UTI in pregnancy - Clinicals, Diagnosis, and Management

Obstetrics

Clinicals - History

Fact Explanation
Asymptomatic As other systems in the body, kidney and urinary tract also undergoes several physiological changes during pregnancy. There is upper tract dilatation, urethral dilatation which starts as early as 6 weeks of gestation and reaches the maximum during 22-24 weeks and urinary stasis is also associated with reduced glomerular filtration rate. Renal threshold for glucose is also reduced making glycosuria is a normal phenomenon during the pregnancy. Asymptomatic bacteriuria may develop into symptomatic stage if left untreated. Escherichia coli and S. aureus are the commonest bacteria associated with UTI in pregnancy. Other gram-negative rods such as Proteus mirabilis and Klebsiella pneumoniae are also common. Asymptomatic
As other systems in the body, kidney and urinary tract also undergoes several physiological changes during pregnancy. There is upper tract dilatation, urethral dilatation which starts as early as 6 weeks of gestation and reaches the maximum during 22-24 weeks and urinary stasis is also associated with reduced glomerular filtration rate. Renal threshold for glucose is also reduced making glycosuria is a normal phenomenon during the pregnancy. Asymptomatic bacteriuria may develop into symptomatic stage if left untreated. Escherichia coli and S. aureus are the commonest bacteria associated with UTI in pregnancy. Other gram-negative rods such as Proteus mirabilis and Klebsiella pneumoniae are also common.
Suprapubic pain Inflammation of the bladder in case of cystits or associated calculi may cause the suprapubic pain. Suprapubic pain
Inflammation of the bladder in case of cystits or associated calculi may cause the suprapubic pain.
Dysuria Dysuria is the pain that occurs during micturition. May be related to either urinary tract infection itself or to the calculi which may contributes to the recurrent UTI Dysuria
Dysuria is the pain that occurs during micturition. May be related to either urinary tract infection itself or to the calculi which may contributes to the recurrent UTI
Fever Inflammation releases cytokines that may cause fever. Cystitis may not cause the fever. Usually lower urinary tract infections and pyelonephritis will cause the fever. Fever
Inflammation releases cytokines that may cause fever. Cystitis may not cause the fever. Usually lower urinary tract infections and pyelonephritis will cause the fever.
Frequency,urgency Frequent passage of urine and inability to hold the urge "urgency" is associated with UTI. Culture-negative symptoms of urinary frequency, urgency and dysuria is called 'urethral syndrome', and is difficult to treat. Frequency,urgency
Frequent passage of urine and inability to hold the urge "urgency" is associated with UTI. Culture-negative symptoms of urinary frequency, urgency and dysuria is called 'urethral syndrome', and is difficult to treat.
Haematuria Passage of blood with urine may be associated with infection. Haematuria
Passage of blood with urine may be associated with infection.
Froth in the urine This is due to the proteinuria associated with infection. Froth in the urine
This is due to the proteinuria associated with infection.
Hyperemesis and loss of appetite May be related to associated cytokine production. Pregnancy may also contribute to these symptoms. But in a case of hyperemesis (exssesive vomiting) UTI should be included in the differential diagnosis. Hyperemesis and loss of appetite
May be related to associated cytokine production. Pregnancy may also contribute to these symptoms. But in a case of hyperemesis (exssesive vomiting) UTI should be included in the differential diagnosis.
Loin/abdominal pain Due to the pyelonephritis or associated calculi that may contribute to the superadded UTI. Loin/abdominal pain
Due to the pyelonephritis or associated calculi that may contribute to the superadded UTI.
History of urinary calculi May predispose the individual to develop the UTI. History of urinary calculi
May predispose the individual to develop the UTI.
History of immunesuppression Immunesuppression (diabetes mellitus , HIV/AIDS, malignancy etc )is a risk factor for the development of UTI. History of immunesuppression
Immunesuppression (diabetes mellitus , HIV/AIDS, malignancy etc )is a risk factor for the development of UTI.

