23.UTI pdf - د. أسيل

Obstetrics

Dr. Aseil

UTI in Pregnancy

Pathophysiology

 Hormonal

Mechanical

 Hypertrophy of the kidney

Hormonal

  Progesterone  relaxation of the smooth muscles of the whole tract
  dilatation of the pelvis & ureter & Vasico-uretral reflux
   stasis of urine  predispose to infection

Mechanical

 By gravid uterus, on :

 Bladder wall get pushed up into the abdomen :

  frequency of urination, Stress incontinence

  ureter at pelvic brim obstruction of the ureters hydronephrosis.
  Hydronephrosis & hydro- ureter is more in right side (50%)
    because of dextro rotation of uterus to the right side.

Hypertrophy of the kidney

 Structural Hypertrophy
 Functional Hypertrophy:

   Renal Blood Flow
   GFR by 40%
   urinary out put & urinary frequency
   BU & serum creatinine
  Glucosuria “sometimes due to  filtration by the kid”
   RBF & GFR over come tubular re-absorption threshould  

loss of glucose, amino-acids&prot…etc  Na and fluid retention.

 # All these changes return back to normal 4 months after delivery:

Obstetrics

Dr. Aseil

PATHOGENESIS OF INFECTION –

1/The female urethra measures only 3 to 4 cm in length. Its proximity to the
vagina and rectum facilitates colonization of urine from the normal flora of the
gastrointestinal tract and vagina.Migration of organisms from the introitus into
the bladder.
2/Lower renal thresholds for excretion of glucose and amino acids during
pregnancy provide an excellent media for proliferation of microorganisms.
3/ the dilated urinary collecting system (ureters and bladder) predispose the
pregnant woman to the development of infection from asymptomatic
bacteriuria.

Types of UTI in pregnancy:

1. Asymptomatic bacteriuria
2. Cystitis
3. Pyelonphritis

Risk factors

– Risk factors for UTI in pregnancy include:

  • History of recurrent UTI
  • Multiparity , Advanced maternal age
  • Lower socioeconomic status
  • Anatomical abnormalities of renal system, urinary calculi
  • Diabetes mellitus
  • Bladder emptying problems e.g MS

MICROBIOLOGY

– The organisms causing UTI are similar in species and

virulence factors in pregnant and nonpregnant women, suggesting that the
basic mechanism of entry of bacteria into the urinary tract is the same.

    Most common organisms:
  Usually comes form the peri-anal area “G-ve
  E.coli 80%
  Klebsiella aerogenes
  Proteus mirabilis
  . Others: Pseudomonus, Staphylococcus aureus, enterobacter

Obstetrics

Dr. Aseil

ASYMPTOMATIC BACTERIURIA

– Asymptomatic bacteriuria refers to

the isolation of actively multiplying bacteria > or =100,000 single organism/mL
from a midstream-voided specimen in a woman without UTI symptoms.

Incidence: Asymptomatic bacteriuria: 8%,

 Complications (if not treated)

 Symptomatic UTI 40% of them will develop “frank cystitis” or

Pyelonephritis

  Preterm labor.  in ¼
  Anemia.
  IUGR.

Cystitis:

 Incidence: 1%
 Presentation:

  Lower abdominal pain
  Dysuria , Urgency ,Frequency , Haematuria
  No systemic manifestations (fever,dehydration)

 Occasionally may present as law back pain ,malaise &flu like symptoms.

Diagnosis:
pyuria(>7WBCs/ml) and urine culture,  RBC  Micro & Macro Hematuria

General Management of Asymptomatic Bacteruria & Cystitis

 Hydration to wash the bacteria
 Antibiotics:

 Should do the urine culture first, and begin empiric antibiotic therapy.

Then adjust, continue, or suspend the treatment depending upon the final
culture results and the patient's response to therapy.

 Types of Antibiotics given:

  Amoxacillin(500mg PO TID)
  Augmentin(1gPO BID)
  Nitrofurantoin(50mg PO QID)
  Cephalosporiens e.g cefixime
  full coarse for7- 10 days

 If persists (i.e. +ve culture), continue Ab daily till delivery as Nitrofurantoin OD

Obstetrics

Dr. Aseil

Pyelonephritis

Intro
 Most serious complication in pregnancy
 Risk factors include asymptomatic bacteriuia, previous history of

pyelonephritis, renal and collecting system anomalies, and renal calculi

 Usually is ascending
 50% unilateral on the right side25% bilateral

Incidence: 1 – 2%.

Specific

General

Flank Pain

Dysurea

Frequency

Urgency.

*Examination should include

simple percussion on the
costophrenic angle to elicit
the pain

Fever, may reach 42

C, or

even Hypothermia

Chills & rigors

Nausea & vomiting

Malaise ,Anorexia.

Dehydration

*these are due to the endotoxin

released in the blood

 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).
  Baby must be monitored with CTG & ULS

 Differential Diagnosis:

  Labour
  Chorioamnionitis
  Acute abdomen as Appendicitis
  Ectopic pregnancy “usually present early”
  Abruption placenta esp. Concealed type


Fibroid

Obstetrics

Dr. Aseil

 Complications:

 Fetal

   the incidence of abortion.
   the incidence of prematurity.
   the incidence of prenatal morbidity and mortality

 Maternal

  Septic shock , ARDS
  Renal insufficiency
  Perinephric abscess

Management

  Admit to hospital  & Bed rest.,opiate analgesia
  Rehydration.
  Antibiotics:

 Empirical treatment with IV antibiotics
 Ampicllin 1g/6hr

 Cloxacillin
 3rd generation cephalosporins

 Shift to oral Ab after 24-48 hr when she is afebrile for acourse of 14

days

 Repeat culture after 2 weeks , Low dose antimicrobial prophylaxis,

such as nitrofurantoin (50 to 100 mg PO 2 times daily), and periodic
urinary surveillance for infection are recommended for the
remainder of the pregnancy to prevent a recurrence.

 If still no response after 48hr parental therapy then have to

investigate the patient with ULS&IVP to exclude perinephric absces
or stones.