PYELONEPHRITIS DURING PREGNANCY

Acute pyelonephritis is an infection of the kidney involving the renal pelvis. It is one of the most common renal diseases.

Pregnancy induces a variety of physiologic changes in the urinary tract. When such changes become accentuated the physiologic becomes the pathologic and symptoms arise, at times of significance enough to threaten the well being of mother and/or fetus. In pregnant women, the incidence of UTI can be as high as 8 percent. Pyelonephritis become afflicted in the third trimester and its attendant associations with prematurity, growth retardation and low birth weight. Etiology Urinary tract infections are common during pregnancy, and the most common causative organism is Escherichia coli. Asymptomatic bacteriuria can lead to the development of cystitis or pyelonephritis. All pregnant women should be screened for bacteriuria and subsequently treated with antibiotics such as nitrofurantoin, sulfisoxazole or cephalexin.Pyelonephritis can be a life-threatening illness, with increased risk of perinatal and neonatal morbidity. Recurrent infections are common during pregnancy and require prophylactic treatment. Pregnant women with urinary group B streptococcal infection should be treated and should receive intrapartum prophylactic therapy.

Symptom
: fatifgue abdominal pain, signs of infection (fever, unintentional weight loss, malaise, decreased appetite), lower urinary tract symptoms and blood in the urine,vommitting, respiratory distress syndrome,

Physical exam:
The exam may reveal generalized muscle tenderness as well as pain and tenderness when pressure is applied to the sides of the abdomen or flank (costovertebral angle tenderness).

Pathogenesis
Pregnant women are at increased risk for UTIs. Beginning in week 6 and peaking during weeks 22 to 24,

approximately 90 percent of pregnant women develop ureteral dilatation, which will remain until delivery (hydronephrosis of pregnancy). Increased bladder volume and decreased bladder tone, along with decreased ureteral tone, contribute to increased urinary stasis and ureterovesical reflux.Additionally, the physiologic increase in plasma volume during pregnancy decreases urine concentration. Up to 70 percent of pregnant women develop glycosuria, which encourages bacterial growth in the urine. Increases in urinary progestins and estrogens may lead to a decreased ability of the lower urinary tract to resist invading bacteria. This decreased ability may be caused by decreased ureteral tone or possibly by allowing some strains of bacteria to selectively grow. These factors may all contribute to the development of UTIs during pregnancy. Bacteriology The organisms that cause UTIs during pregnancy are the same as those found in nonpregnant patients. Escherichia coli accounts for 80 to 90 percent of infections. Other gram-negative rods such as Proteus mirabilis and Klebsiella pneumoniae are also common. Gram-positive organisms such as group B streptococcus and Staphylococcus saprophyticus are less common causes of UTI. Group B streptococcus has important implications in the management of pregnancy and will be discussed further. Less common organisms that may cause UTI include enterococci, Gardnerella vaginalis and Ureaplasma ureolyticum.

Acute pyelonephritis During pregnancy is a serious systemic illness that can progress to maternal sepsis, preterm labor and premature delivery. The diagnosis is made when the presence of bacteriuria is accompanied by systemic symptoms or signs such as fever, chills, nausea, vomiting and flank pain. Symptoms of lower tract infection (i.e., frequency and dysuria) may or may not be present. Pyelonephritis occurs in 2 percent of pregnant women; up to 23 percent of these women have a recurrence during the same pregnancy. Early, aggressive treatment is important in preventing complications from pyelonephritis. Hospitalization, although often indicated, is not always necessary. However, hospitalization is indicated for patients who are exhibiting signs of sepsis, who are vomiting and unable to stay hydrated, and who are having contractions. A randomized study of 90 obstetric inpatients with pyelonephritis compared treatment with oral cephalexin to treatment with intravenous cephalothin (Keflin) and found no difference between the two groups in the success of therapy, infant birth weight or preterm deliveries. Further support for outpatient therapy is provided in a randomized clinical trial that compared standard inpatient, intravenous treatment to outpatient treatment with intramuscular ceftriaxone (Rocephin) plus oral cephalexin. Response to antibiotic therapy in each group was similar, with no evident differences in the number of recurrent infections or preterm deliveries.

Antibiotic therapy (and intravenous fluids, if hospitalization is required) may be initiated before obtaining the results of urine culture and sensitivity. Several antibiotic regimens may be used. A clinical trial comparing three parenteral regimens found no differences in length of hospitalization, recurrence of pyelonephritis or preterm delivery. Patients in this trial were randomized to receive treatment with intravenous cefazolin (Ancef), intravenous gentamycin plus ampicillin, or intramuscular ceftriaxone. Parenteral treatment of pyelonephritis should be continued until the patient becomes afebrile. Most patients respond to hydration and prompt antibiotic treatment within 24 to 48 hours. The most common reason for initial treatment failure is resistance of the infecting organism to the antibiotic. If fever continues or other signs of systemic illness remain after appropriate antibiotic therapy, the possibility of a structural or anatomic abnormality should be investigated. Persistent infection may be caused by urolithiasis, which occurs in one of 1,500 pregnancies,or less commonly, congenital renal abnormalities or a perinephric abscess.

