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UTI in Pregnancy

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Title: UTI in Pregnancy


1
UTI in Pregnancy
Done By
Dr.Sunil
2
Agenda
  • Background
  • Pathophysiology
  • Incidence
  • Classifications
  • Clinical Approach
  • Workup
  • Treatment

3
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.

4
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 (gt7
    WBCs/mL).

5
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

6
Pathophysiology
  • Hormonal
  • Mechanical
  • Hypertrophy of the kidney

7
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

8
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.

9
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-acidsetc ? Na and fluid
    retention.
  • All these changes return back to normal 4
    months after delivery

10
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)

11
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

12
Classifications
  • Asymptomatic bacteriuria
  • Cystitis
  • Pyelonephritis

13
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

14
Asymptomatic bacteriuria
  • Most common organisms
  • Usually comes form the peri-anal area G-ve
  • E.coli 77
  • Klebsiella
  • Proteus
  • . Others Pseudomonus, Staphylococcus
    aureus,enterobacter.

15
Asymptomatic bacteriuria
  • Predisposing factors
  • DM
  • Race
  • Multiparous
  • Sickle cell trait not disease
  • chronic cystitis or chronic pyelonephritis

16
Asymptomatic bacteriuria
  • Diagnosis
  • History of recurrent attacks recurrent
    analgesics intake.
  • Urine will show gt/ 105/ml urine bacteria
  • Isolation of organism

17
Asymptomatic bacteriuria
  • Complications (if not treated)
  • Symptomatic UTI frank cystitis
  • Pyelonephritis i.e. active infection ? in 30
  • Preterm labor. ? in ¼
  • Anemia.
  • IUGR.
  • PET.

18
Cystitis
  • Intro
  • Less benign than asymptomatic
  • 40 if not treated will end up by Pyelonephritis
  • Incidence
  • 1
  • rare in pregnancy

19
Cystitis
  • Presentation
  • Lower abdominal pain
  • Dysuria
  • Urgency
  • Frequency
  • No systemic manifestations

20
Cystitis
  • Urinalysis
  • ? WBC
  • ? RBC ? Micro Macro Hematuria

21
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

22
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

23
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

24
Pyelonephritis
Specific General
Flank Pain Dysurea Frequency Urgency. Examination should include simple percussion on the costophrenic angle to elicit the pain Fever, may reach 420C, or even Hypothermia Chills rigors N/V. Malaise. Anorexia these are due to the endotoxin released in the blood
25
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).

26
Pyelonephritis
  • Differential Diagnosis
  • Labour
  • Chorioamnionitis
  • Acute abdomen as Appendicitis
  • Ectopic pregnancy usually present early
  • Abruption placenta esp. Concealed type
  • Fibroid

27
Pyelonephritis
  • Effect on fetus
  • ? the incidence of abortion.
  • ? the incidence of prematurity.
  • ? the incidence of prenatal morbidity and
    mortality

28
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 shes pregnant (One
    x-ray will not harm her).

29
WORKUP
  • Lab Studies.
  • Imaging Studies.
  • Other Tests.
  • Histology

30
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

31
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

32
Imaging Studies 2/4
  • Routine imaging studies are not indicated in the
    evaluation of pregnancy-related UTI.
  • Renal ultrasoundor limited intravenous
    pyelography (IVP) may be helpful in patients with
    recurrent UTI or symptoms that are suggestive of
    nephrolithiasis

33
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

34
Histologic Findings 4/4
  • Clumping WBCs and WBC casts
  • ? pyelonephritis
  • RBC casts are characteristic of
  • ? acute glomerulonephritis

35
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).

36
Antibiotics 1/6
  • Amoxillin
  • Action bactericidal against Gve 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

37
Antibiotics 2/6
  • Augmentin
  • Action Clavulanic acid is active against
    plasmid-mediated beta-lactamases
  • Dose 1 g PO q 12h

38
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

39
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

40
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

41
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

42
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