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 (>7 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-acids…etc  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 >/= 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

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 she’s 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 ultrasound—or 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 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

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. Thank You