Diagnostic tests may include renal ultrasonography or an abbreviated intravenous pyelogram. The indication to perform an intravenous pyelogram is persistent infection after appropriate antibiotic therapy when there is the suggestion of a structural abnormality not evident on ultrasonography. Even the low-dose radiation involved in an intravenous pyelogram, however, may be dangerous to the fetus and should be avoided if possible.

Antibiotic Choices for Treatment of UTIs During Pregnancy

Diagnostic tests may include renal ultrasonography or an abbreviated intravenous pyelogram. The indication to perform an intravenous pyelogram is persistent infection after appropriate antibiotic therapy when there is the suggestion of a structural abnormality not evident on ultrasonography. Even the low-dose radiation involved in an intravenous pyelogram, however, may be dangerous to the fetus and should be avoided if possible.

Antibiotic Choices for Treatment of UTIs During Pregnancy

Antibiotic Cephalexin (Keflex) Erythromycin Nitrofurantoin (Macrodantin) Sulfisoxazole (Gantrisin)

Pregnancy category Dosage B B B C* 250 mg two or four times daily 250 to 500 mg four times daily 50 to 100 mg four times daily 1 g four times daily 250 mg four times daily One 3-g sachet 160/180 mg twice daily

Amoxicillin-clavulanic acid (Augmentin) B Fosfomycin (Monurol) B

Trimethoprim-sulfamethoxazole (Bactrim) C *--Contraindicated in pregnant women at term. --Avoid during first trimester and at term.

Chronic pyelonephritis
It is renal injury induced by recurrent or persistent renal infection. It occurs almost exclusively in patients with major anatomic anomalies, including urinary tract obstruction, struvite calculi, renal dysplasia, or, most commonly, vesicoureteral reflux (VUR) in young children. Sometimes, this diagnosis is established based on radiologic evidence obtained during an evaluation for recurrent urinary tract infection (UTI) in young children. VUR is a congenital defect that results in incompetence of the ureterovesical valve due to a short intramural segment. The condition is present in 30-40% of young children with symptomatic UTIs and in almost all children with renal scars. VUR may also be acquired by patients with a flaccid bladder due to spinal cord injury. VUR is classified into 5 grades (I-V), according to the increasing degree of reflux.

Symptoms
Patients with chronic pyelonephritis may report the following: Fever,

Lethargy, Nausea and vomiting, Flank pain or dysuria

Pathophysiology Chronic pyelonephritis is associated with progressive renal scarring, which can lead to end-stage renal disease (ESRD), eg, reflux nephropathy. Intrarenal reflux of infected urine is suggested to induce renal injury, which heals with scar formation. In some cases, scars may form in utero in patients with renal dysplasia with perfusion defects. Infection without reflux is less likely to produce injury. Dysplasia may also be acquired from obstruction. Scars of high-pressure reflux can occur in persons of any age. In some cases, normal growth may lead to spontaneous cessation of reflux by age 6 years. Factors that may affect the pathogenesis of chronic pyelonephritis are : (1) the sex of the patient and his or her sexual activity; (2) pregnancy, which may lead to progression of renal injury with loss of renal (3) genetic factors; (4) bacterial virulence factors; and (5) neurogenic bladder dysfunction. function;

Race: Chronic pyelonephritis is less common in black children than in white children. Sex: Chronic pyelonephritis is more common in females than in males. Age: Chronic pyelonephritis occurs in children and adults.

Complications
Including premature delivery, infants with low birth weight, fetal mortality, preeclampsia, pregnancy-induced hypertension, anemia, thrombocytopenia, and transient renal insufficiency.

Treatment Amoxicillin (Amoxil), Cephalexin (Keflex), Usually safe but benefits must outweigh the risks

Trimethoprim and sulfamethoxazole (Bactrim DS, Septra DS),

In/Out Patient Meds In young children, the choice of antibiotics is either amoxicillin or a first-generation cephalosporin. In children aged 3-6 months, therapy can be changed to sulfamethoxazole or nitrofurantoin. Once an antibiotic is chosen, frequent changes in the antibiotic regimen are discouraged to help prevent the development of resistance.

Prevention Diet: Progressive renal injury can be reduced by dietary protein restriction. Hypertension therapy: Aggressive blood pressure control is beneficial to slow the progression of renal failure. ACE inhibitors are particularly beneficial in this setting. Pregnancy: Careful follow-up and monitoring of renal function is beneficial. Vigorously treat a UTI or bacteriuria in a patient who is pregnant to prevent renal failure, preeclampsia, and abortions. Screening: Renal sonography is recommended for siblings of patients with VUR.