echo ****. We continue to check for protein at each visit in all patients, and I certainly would have recommended it being done for the particular patient scenario presented. It has been my experience that there is a small cadre of patients who suddenly develop proteinuria with borderline blood pressures who subsequently flare with the full deal (eclampsia, stroke) within the next two weeks, certainly a departure from the usual pattern as depicted by **** of blood pressure first, protein second. At the very least patients at risk for preeclampsia, chronic hypertensives, diabetics, first prenatal visits, third trimester visits probably deserve the screening for proteinuria in my opinion until further evidence is in place.

Information provided on this site is provided for informational purposes only and is not meant to substitute for the advice provided by your own physician or other medical professional. You should not use the information contained herein for diagnosing or treating a health problem or disorder, or prescribing any medication. The Preeclampsia Foundation presents all data as is, without any warranty of any kind, express or implied, and is not liable for its accuracy, for mistakes or omissions of any kind, nor for any loss or damage caused by a user's reliance on information obtained on the site. Professional opinions on this condition vary greatly. The Preeclampsia Foundation endorses no one course of treatment or "cure". Responses generated by our Experts to specific questions are based on information anonymously submitted to this site via email, are not based on a complete review of any patient’s medical records and should not be construed as the only reasonable expert response to the info submitted and/or the scenario described.