URINARY TRACT INFECTION INPREGNANCY
- Clinical Features
- Complications Urinary t track infection in Pregnancy
- Treatment of Urinary t track infectionin Pregnancy
- Prevention of Urinary t track infection
- Urinary t track infection – is infection of any part of the urinary tract/system by a pathogenic microbial agents.
- Asymptomatic bacteriuria (ASB) – presence of ≥ 100000 microorganisms/ml of urine of the same species in cultured mid-stream urine culture
- Cystitis – inflammation of the urinary bladder mucosa as a result of UTI
- Pyelonephritis – inflammation of the kidney Pelvis & parenchyma
- The prevalence of ASB in pregnant women is 5-11% (as opposed to 3-8% in nonpregnant women) – USA statistics
- 8% of pregnant women have asymptomatic bacteriuria if untreated; 25% of these may progress to symptomatic UTI.
- The organisms that cause UTIs during pregnancy are the same as those found in nonpregnant patients.
- Organisms that cause urinary infections are those from the normal perineal flora.
- Commonest is Escherichia coli, less commonly implicated are Streptococci, Proteus, Pseudomonas and Klebsiella
Predisposing Factors for UTI in Pregnancy
- Physiological and anatomical changes during pregnancy i.e. dilatation of ureter and kidneys leading to increased stasis
- Sexual activity
- Low social economic activity
- History of recurrent cystitis
- Renal tract abnormalities (duplex system, scarred kidneys, ureteric damage and stones)
- Immunosupression e.g. HIV and AIDS, Diabetes
- Bladder emptying problems
- Haemoglobinopathies (i.e., sickle cell anaemia or trait)
Pathogenesis of UTI in Pregnancy
- Pregnant women are at increased risk for UTIs.
- From week 6 and to weeks 22 – 24, approximately 90% of pregnant women develop ureteral dilatation, which will remain until delivery (hydronephrosis of pregnancy).
- There is Increased bladder volume and decreased bladder tone, along with decreased ureteral tone(hormonal)
- These à increased urinary stasis and ureterovesical reflux à UTI
- Additionally, the physiologic increase in plasma volume during pregnancy decreases urine concentration.
- Up to 70% of pregnant women develop glycosuria, which encourages bacterial growth in the urine.
- Increases in urinary progestins and estrogens may lead to a decreased ability of the lower urinary tract to resist invading bacteria
- This allows some strains of bacteria to selectively grow
- These factors altogether contribute to the development of UTIs during pregnancy
- Additionally, shifts in the position of the urinary tract during pregnancy & compression of bladder make it easier for bacteria to travel up the ureters to the kidneys
Clinical Presentation of Urinary t track infection in Pregnancy
Similar to overall, and may include:
- Dysuria , hematuria
- Increased urinary frequency
- A feeling of urgency after urinating
- Cramps or pain in the lower abdomen
- Lower back pain
- General malaise
Clinical features contd
- Chills, fever, sweats, +incontinence
- Change in amount of urine, either more or less
- Urine that looks cloudy, smells foul or unusually concentrated
- Tenderness in the lower abdomen
- When bacteria spreads to the kidneys one may experience: flank pain, chills, fever, nausea, and vomiting.
- Flank/loin tenderness
- Tenderness on the lower abdomen
Complications Of UTI in Pregnancy
- Premature labor
- Premature rupture of membrane
- Perinatal mortality and morbidity
- Low birth weight
- Hypertensive disorders of pregnancy (such as Pregnancy Induced Hypertension and preeclampsia)
- Means – Presence of at least 100,000 colony-forming units (CFU)/mL of urine in a voided midstream clean-catch specimen in absence of clinical features of UTI
- ASB develops in 10-15% of pregnant women
- However, it is more likely to lead to acute pyelonephritis in pregnant women
- 25-30% of pregnant women with untreated bacteriuria develop pyelonephritis Vs 1-4% of non-pregnant women
CYSTITIS IN PREGNANCY
- Not more common in pregnant women than in non pregnant women.
- Symptoms of cystitis are often confused with symptoms noted in normal pregnancy
- Include urgency, frequency, suprapubic discomfort, etc.
- Acute pyelonephritis is more common in pregnant women than in nonpregnant women
- Reason – stasis of urine and bacteria in the urinary tract caused by relative obstruction.
– Dilatatioprogesterone in early pregnancy
– Mechanical obstruction from the gravid uterus later in pregnancy
– n of the ureters secondary to
Acute Pyelonephritis contd
- Second only to obstetric complications, acute pyelonephritis is the most common indication for hospitalization in pregnant patients
- Features typical for A.P. include fever, costovertebral angle tenderness(flanks), urinalysis findings with WBC and bacteria, and significant bacteriuria
DIAGNOSIS OF UTI IN PREGNANCY
- Urinalysis – midstream, clean-catch urine specimen for urine microscopy;
- Nitrites, leukocyte esterase, WBCs, RBCs, and protein suggest UTI.
- Urine Culture – criterion standard for evaluation of UTI during pregnancy
- ≥ 100,000 CFUs/ml – positive culture
- Added advantage of testing 4 antimicrobial sensitivity
- Urine dipstick
– Finding nitrites and leukocyte esterase is suggestive of ASB.
– Sensitivities range 50-92%, and specificity is 86-97% when compared with culture in the diagnosis of ASB.
– Useful test In the evaluation of symptomatic patients
– The addition of protein and blood cells increases the sensitivity and specificity of test for UTI.
- Full blood count
- Renal ultrasound scan.
- Oral fluids, Nitrofurantoin – is a safe and effective drug; however, be avoided in the 3rd trimester à haemolytic anaemia in a newborn infant.
- amoxicillin or cephalosporins( cephalexin, ceftriaxone)
- Bactrim can be used in 2nd trimester only.
- Avoid quinolones due to risk of cartilage abnormalities to fetus
- Hospitalize ,IV fluids
- Pyelonephritis – treated with cephalosporins (cephalexin, ceftriaxone etc), nitrofurantoin or ampicillin( if culture negative 4 coli)
- may need to add gentamycin.
NB: Avoid penicillins if E.coli is the offending microbe (resistance ~40%)
Simple analgesics and antipyretics to keep temp <101°F/38°C. e.g., Paracetamol, acetaminophen
- Avoid NSAD
- ASB – should be treated with similar drugs
Drugs 2 b avoided 4 Rx of UTI in Pregnancy:
- Tetracyclines – (adverse effects on fetal teeth and bones, congenital defects),
- Quinolones – (various congenital defects),
- Trimethoprim – in the first trimester (facial defects, cardiac abnormalities),
- Sulfonamides – (last trimester) – hemolytic anemia in mothers ċ G-6-PD deficiency, jaundice and kernicterus
- Chloramphenicol – Gray syndrome
- Nitrofurantoin – 3rd trimester only
Prevention of UTI (General)
- Drink 6-8 glasses of water each day
- Eliminate refined foods, fruit juices, caffeine, alcohol, and sugar.
- Take Vitamin C (250 to 500 mg), β-carotene to help fight infection.
- Develop a habit of urinating as soon as the need is felt and empty your bladder completely when you urinate.
- Urinate before and after sexual intercourse (both partners).
- Avoid intercourse while you are being treated for an UTI
- After urinating, blot dry (do not rub), and keep your genital area clean.
- Wipe from the front toward the back.
- Avoid using strong soaps, douches, antiseptic creams, feminine hygiene sprays, and powders.
- Change underwear and pantyhose every day.
- Avoid wearing tight-fitting pants.
- Wear all cotton or cotton-crotch underwear