URINARY TRACT INFECTION IN PREGNANCY TEXT REVIEW ANEESHA BASNYAT NISHCHAL DHAKAL
URINARY TRACT INFECTION
IN PREGNANCY TEXT REVIEWANEESHA BASNYATNISHCHAL DHAKAL
URINARY TRACT INFECTION It is the most common bacterial infection during
pregnancy Broadly can be classified into:
Asymptomatic Symptomatic
Lower tract infection [Urethritis & Cystitis] Upper tract infection [Acute Pyelonephritis & Renal
Abscess] Infections at various sites may occur together or
independently and may either be asymptomatic or present with some of clinical syndromes
URINARY TRACT CHANGES IN PREGNANCY Kidney:
Increase in size GFR increase by 50%+
There is dilatation of the Ureter As a result of –
Progesterone Uterus rests on the ureters (compressing them
at pelvic brim.) Right Ovarian vein complex
Increased vesicoureteral reflux
ETIOLOGY
Escherichia coli is the cause of about 80% of UTI
Occasionally may be due to Proteus Klebsiella spp. Enterobacter spp.
Adherence of fluorescein labeled E. Coli to a Uroepithelial cell
SOURCES OF INFECTION Enteric gram-negative organisms(eg. E.
Coli) of bowel colonize the vaginal introitus, periurethral skin, and distal urethra
before and during the episode of bacteriuria.
Catheterisation (nosocomial infection)
PATHOGENESIS Ascending infection
In vast majority of UTIs, bacteria gain access to the bladder via the urethra.
Ascent of bacteria from the bladder may follow and is probably the pathway Upper tract infection.
Hematogenous pyelonephritis occurs usually in chronically ill, immunocompromised patient.
PATHOGENESIS Predisposition to UTI
in pregnancy results from Dilatation of Ureter Decreased ureteral
tone Decreased ureteral
peristalsis Temporary
incompetence of the vesicoureteral valves.
Causing Stasis Of Urine
ASYMPTOMATIC BACTERIURIA
ASYMPTOMATIC BACTERIURIA
This refers to state of persistent, actively multiplying bacteria within the urinary tract in women who have no symptoms.
Asymptiomatic bacteriuria is seen in 2 to 7 % of pregnancy as opposed to 5 to 6 % of non pregnant women which is almost similar
Diagnosis: A clean-voided urine specimen containing more than 105 organisms/mL is diagnostic.
ASYMPTOMATIC BACTERIURIA COMPLICATION
The most important complication is high conversion rate to serious urinary tract infection.
12.5% – 30 % may have Acute pyelonephritis in that pregnancy.
Besides that it may also cause – Fetus:
Low birth weight ,& Preterm delivery
Mother: Hypertension or preeclampsia
ASYMPTOMATIC BACTERIURIA Eradication of bacteriuria with
antimicrobial agents is the important step.
If treated properly only <1% have chances of Acute Pyelonephritis
(Compared to 30% in untreated cases)
ASYMPTOMATIC BACTERIURIA TREATMENT
Several antimicrobial regimens can be used. Common drug and their regimens are:
Single-dose treatment 3-day course Other
Amoxicillin, 3 g Amoxicillin, 500 mg TDS Nitrofurantoin, 100 mg QID for 10 days
Ampicillin, 2 gAmpicillin, 250 mg QID Nitrofurantoin, 100
mg at bedtime for 10 days
Cephalosporin, 2 g Cephalosporin, 250 mg QID
Nitrofurantoin, 200 mg
Nitrofurantoin, 50 -100mg QID; 100 mg twice daily
Treatment with Nitrofurantoin, 100 mg at bedtime for 10 days is usually effective.
ASYMPTOMATIC BACTERIURIA RECURRENCE
Monthly screening is required as 30% have chances of recurrence*
Recurrence is treated with Nitrofurantoin, 100 mg at bedtime for 21 days.
Persistent or frequent bacteriuria recurrences is treated with Nitrofurantoin, 100 mg at bedtime for remainder of pregnancy (suppression therapy).
* Source:High Risk Pregnancy 2006
ACUTE PYELONEPHRITIS
ACUTE PYELONEPHRITIS Is a very serious condition. Urosepsis is one of the most common
cause of septic shock during pregnancy. More common in 2nd trimester, young
age. Right sided unilateral is more
common(>½ of the cases) Bilateral in ¼th of the cases.
