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Uti in Pregnancy
Uti in Pregnancy
Background
Pathophysiology
Incidence
Classifications
Clinical Approach
Workup
Treatment
Background
Hormonal
Mechanical
Hypertrophy of the kidney
Hormonal
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
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
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
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
Specific General
1. Flank Pain 1.Fever, may reach 420C, or
2. Dysurea even Hypothermia
3. Frequency 2.Chills & rigors
4. Urgency. 3.N/V.
4.Malaise.
* Examination should 5.Anorexia
include simple percussion
on the costophrenic angle * these are due to the
to elicit the pain endotoxin released in the
blood
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
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