Transcript UTI in Pregnancy

Agenda
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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
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Hormonal
Mechanical
Hypertrophy of the kidney
Hormonal
 Progesterone  relaxation of on smooth
muscles of the whole tract
 dilatation of the pelvis & ureter & Vasicouretral 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:
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 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
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Diagnosis:
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History of recurrent attacks & recurrent
analgesics intake.
Urine will show >/= 105/ml urine bacteria
Isolation of organism
Asymptomatic bacteriuria
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Complications (if not treated)
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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:
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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
1.Fever,
may reach 420C,
or even Hypothermia
2.Chills & rigors
3.N/V.
4.Malaise.
5.Anorexia
*these are due to the
endotoxin released in the
blood
Specific
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Flank Pain
Dysurea
Frequency
Urgency.
*Examination should
include simple
percussion on the
costophrenic angle to
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:
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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