ACUTE PYELONEPHRITIS CLINICAL FEATURE
Symptoms Abrupt onset of over a few hours or a day of
Fever Chills & Rigor Costovertebral pain
Also present may be Nausea Anorexia Vomiting Diarrhoea Symptoms of cystitis (frequency, urgency, and
suprapubic pain) Bodyache
seen in 80% of cases
ACUTE PYELONEPHRITIS CLINICAL FEATURE
Signs Patient is ill looking, toxic Fever of varying degree with proportional
tachycardia Marked renal angle tenderness. On deep palpation abdominal tenderness Generalised muscle tenderness.
Patients may also present with signs & symptoms of septic shock.
ACUTE PYELONEPHRITIS DIFFERENTIAL DIAGNOSIS
Labor Chorioamnionitis Acute Appendicitis Abruptio Placenta
ACUTE PYELONEPHRITIS COMPLICATION
Uterine contraction may be triggered leading to Pre term labour
Sepsis Transient Renal dysfunction Endotoxin - induced:
Respiratory insufficiency due to alveolar injury and pulmonary edema 1-2%
Thrombocytopenia Hemolysis thereby leading to Anemia
Chronic renal disease rarely
ACUTE PYELONEPHRITIS COMPLICATION
Women with Serious risk are those with Highest fever >39.4°C Tachycardia >110bpm >20 weeks of gestation Received tocolytics agents Received Injudicious fluid replacement
ACUTE PYELONEPHRITIS INVESTIGATION
Urine Routine & microscopic examination: Pus Cells- Plenty Leukocyte casts (is pathognomonic) RBC may be present during acute phase of the disease. Bacteria detectable in gram stain.
Urine / Blood culture – organism is isolated{Bacteremia may be demonstrated (15-20%)}
Blood Total count – Increased Differential count – Leukocytosis
Serum Urea & Creatinine values may be deranged. C-Reactive proteins – Elevated Ultrasound: to exclude a perinephric collection and
obstruction
ACUTE PYELONEPHRITIS MANAGEMENT
Admission Investigations as mentioned previously Monitor
Vitals, urinary output, Fetal Heart Rate& Contraction in case of late Pregnancy
Intravenous fluids Crystalloids are given with the aim to maintain urinary
output of >1ml/kg/hr Intravenous antimicrobials
CeftriaxoneAmpicillin plus Gentamicin, orCefazolin
Prevent hyperthermia (Paracetamol, cold sponging)
ACUTE PYELONEPHRITIS MANAGEMENT
Chest X ray if dyspnea or tachypnea (with Abdominal Shield)
Change antimicrobials if required as per culture/sensitivity report.
Change to oral antimicrobials when afebrile Discharge when afebrile 24 hours; with
antimicrobial therapy for 7 to 10 days Repeat urine RME 7-10 days after starting
therapy Follow up Urine culture 1 to 2 weeks after drug
therapy complete
ACUTE PYELONEPHRITIS MANAGEMENT 4 weekly Urine examination to rule out
recurrence If repeat infection treat with antibiotics
again. Ultrasonogram of renal tract to rule out
calculus or any anomalies. Persistent/ recurrent infection can be
treated with low dose antibiotics.
CYSTITIS
CYSTITIS Infection of the urinary bladder. Patient presents with feature of
Dysuria Urgency Frequency Suprapubic pain
On examination Mild tenderness over supra pubic area,
urethra
CYSTITIS TREATMENT
Patient respond well to antimicrobial therapy 3 day therapy is usually
effective
3-day course Amoxicillin, 500 mg TDSAmpicillin, 250 mg QIDCephalosporin, 250 mg QIDNitrofurantoin, 50 -100mg QID; 100 mg twice daily
URETHRITIS
URETHRITIS As the name suggest it is the infection of the
urethra Frequency, urgency, dysuria, and pyuria
accompanied by a urine culture with no growth may be urethritis caused by Chlamydia trachomatis
Often associated with mucopurulent discharge Treatment
Erythromycin , 500 mg orally QID for 7 days or Azithromycin, 1 g orally as a single dose.
IN THE END… UTI is a serious disease which can be
treated easily. There is high chances of conversion of
even asymptomatic condition to serious life threatening condition
Routine Urine Examination in First Antenatal Checkup is Important
Pyelonephritis can have serious implication
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