Clinicals - Examination

Fact Explanation
Febrile Fever is seen in lower UTI and pyelonephritis. Febrile
Fever is seen in lower UTI and pyelonephritis.
Loin/abdominal tenderness Due to associated calculi/pyelonephritis causing renal angle tenderness. Loin/abdominal tenderness
Due to associated calculi/pyelonephritis causing renal angle tenderness.
Ballotable kidneys Polysystic kidney disease is a risk factor for the development of UTI. Hypocitruria, aciduria and low urinary magnesium are common metabolic defects in polycystic kidney disease that will cause stone formation and predisposition to UTI. Ballotable kidneys
Polysystic kidney disease is a risk factor for the development of UTI. Hypocitruria, aciduria and low urinary magnesium are common metabolic defects in polycystic kidney disease that will cause stone formation and predisposition to UTI.
Hypotension Sepsis and shock during pregnancy can be occurred due to the pyelonephritis. Hypotension
Sepsis and shock during pregnancy can be occurred due to the pyelonephritis.
Dyspnea Pyelonephritis is known to cause acute respiratory distress during the pregnancy. Dyspnea
Pyelonephritis is known to cause acute respiratory distress during the pregnancy.

Investigations - Diagnosis

Fact Explanation
Dipstic testing Urine is tested with a dipstick for the presence of nitrite and leucocyte esterase. Dipstic testing
Urine is tested with a dipstick for the presence of nitrite and leucocyte esterase.
Urine full report Infections may increase the number of pus cells(WBC count of ≥ 10/HPF), red cells and there will be appearance of proteinuria. Urinary cast will be helpful in differentiating the other conditions that may cause symptoms like haematuria. Urine full report
Infections may increase the number of pus cells(WBC count of ≥ 10/HPF), red cells and there will be appearance of proteinuria. Urinary cast will be helpful in differentiating the other conditions that may cause symptoms like haematuria.
Urine culture Urine culture is suggestive of urinary tract infection when there is > 10000 colony forming units (CFU)/ml, two organisms in similar proportions at > 10000 CFU/ml, or 10000–10000 CFU/ml of a Gram negative organism or two organisms where the Gram negative clearly predominates. Antibiotic sensitivity testing may also be needed in culture proven patients. Urine culture
Urine culture is suggestive of urinary tract infection when there is > 10000 colony forming units (CFU)/ml, two organisms in similar proportions at > 10000 CFU/ml, or 10000–10000 CFU/ml of a Gram negative organism or two organisms where the Gram negative clearly predominates. Antibiotic sensitivity testing may also be needed in culture proven patients.
Renal ultrasound scan n be used for the evaluation of any associated hydronephrosis, hydroureter, structural abnormalities, polycystic kidney disease and function of the kidneys. Renal ultrasound scan
n be used for the evaluation of any associated hydronephrosis, hydroureter, structural abnormalities, polycystic kidney disease and function of the kidneys.

Investigations - Management

Fact Explanation
Urine full report Follow up is needed with urine full report in culture proven cases. Urine full report
Follow up is needed with urine full report in culture proven cases.
Urine culture Pregnant mothers who had been diagnosed with pyelonephritis should be reviewed weekly for 6 weeks with repeat urine dipsticks, repeat urine cultures at days 14 and 42. Urine culture
Pregnant mothers who had been diagnosed with pyelonephritis should be reviewed weekly for 6 weeks with repeat urine dipsticks, repeat urine cultures at days 14 and 42.
Full blood count May show elevated white blood cells due to bacterial infections. It is also important in ruling out the other conditions that causes fever such as low platelets in dengue , elevated lymphocytes in viral infections. Full blood count
May show elevated white blood cells due to bacterial infections. It is also important in ruling out the other conditions that causes fever such as low platelets in dengue , elevated lymphocytes in viral infections.
Blood culture Is needed in septic patients to exclude septicaemia. Blood culture
Is needed in septic patients to exclude septicaemia.
Urine full report Pregnant mothers should have screened for asymptomatic urinary tract infections at the booking visit and if indicative further investigations are needed. Urine full report
Pregnant mothers should have screened for asymptomatic urinary tract infections at the booking visit and if indicative further investigations are needed.
Renal function tests(serum creatinine, blood urea, serum electrolytes) Recurrent urinary tract infections or associated urinary calculi may cause renal damage that result in renal failure. Renal functions needs to be monitored even during the antibacterial treatment. Renal function tests(serum creatinine, blood urea, serum electrolytes)
Recurrent urinary tract infections or associated urinary calculi may cause renal damage that result in renal failure. Renal functions needs to be monitored even during the antibacterial treatment.

