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URINARY TRACT INFECTIONS

•What are the changes in Urinary System that occur in pregnancy ?

CHANGES IN PREGNANCY• Increased renal parenchymal volume due

to intrarenal fluid accumulation, hence…

• massive dilatation of renal calyces and ureter. [approximately 90 % of pregnant women develop ureteral dilatation, which will remain until delivery, and up to 12th – 16th postpartum week.]

• By 2nd trimester, there is increased renal blood flow up to 70-80 % and also GFR by 45-50%.

• If the measurement on one clean-catch specimen is at least 2+ (100mg/dL) OR

if there is persistent 1+ proteinuria (30mg/dL), a 24 hour urine specimen should be obtained.

• In the absence of preeclampsia, when the 24 hour urine protein excretion exceeds 500mg/24h, it is obviously abnormal, and the patient should be evaluated for underlying renal disease.

• The excretion of glucose may present up to 20-100 mg/day. Why? (and Glycosuria promotes bacteria growth in urine).

• There is a vesicoureteral reflux seen in pregnancy.

INTRODUCTION• An urinary tract infection (UTI): Bacteriuria:

i] presence of at least 100,000 organisms/mL of urine in an asymptomatic patient

ii] as more than 100 organisms/mL of urine with accompanying pyuria (>7 WBCs/mL) in a symptomatic patient

can be lower/upper UTI

• Pregnant women are at increased risk for UTI's starting in week 6 through week 24.

CLASSIFICATION

• Uncomplicated (normal renal tract & f(x))• Complicated (abnormal renal/GU

tract,voiding difficulty/outflow obstruction, decrease renal f(x), impaired host defences)

• Recurrent UTI• Relapse UTI

How ? Blood-volume expansion is accompanied by increases

in the glomerular filtration rate (GFR) and urinary output.

The ureters undergo tonic relaxation because of the mass production of hormones, particularly progesterone.

This loss in tone, along with the increased urinary tract volume, results in urinary stasis,

can lead to dilatation of the ureters and the calyceal pelvis.

Urinary stasis and the presence of vesicoureteral reflux predispose some women to upper tract UTIs and acute pyelonephritis

• The infections can be symptomatic or asymptomatic.

• Symptomatic : 1) Lower UTI : acute cystitis 2) Upper UTI : acute

pyelonephritis

CYSTITIS AND URETHRITIS

• Symptomatic bacteriuria.

• Common symptoms: Suprapubic pain, urgency, frequency and dysuria.

Mucopurulent cervicitis usually co-exists.

• Haematuria/pyuria are present.

• If symptoms are present but urine are STERILE, the agent could be Chlamydia trachomatis. (Antibiotic: erythro.)

ACUTE PYELONEPHRITIS

• Potentially life threatening in pregnancy.

• In contrast to non pregnant, acute pyelonephritis in pregnancy leads to acute renal failure if not treated.

• Cx: Septic shock, renal abscess and renal vein thrombosis.

ACUTE PYELONEPHRITIS: PATHOLOGY

• 1%-2% incidence.

• Presents as high fever + loin pain + vomiting + rigors .Oliguria (if acute renal failure).

• Dysuria pyuria + bacteriuria are present.

• Most cases are bilateral or right sided. Why?

• ~15% of APN also have bacteraemia.

ACUTE PYELONEPHRITIS: COMPLICATION

• Moderate Cx: -PROM -Fetal death

• Severe Cx: -Perinephric cellulitis or abscess -Septicaemia -Septic shock -ARDS -Death

FACTORS LEAD TO UTI IN PREGNANCY & POSTPARTUM

• Urine stasis during pregnancy.

• Perineal discomfort in postpartum period due to tears / episiotomy / injury.

• Bladder insensitivity to increased urinary tension in immediate postpartum period.

• Catheterization due to overdistension.

Risk factors for UTI• A new sex partner or multiple partners. • More frequent intercourse.

• A history of diabetes, sickle-cell anemia, stroke, kidney stones or any problem that causes the bladder not to empty completely.

• Pregnancy increases your risk for developing a UTI.

• Use of contraceptives such as diaphragms, condoms exposure and spermicides.

Risk factors for UTI• A history of UTI's, especially if the

infections were less then six months apart.

• Waiting too long to urinate.

