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Uti in Pregnancy
Uti in Pregnancy
OUTLINE
Introduction
Pathophysiology
Risk Factors
Asymptomatic Bacteriuria
Acute Cystitis
Acute Pyelonephritis
Antibiotic use in UTI in pregnancy
Interpretation of urinalysis
Recurrent UTI In Women
Urinary tract infection
Most common infection in pregnancy
5 10% of pregnancy
Classified as
Asymptomatic bacteriuria
Symptomatic UTI
Acute cystitis
Acute pyelonephritis
Pathophysiology
Urine is bacteriostatic to most local commensal bacteria and
this is thought to result from its relatively acidic pH, high
osmolality and high urea concentration.
In an anatomically normal urinary tract, sterility is maintained
by free antegrade flow through the ureteral and urethral valves
Infections result from ascending colonization of the urinary
tract, primarily by existing vaginal, perineal, and fecal flora
Various maternal physiologic and anatomic factors predispose
to ascending infection
Pathophysiology
Bladder volume increases and detrusor tone decreases
Relaxation of ureteric smooth muscle induced by progesterone and
pressure from the expanding uterus result in ureteric dilatation. This
leads to increased urinary stasis, compromised ureteric valves and
vesicoureteric reflux
Immunocompromised
Short urethra - approximately 3-4 cm in females
Difficulty with hygiene due to a distended pregnant belly
Glycosuria and aminoaciduria and fall in urinary osmolality
Sexual activity - Intercourse can traumatise the urothelium of the distal
urethra
Urinary Tract Infections in Pregnancy, emedicine, updated may 2016
Review Urinary tract infection in pregnancy, Timothy McCormick, The Obstetrician & Gynaecologist, 2008;10:156162
Aetiology
E coli is the most common (80-90%)
Other pathogens include the following
Klebsiella pneumoniae (5%)
Proteus mirabilis (5%)
Enterobacter species (3%)
Staphylococcus saprophyticus (2%)
Group B beta-hemolytic Streptococcus (GBS; 1%)
Proteus species (2%)
1.Review Urinary tract infection in pregnancy, Timothy McCormick, The Obstetrician & Gynaecologist,
2008;10:156162
2.CPG Management Of Urinary Tract Infections In Pregnancy. Institute Of Obstetricians And
Gynaecologists, Royal College Of Physicians Of Ireland And The Clinical Strategy And Programmes
Division, Health Service Executive
Asymptomatic bacteriuria
Diagnostic criteria
2 consecutive voided urine specimen with isolation of the
same bacterial strain in quantitative count of 105 colony
forming units (cfu)/mL or a single catheterized urine
specimen with 1 bacterial species isolated in a quantitative
count of 102 cfu/mL
Nicolle LE, Bradley S, Colgan R et al (2005) Infectious diseases society of America guidelines for the
diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 40: 64354
Urinary tract infections and asymptomatic bacteriuria in pregnancy. UpToDate. May 2016
However, only one voided urine specimen is typically obtained
and diagnosis (and treatment initiation) is made in women with
105 cfu/mL without obtaining a confirmatory repeat culture.
Urinary tract infections and asymptomatic bacteriuria in pregnancy. UpToDate. May 2016
The limiting factor is high cost and delay in results (it take
24 to 48 hrs to culture the organism)
SIGN 2012
Urinalysis
Nitrites, leukocytes esterase UTI
Specificity of 97-100%
Sensitivity of only 25-67%
Alternative
Cephalexin 500mg bd for 7 days or
Amoxycillin/Clavulanate 625mg tds for 7 days
Acute Cystitis
Diagnosis
- Symptomatic + pyuria (WBC/leukocytes) +
presence of 102 cfu/ml
Preferred
Nitrofurantoin 50mg bd for 7 days or
Cefuroxime 250mg bd for 7 days
Alternative
Cephalexin 500mg bd for 7 days or
Amoxycillin/Clavulanate 625mg tds for 7 days
Urinary tract infections and asymptomatic bacteriuria in pregnancy. UpToDate. May 2016
Case 3
Mr A, G3P2 @ 30 wk POA
c/o fever and back pain x 3/7.
History of UTI at 26 wk POA. Treated with antibiotic
for 5/7.
On examination
Alert, tongue coated
BP 110/72, PR 96
Lungs clear, CVS DRNM
PA soft, tender at left illiac fossa, BS +ve, renal
punch positive at left side, negative at right side
What investigation you would do?
FBC
UFEME
Urine C+S
Urinary tract infections and asymptomatic bacteriuria in pregnancy. UpToDate. May 2016
Diagnosis
- Symptomatic + pyuria (WBC/leukocytes) + presence of
102 cfu/ml
Management
- Refer for admission
- Antibiotic
Preferred
Cefuroxime 750mg IV tds for 14 days
Alternative
Amoxycillin/Clavulanate 1.2gm IV tds for 14 days or
Ceftriaxone 1-2gm IV od for 14 days
Antibiotics in pregnancy
Urinary tract infections in pregnancy: old and new unresolved diagnostic and therapeutic problems.
Arch Med Sci 1, February / 2015
UTI: Interpretation of
urinalysis
pH stone/infection/RTA
pH 4.5 - 8 Alkaline UTI urea splitting
organism/calcium oxalate/phosphate
SG 1.005 - 1.025 Acidic uric acid/cysytine calculi
Recurrent UTI
Acute pyelonephritis
Complicated
Risk factors
Frequency of sexual intercourse
Age at first UTI before 15 years old
Maternal history of UTI
New sex partners
Spermicide use
Predisposing factors for complicated
UTI
Anatomic abnormality polycystic kidney disease, urethral
valves, VUR
Urinary tract obstruction bladder outlet obstruction,
congenital abnormality, ureteral or urethral stricture,
urolithisis
Voiding dysfunction cystocele, neurogenic bladder, pelvic
floor dysfunction, high post void residual, incontinence
Inatrogenic indwelling urinary catheter, intermittent
catheterization, nephrostomy tube, urethral stent
Immunosupression DM, renal transplant, pregnancy
Indications for Further
Investigation
Prior urinary surgery or trauma
Gross hematuria after resolution of infection
Previous bladder or renal calculi
Obstructive symptoms (straining, weak stream, intermittentcy,
hesitancy), low urometry or high PVR
Urea splitting bacteria on culture (proteus, yersinia
Bacterialpersistence after sensitivity based therapy
Prior abdominopelvic malignancy
DM or otherwise immunocompromised
Pneumaturia, fecalturia, anaerobic bacteriuria or history of
divertivulits
Repeated pyelonephritis
Asymptomic microhematuria after resolution of infection
Investigations
American College of Radiology ACR
Appropriateness Criteria
ACR 2011
Management Preferred
Nitrofurantoin 50mg PO nocte
for 3 12 months
OR
Trimethoprim 100mg PO nocte
for 3 12 months
Alternative
Trimethoprim/Sulphamethoxazol
e 80/400mg PO nocte for 3 12
months
OR
Cephalexin250mgPO ON for 3
12 months