UTI in Pregnancy

					Agenda
   Background
   Pathophysiology
   Incidence
   Classifications
   Clinical Approach
   Workup
   Treatment
Background

 Hormonal and mechanical changes put even
  a woman who is not pregnant at risk for
  urinary stasis and ureterovesical reflux
 along with a short urethra and difficulty with
  hygiene due a distended, pregnant belly,
  cause urinary tract infections (UTIs) to
  become a common occurrence for pregnant
  women.
Background

 UTI is defined as the presence of at least
  100,000 organisms per milliliter of urine in an
  asymptomatic patient or as more than 100
  organisms per milliliter of urine in a
  symptomatic patient with accompanying
  pyuria (>7 WBCs/mL).
Background

 Vaginal infections can cause or mimic UTIs,
  which are common in women of reproductive
  years, affecting 25-35% of women aged 20-40
  years. The main method of discriminating
  between the 2 depends upon vaginal and
  urinary cultures
Pathophysiology

   Hormonal
   Mechanical
   Hypertrophy of the kidney
Hormonal

 Progesterone  relaxation of on smooth
  muscles of the whole tract
 dilatation of the pelvis & ureter & Vasico-
  uretral reflux
 stasis of urine  predispose to infection
Mechanical

 By gravid uterus, on :
   Bladder wall get pushed up into the abdomen :
        intravesical pr  urine stasis
        frequency of urination
       Stress incontinence
   50% in primigravida.
   Less in multigravida (unknown cause).
   ureter at pelvic brim obstruction of the ureters
    hydronephrosis.
   Hydronephrosis & hydro-ureter is more in right side
    (50%)
     b/c of dextro rotation of uterus to the right side.
Hypertrophy of the kidney

 Structural Hypertrophy
 Functional Hypertrophy:
      Renal Blood Flow
      GFR by 40%
      Renal plasma volume by 60%
      BUN & serum creatinine
     Glucosuria “sometimes due to  filtration by the kid”
        RBF & GFR  tubular re-absorption  loss of glucose,
        amino-acids…etc  Na and fluid retention.
 # All these changes return back to normal 4
  months after delivery:
Incidence

 In the US: The prevalence of ASB in pregnant
  women is 2.5-11%
 Internationally: higher prevalence of
  bacteriuria in Caucasian women during
  pregnancy (6.3%) when compared to
  Bangladeshi women (2%)
Incidence

 prevalence of UTI during pregnancy is 28.7%
  in whites and Asians, 30.1% in blacks, and
  41.1% in Hispanics.
 Prevalence increases with age, low
  socioeconomic status, sexual activity,
  multiparity, and untreated pathologies
Classifications

 Asymptomatic bacteriuria
 Cystitis
 Pyelonephritis
Asymptomatic bacteriuria

 Definition:
   Presence of actively multiplying bacteria
    (100000/ml) without symptoms
 Incidence:
   5 – 10%. (2-7%)
     2x more in sickle cell trait
     3x more in diabetes
Asymptomatic bacteriuria

 Most common organisms:
   Usually comes form the peri-anal area “G-ve “
     E.coli 77%
     Klebsiella
     Proteus
    . Others: Pseudomonus, Staphylococcus
      aureus,enterobacter.
Asymptomatic bacteriuria

 Predisposing factors :
   DM
   Race
   Multiparous
   Sickle cell trait “not disease”
   chronic cystitis or chronic pyelonephritis
Asymptomatic bacteriuria

       Diagnosis:
         History of recurrent attacks & recurrent
          analgesics intake.
         Urine will show >/= 105/ml urine bacteria
         Isolation of organism
Asymptomatic bacteriuria

       Complications (if not treated)
         Symptomatic UTI “frank cystitis”
         Pyelonephritis “i.e. active infection”  in 30%
         Preterm labor.  in ¼
         Anemia.
         IUGR.
         PET.
Cystitis

 Intro:
   Less benign than asymptomatic
   40% if not treated will end up by Pyelonephritis
 Incidence
   1%
   rare in pregnancy
Cystitis

 Presentation:
   Lower abdominal pain
   Dysuria
   Urgency
   Frequency
   No systemic manifestations
Cystitis

 Urinalysis:
    WBC
    RBC  Micro & Macro Hematuria
General Management of
Asymptomatic Bacteruria &
Cystitis
  Hydration to wash the bacteria
  Antibiotics:
    Should do the culture first, otherwise the picture will be
     masked
    Types of Antibiotics given:
        Ampicllin
        Amoxacillin
        Augmentin
        Nitrofurantoin
    Regimens:
      Single dose regimen good for compliance
      3 day regimen
      full coarse for 10 days
    If persists (i.e. +ve culture), continue Ab daily till delivery as
     Nitrofurantoin OD
Pyelonephritis

 Intro
   Most serious complication in pregnancy
   May cause renal dysfunction and even renal failure
   40% is ascending
 Incidence
   1 – 2%.
 Most common organisms
   G-ve organisms
Pyelonephritis

 Symptoms:
  Symptoms vary; it could be asymptomatic or
   patient present with septicemia and shock.
  Sudden onset
  50% unilateral on the right side
  25% bilateral
Pyelonephritis