• Decrease host defences (immunosupp, DM)

• Urinary tract: obstruction; stones; catheter; malformation.

What are the complaints?

• Pain or burning (discomfort) when urinating

• Frequent urination • A feeling of urgency when you

urinate • Blood or mucus in the urine • Cramps or pain in the lower abdomen • Pain during sexual intercourse

• Chills, fever, sweats, leaking of urine (incontinence)

• Waking up from sleep to urinate • Change in amount of urine, either more or

less • Urine that looks cloudy, smells foul or

unusually strong • Pain, pressure, or tenderness in the area of

the bladder • When bacteria spreads to the kidneys : back

pain, chills, fever, nausea, and vomiting.

Physical examination

• ASYMPTOMATIC BACTERIURIA : – Often, no physical findings are present. – Symptoms may arise intermittently, only

to be overlooked because of lack of persistence or severity.

• CYSTITIS : Patients may have suprapubic tenderness upon palpation.

• PYELONEPHRITIS :– Patients have fever (usually >38°C),

flank tenderness upon palpation, and an ill appearance.

– Based on gestational age, include fetal heart rate as part of the evaluation. Often, owing to maternal fever, the fetal heart rate is elevated to more than 160 beats per minute.

Common Uropathogen

• Escherichia coli (most common,70% of cases)

• Group B Streptococcus (10%) (Quite rare, but has important implication!)

• Klebsiella or Enterobacter species (3%)

• Proteus species (2%)

What GBSinfectioncan cause to apregnantwoman ?

Group B Streptococcal Infection

• Group B streptococcal (GBS) vaginal colonization is known to be a cause of neonatal sepsis and is associated with preterm rupture of membranes, and preterm labor and delivery.

• GBS is found to be the causative organism in UTIs in approximately 5-10% of patients.

• It is unclear if GBS bacteriuria is equivalent to GBS vaginal colonization, but pregnant women with GBS bacteriuria should be treated as GBS carriers and should receive a prophylactic antibiotic during labor.

Diagnosis

• Hx Taking and PE + temperature + abdominal examination + assessment of costovertebral angle for tenderness.

• Urine C&S : Culture results can be used to identify specific organisms and antibiotic sensitivities. (Should be performed in all pregnant women)

• Urine analysis (dipstick) : Positive results for nitrites (to detect what?), leucocytes esterase (to detect what?) , WBCs, RBCs, and protein suggest UTI.

Differential Diagnosis

• Vaginitis

• Cervicitis

• PID

• Gonorrhea

Are you ok or blur ?

COMPLICATION

 UTIs are associated with risks to both the fetus and the mother

* pyelonephritis * preterm birth * low birth weight * increased perinatal mortality

Treatment• Medical care :

1) Oral antibiotics are the treatment of choice for asymptomatic bacteriuria (ASB)x3 days and cystitis x7 days.

* A test-for-cure urine culture should show negative findings 1-2 weeks post-therapy

2) Standard course of treatment for pyelonephritis is

admission with intravenous antibiotics.

3) Manage fever with antipyretics (eg, acetaminophen). Manage nausea and vomiting with antiemetics.

Medication

• Asymptomatic patients : 7-10 days regimen (cephalexin 500 mg qid, ampicillin 500 mg qid, nitrofurantoin 100 mg bid, or sulfisoxazole 1 g qid. )

• Acute pyelonephritis : systemically treated with cephalosporins or gentamicin

• Tetracyclines (adverse effects on fetal teeth and bones, congenital defects), quinolones (various congenital defects)

Prevention• Drink 6-8 glasses of water each day and eliminate

refined foods, fruit juices, caffeine, alcohol, and sugar.

• Take Vitamin C (250 to 500 mg), Beta-carotene (25,000 to 50,000 IU per day) and Zinc (30-50 mg per day) to help fight infection.

• Develop a habit of urinating as soon as the need is felt and empty your bladder completely when you urinate.

• Urinate before and after intercourse.

• Avoid intercourse while you are being treated for an UTI.

• After urinating, blot dry (do not rub), and keep your genital area clean. Make sure you wipe from the front toward the back.

• Avoid using strong soaps, douches, antiseptic creams, feminine hygiene sprays, and powders.

• Avoid wearing tight-fitting pants.

• Don't soak in the bathtub longer than 30 minutes or more than twice a day.

Thank You For Sincerely Paying Attention…