Management - Supportive

Fact Explanation
Supportive management Severely ill mothers should be admitted to hospital, Symptomatic treatment such as antipyretics to control the fever and anti emetics to control the vomiting should be given. Supportive management
Severely ill mothers should be admitted to hospital, Symptomatic treatment such as antipyretics to control the fever and anti emetics to control the vomiting should be given.
Maintain hydration Intravenous fluid may be needed in a case of pyelonephritis. Maintain hydration
Intravenous fluid may be needed in a case of pyelonephritis.
Prevention of urinary tract infections Pregnant mothers should receive health education on proper hygienic practices, maintain adequate fluid intake and double voiding to empty the bladder after sexual intercourse. Because it is clearly shown that tha incidence of asymptomatic bacteriuria is related to the sexual activities. Special attention is needed for the high risk people such as those with a history of urinary calculi, polysystic kidney disease, immunesuppression etc. Prevention of urinary tract infections
Pregnant mothers should receive health education on proper hygienic practices, maintain adequate fluid intake and double voiding to empty the bladder after sexual intercourse. Because it is clearly shown that tha incidence of asymptomatic bacteriuria is related to the sexual activities. Special attention is needed for the high risk people such as those with a history of urinary calculi, polysystic kidney disease, immunesuppression etc.
Preventive antibiotics Cephalexin or nitrofurantoin in patients with recurrent UTIs will be beneficial in preventing UTI. Preventive antibiotics
Cephalexin or nitrofurantoin in patients with recurrent UTIs will be beneficial in preventing UTI.
Further evaluation during the postpartum period Patients with urinary calculi, recurrent UTI (more than one episode) ,recurrent UTI while on prophylactic antibiotic therapy should undergo further evaluation specially looking for the structural abnormalities of the urinary tract. Further evaluation during the postpartum period
Patients with urinary calculi, recurrent UTI (more than one episode) ,recurrent UTI while on prophylactic antibiotic therapy should undergo further evaluation specially looking for the structural abnormalities of the urinary tract.

Management - Specific

Fact Explanation
Management setting Hospitalization may be needed in patients who are exhibiting signs of sepsis, who are vomiting and unable to stay hydrated, and who are having contractions. Management setting
Hospitalization may be needed in patients who are exhibiting signs of sepsis, who are vomiting and unable to stay hydrated, and who are having contractions.
Antibiotics Antibiotics should be able to target the common infecting organisms (gram-negative gastrointestinal organisms), and safe for the mother and fetus. Nitrofurantoin, and cephalosporins, fosfomycin are good choices. Sulfonamides should be avoided during the third trimeste due to the risk kernicterus. Fluoroquinolones and tetracyclines should also be avoided due to the toxic effects on the fetus. Duration will be 7-10 days. A three-day treatment course is sufficient for the cystitis.Intravenous antibiotics are needed in pyelonephritis. Antibiotics
Antibiotics should be able to target the common infecting organisms (gram-negative gastrointestinal organisms), and safe for the mother and fetus. Nitrofurantoin, and cephalosporins, fosfomycin are good choices. Sulfonamides should be avoided during the third trimeste due to the risk kernicterus. Fluoroquinolones and tetracyclines should also be avoided due to the toxic effects on the fetus. Duration will be 7-10 days. A three-day treatment course is sufficient for the cystitis.Intravenous antibiotics are needed in pyelonephritis.
Management of asymptomatic bacteriuria Asymptomatic bacteriuria in early pregnancy has a 20–30-fold increased risk of developing pyelonephritis. Duration of antimicrobial therapy is usually 3–7 days and screening for recurrent bacteriuria is needed. Amoxicillin, cephalexin ,ampicillin, fosfomycin, trimethoprim/sulfamethoxazole and nitrofurontoin are the usual treatments used. Trimethoprim/sulfamethoxazole is contraindicated in 1st trimester due to teratogenicity and folic acid antagonism. and in late 3rd trimester due to risk of neonatal kernicterus. Colonization with group B streptococci needs specific treatment. Management of asymptomatic bacteriuria
Asymptomatic bacteriuria in early pregnancy has a 20–30-fold increased risk of developing pyelonephritis. Duration of antimicrobial therapy is usually 3–7 days and screening for recurrent bacteriuria is needed. Amoxicillin, cephalexin ,ampicillin, fosfomycin, trimethoprim/sulfamethoxazole and nitrofurontoin are the usual treatments used. Trimethoprim/sulfamethoxazole is contraindicated in 1st trimester due to teratogenicity and folic acid antagonism. and in late 3rd trimester due to risk of neonatal kernicterus. Colonization with group B streptococci needs specific treatment.

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