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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
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
Hormonal
Progesterone relaxation of on smooth muscles of the whole tract
dilatation of the pelvis & ureter & Vasico-
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.
(50%)
b/c of dextro rotation of uterus to the right side.
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.
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
Incidence:
5 10%. (2-7%)
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
Diagnosis:
History of recurrent attacks & recurrent analgesics intake. Urine will show >/= 105/ml urine bacteria Isolation of organism
Asymptomatic bacteriuria
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
Regimens:
Single dose regimen good for compliance 3 day regimen full coarse for 10 days
Pyelonephritis
Intro
Most serious complication in pregnancy May cause renal dysfunction and even renal failure 40% is ascending
Incidence
1 2%.
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 may reach 420C, or even Hypothermia 2.Chills & rigors 3.N/V. 4.Malaise. 5.Anorexia
1.Fever, 1. 2. 3. 4.
*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
Fibroid
Pyelonephritis
Effect on fetus:
the incidence of abortion. the incidence of prematurity.
mortality
Management
Should be more aggressive Admit to hospital some pt can be managed as
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).
WORKUP
Lab Studies.
Imaging Studies. Other Tests. Histology
pyelography (IVP) may be helpful in patients with recurrent UTI or symptoms that are suggestive of nephrolithiasis
rare upper urinary tract lesions ASO titer greater than 200 Todd units suggests recent group A streptococcal infection
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
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-
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
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