            General                     Specific
 1.Fever, may reach 420C,    1.   Flank Pain
 or even Hypothermia         2.   Dysurea
 2.Chills & rigors           3.   Frequency
 3.N/V.                      4.   Urgency.
 4.Malaise.
 5.Anorexia                  *Examination should
                               include simple
  *these are due to the        percussion on the
 endotoxin released in the     costophrenic angle to
 blood                         elicit the pain
Pyelonephritis

 Investigations:
   CBC  anemia , thrombocytopenia
   RFT   GFR & Creatinine clearance, serum
    creatinine
   MSU  Significant bacteruria, Proteinurea ,RBC
    cast,
   Urine culture to isolate the organism (mostly
    E.coli).
Pyelonephritis

 Differential Diagnosis:
   Labour
   Chorioamnionitis
   Acute abdomen as Appendicitis
   Ectopic pregnancy “usually present early”
   Abruption placenta esp. Concealed type
   Fibroid
Pyelonephritis

 Effect on fetus:
    the incidence of abortion.
    the incidence of prematurity.
    the incidence of prenatal morbidity and
    mortality
Management
 Should be more aggressive
 Admit to hospital “ some pt can be managed as
  outpatients” & Bed rest.
 Rehydration.
 Antibiotics:
   Empirical treatment with IV antibiotics
   Types of Antibiotics given:
          Ampicllin
          Cloxacillin
          3rd generation cephalosporins
          Gentamycin  Check RFT
          Nitrofurantoin
   Shift to oral Ab after 24-48 hr when she is afebrile
   Repeat culture after 2 weeks , b/c it might persist
   If still no response then have to investigate the patient with IVP
    even when she’s pregnant (One x-ray will not harm her).
WORKUP

 Lab Studies.
 Imaging Studies.
 Other Tests.
 Histology
Lab Studies 1/4
 Urine specimen collection
   midstream
   catheterization
 Urine culture
   A colony count of 100,000 colony-forming units
    (CFUs) per milliliter historically has been used to
    define a positive culture result
Lab Studies 1/4
 Urinalysis
   Positive results for nitrites, leukocyte esterase,
    WBCs, RBCs, and protein are suggestive of a UTI
   Urinalysis has a specificity of 97-100%, but it has a
    sensitivity that ranges from 25-67% when compared
    to culture in the diagnosis of ASB
 Urine dip
   Sensitivities 50-92%, and specificity is 86-97%
    compared to culture in the diagnosis of ASB.
   this is a useful and inexpensive test
Imaging Studies 2/4

 Routine imaging studies are not indicated in
  the evaluation of pregnancy-related UTI.
 Renal ultrasound—or limited intravenous
  pyelography (IVP) may be helpful in patients
  with recurrent UTI or symptoms that are
  suggestive of nephrolithiasis
Other Tests 3/4

 rarely are indicated
 Urine cytology may be useful in detecting
  rare upper urinary tract lesions
 ASO titer greater than 200 Todd units
  suggests recent group A streptococcal
  infection
Histologic Findings 4/4

 Clumping WBCs and WBC casts
   pyelonephritis
 RBC casts are characteristic of
   acute glomerulonephritis
Antibiotics

 Oral antibiotics
   treatment of choice for ASB and cystitis
   Although antibiotic courses of 1, 3, and 7 days have been
    evaluated, 10-14 days of treatment is usually
    recommended in order to eradicate the offending bacteria
 Intravenous treatment
   The standard course of treatment for pyelonephritis
   Patients with pyelonephritis can become dehydrated
    because of nausea and vomiting. However, patients are at
    high risk for development of pulmonary edema and adult
    respiratory distress syndrome (ARDS).
Antibiotics 1/6

 Amoxillin
   Action: bactericidal against G+ve & G-ve Bacteria
   Dose:
     1-Day regimen: 3 g PO bid
     3-Day regimen: 500 mg PO qid
     7-Day regimen: 250 mg PO q8h
Antibiotics 2/6

 Augmentin
  Action: Clavulanic acid is active against plasmid-
   mediated beta-lactamases
  Dose: 1 g PO q 12h
Antibiotics 3/6

 Ceftriaxone
   Action:
     Arrests bacterial growth.
     broad-spectrum gram-negative activity, lower efficacy against
      gram-positive organisms, and higher efficacy against resistant
      organisms
   Dose: 1 g IV/IM qd
   Precaution with breast feeding
Antibiotics 4/6

 Vancomycin:
   Action:
     Potent antibiotic directed against gram-positive organisms and
      active against Enterococcus species
     Useful in the treatment of septicemia
   Dose:
     500 mg/d to 2 g/d IV divided tid/qid for 7-10 d
   S/E:
     red man syndrome is caused by too rapid IV infusion
Antibiotics 5/6

 Nitrofurantoin:
   Action:
     Bactericidal in urine at therapeutic doses
     inactivates vital cellular biochemical processes of protein synthesis
   Dose:
     1 tab PO bid for 3-5 d
   S/E:
     irreversible peripheral neuropathy
Antibiotics 6/6

 Trimethoprim & sulfamethoxazole
   Action:
     Sulfamethoxazole inhibits metabolism of dihydrofolic acid by
      competing with para-aminobenzoic acid
     trimethoprim blocks the production of tetrahydrofolic acid
      from dihydrofolic acid
   Dose:
     2 tabs PO for 1 d
     1 DS tab PO bid for 3-5 d
   S/E:
     Trimethoprim  decrease Folic Acid
     Sulphonamide  kernicterus

				
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