In The Name Of God

URINARY TRACT INFECTIONS

These are the most common bacterial infections during pregnancy These are the most common bacterial infections during pregnancy. :Its prevalence is (5-6 %)asymptomatic bacteriuria 1 - 2 %) )cystitis (0.5 - 2 % )Pyelonephritis

Microbiology Organisms that cause urinary infections are from the normal perineal flora. E. coli is the predominant uropathogen found in both asymptomatic bacteriuria and urinary tract infection (70 % ) Klebsiella and Enterobacter species (3 % each), Proteus (2 %), gram-positive organisms, including group B Streptococcus (10 %).

Asymptomatic Bacteriuria

Asymptomatic Bacteriuria persistent, actively multiplying bacteria within the urinary tract in asymptomatic women is typically present at the first prenatal visit. risk Factors: ---a history of prior urinary tract infection ---pre-existing diabetes mellitus ---increased parity ---low socioeconomic status

Significance Without treatment, 30-40 % of pregnant women will develop a symptomatic urinary tract infection during pregnancy . This risk is reduced by 70-80 % if bacteriuria is eradicated

In some studies, covert bacteriuria Has been associated with: ---low-birthweight infants ---preterm delivery ---hypertension ---anemia Pregnancy associated Benefits of treatment for asymptomatic bacteria are limited to the reduction of the incidence pyelonephritis

recommend screening for bacteriuria at the first prenatal visit. Rescreening every4-6 w: urinary tract anomalies hemoglobin S preterm labor Diabetes mellituse Nephropathy Immmunodeficiency Neurologic dysfunction Calculi Genitourinar instrumentation

Diagnosis  The diagnosis of asymptomatic bacteriuria should be based on culture of a urine specimen of a clean-catch voided) An initial positive urine culture result prompts treatment, after A clean-voided specimen containing more than 100,000 organisms/mL. It may be prudent to treat when lower concentrations are identified, because pyelonephritis develops in some women despite colony counts of only 20,000 to 50,000 organisms/mL

Treatment Bacteriuria responds to empirical treatment with any of several antimicrobial regimens listed in Table. Regardless of regimen given, the recurrence rate is 30%.

Management After antibiotic therapy ,urine culture ; must be sterilise. with persistent or recurrent bacteriuria, prophylactic or suppressive antibiotics may be warranted in addition to retreatment . nitrofurantoin,100 mg orally at bedtime. Cephalexin 250 mg orally at bedtime. This drug may rarely cause an acute pulmonary reaction that dissipates on its withdrawal

Cystitis And Urethritis

Cystitis And Urethritis Cystitis is characterized by: ---dysuria ---urgency ---Frequency ---few associated systemic findings. ---Pyuria , bacteriuria and microscopic hematuria are usually found. Lower urinary tract symptoms with pyuria accompanied by a sterile urine culture may be from urethritis caused by Chlamydia trachomatis

Almost 40 % of pregnant women with acute pyelonephritis have preceding symptoms of lower tract infection . Most of these regimens are usually 90% effective

Acute Pyelonephritis

Renal infection is the most common serious medical complication of pregnancy leading cause of septic shock during pregnancy urosepsis may be related to an increased incidence of cerebral palsy in preterm infants . Fortunately, there appear to be no serious longterm maternal sequelae Develops more frequently in the second trimester, Pyelonephritis is unilateral and right-sided in more than half of cases, and it is bilateral in a fourth.

Increased Risk Of : Preterm labor Low birth weight Perinatal mortality preeclampsiaanemia sepsis ARDS(10%)-respiratory distress Hemolysis(30%) Renal failure

Clinical Findings There is usually a rather abrupt onset with: ---fever ---shaking chills ---aching pain in one or both lumbar regions ---Anorexia ---nausea,and vomiting ---Tenderness in one or both costovertebral Angle ---Pyuria & bacteruria & microscopic hematuria. ---Bacteremia is demonstrated in 15 -20 %

Differential Diagnosis Labor Appendicitis Chorioamnionitis placental abruption infarcted leiomyoma

Management ---- hospital admission electrolytes, CBC , Cr , urine and blood cultures ----Intravenous hydration to ensure adequate urinary output (cornerstone of treatment). ----Monitor by serial determination of urinary output, BP, PR, BT,and oxygen saturation. ----High fever should be lowered with a cooling blanket or acetaminophen. (because of possible teratogenic effects of hyperthermia). ----Antimicrobials are begun promptly (they may initially worsen endotoxemia from bacterial lysis) Antimicrobial therapy usually is empirical, and ampicillin plus gentamicin; cefazolin or ceftriaxone; an extended spectrum antibiotic were all 95% effectiv.

response is usually prompt, and 95 % of women are afebrile by 72 h response is usually prompt, and 95 % of women are afebrile by 72 h. After discharge, most recommend oral therapy for a total of 7 -14 d If cesarean or NVD is indicated delay until patient is afebrile

Persistent Infection With persistent spiking fever or lack of clinical improvement by 48 to 72 h, urinary tract obstruction or another complication or both are considered. persistent infection can be due to an intrarenal or perinephric abscess or phlegmon Renal sonography is recommended to search for obstruction manifest by abnormal ureteral or pyelocaliceal dilatation

If stones are strongly suspected despite a nondiagnostic sonographic examination, a plain abdominal radiograph will identify nearly 90 %. Another option is the modified one-shot intravenous pyelogram—a single radiograph obtained 30 min after contrast injection. MRI may disclose the cause of persistent infection .

Obstruction relief is important, and one method is cystoscopic placement of a double-J ureteral stent surgical removal of stones may be required in some women

Surveillance Recurrent infection—either covert or symptomatic—is common and develops in 30-40 % of women after pyelonephritis therapy . nitrofurantoin, 100 mg orally at bedtime given for the remainder of the pregnancy mg orally at bedtime 250cephalexin U/C in 3rd trimester

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