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

THANK YOU