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UTIs in pregnancy
The document discusses urinary tract infections (UTIs) in pregnancy, highlighting that they are the most common bacterial infections in pregnant women, often asymptomatic, but can lead to serious complications such as preterm birth and pyelonephritis. It emphasizes the importance of screening for asymptomatic bacteriuria and provides guidelines for diagnosis and treatment, including specific antibiotics. Additionally, it addresses the implications of HIV during pregnancy, including the risk of vertical transmission and recommended management strategies to reduce transmission risks.
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UTIs in pregnancy
- 1. UTIs In Pregnancy ShreyaSusan Koshy
- 2. INTRODUCTION By convention,UTI is defined either as a lower tract (acute cystitis) or upper tract (acute pyelonephritis) infection UTI may be asymptomatic (subclinical infection) or symptomatic (disease). Thus, the term UTI encompasses a variety of clinical entities, including asymptomatic bacteriuria (ABU), cystitis, prostatitis, and pyelonephritis. ABU occurs in the absence of symptoms attributable to the bacteria in the urinary tract and does not usually require treatment UTI has more typically been assumed to imply symptomatic disease that warrants antimicrobial therapy.
- 3. IN PREGNANCY Theseare the most common bacterial infections during pregnancy. Asymptomatic bacteriuria is the most common In pregnant women, ABU has clinical consequences, and both screening for and treatment of this condition are indicated Specifically, ABU during pregnancy is associated with preterm birth and perinatal mortality for the fetus and with pyelonephritis for the mother.
- 4. ETIOLOGY Normal perinealflora E.coli (75-90% of isolates), Klebsiella, Proteus, Citrobacter, Enterococcus Complicated UTI – All the above, plus Acinetobacter species, Morganella species, and Pseudomonas aeruginosa
- 5. ASYMPTOMATIC BACTERIURIA Theincidence during pregnancy is similar to that in nonpregnant women and varies from 2 to 7 percent Recurrent bacteriuria is more common during pregnancy Typically occurs during early pregnancy, with only approximately a quarter of cases identified in the second and third trimesters A clean-voided specimen containing more than 100,000 organisms/mL is diagnostic. there have been instances of counts from 20,000- 50,000/ml resulting in pyelonephritis
- 6. SIGNIFICANCE If nottreated, approximately 25 percent of infected women will develop symptomatic infection during pregnancy. In some, but not all studies, covert bacteriuria has been associated with preterm or low-birthweight infants Schieve and coworkers (1994) reported urinary tract infection to be associated with increased risks for low- birthweight infants, preterm delivery, pregnancy associated hypertension, and anemia.
- 7. Screening And Treatment Performed at 12 to 16 weeks gestation (or the first prenatal visit, if that occurs later) with a urine culture Reasonable to rescreen women at high risk for infection (eg, history of UTI or presence of urinary tract anomalies, diabetes mellitus, hemoglobin S, or preterm labor) Specimen – Mid stream clean catch Diagnosis – one specimen growing organisms ≥105 Treatment - antibiotic therapy tailored to culture results and follow-up cultures to confirm sterilization of the urine. For those women with persistent or recurrent bacteriuria, prophylactic or suppressive antibiotics may be warranted in addition to retreatment
- 8. Oral Antimicrobial AgentsUsed for Treatment of Pregnant Women with Asymptomatic Bacteriuria Single-dose treatment Amoxicillin, 3 g Ampicillin, 2 g Cephalosporin, 2 g Nitrofurantoin, 200 mg Trimethoprim-sulfamethoxazole, 320/1600 mg 3-day course Amoxicillin, 500 mg three times daily Ampicillin, 250 mg four times daily Cephalosporin, 250 mg four times daily Ciprofloxacin, 250 mg twice daily Levofloxacin, 250 or 500 mg daily Nitrofurantoin, 50 to 100 mg four times daily or 100 mg twice daily Trimethoprim-sulfamethoxazole, 160/800 mg two times daily Other Nitrofurantoin, 100 mg four times daily for 10 days Nitrofurantoin, 100 mg twice daily for 5 to 7 days Nitrofurantoin, 100 mg at bedtime for 10 days Treatment failures Nitrofurantoin, 100 mg four times daily for 21 days Suppression for bacterial persistence or recurrence Nitrofurantoin, 100 mg at bedtime for pregnancy remainder
- 9. ACUTE CYSTITIS CLINICALMANIFESTATIONS The typical symptoms of acute cystitis in the pregnant woman are the same as in nonpregnant women Include the sudden onset of dysuria and urinary urgency and frequency. Hematuria and pyuria are also frequently seen on urinalysis. Systemic symptoms, such as fevers and chills, are generally absent in isolated cystitis
- 10. DIAGNOSIS AND TREATMENT Acute cystitis should be suspected in pregnant women who complain about dysuria The presence of fever and chills, flank pain, and costovertebral angle tenderness should raise suspicion for pyelonephritis Urinanalysis, and culture Prior to confirming the diagnosis, empiric treatment is typically initiated in a patient with consistent symptoms and pyuria on urinalysis it is reasonable to use a quantitative count ≥103 cfu/mL in a symptomatic pregnant woman as an indicator of symptomatic UTI Treatment is by the same drugs used in treatment of asymptomatic bacteriuria
- 11. ACUTE PYELONEPHRITIS Fever(>38ºC or 100.4ºF), flank pain, nausea, vomiting, and/or costovertebral angle tenderness Pyuria is a typical finding Most cases of pyelonephritis occur during the second and third trimesters Pregnant women may become quite ill and are at risk for both medical and obstetrical complications from pyelonephritis As many as 20 percent of women with severe pyelonephritis develop complications that include septic shock syndrome or its variants, such as acute respiratory distress syndrome
- 12. DIAGNOSIS AND TREATMENT Clinical symptoms + urinanalysis and culture Low threshold for suspicion Pyuria seen in a majority In patients with pyelonephritis who are severely ill or who also have symptoms of renal colic or history of renal stones, diabetes, history of prior urologic surgery, immunosuppression, repeated episodes of pyelonephritis, or urosepsis, imaging of the kidneys can be helpful to evaluate for complications Hospital admission for parenteral antibiotics, that can later be converted to an oral regime following profiling of organism suppressive antibiotics are typically used for the remainder of the pregnancy to prevent recurrence. Parenteral, broad spectrum beta-lactams are the preferred antibiotics for initial empiric therapy of pyelonephritis
- 13. OBSTRETRIC MANAGEMENT Pyelonephritisis not itself an indication for delivery If induction of labor or c-section is planned then wait till patient is afebrile.
- 14.
- 15. EFFECT OF Pregnancy onHIV Does not increase progression of HIV to AIDS Opportunistic infections maybe less aggressively investigated and treated due to concerns for fetus, causing maternal risk HIV on pregnancy Increased risk of Miscarriage Preeclampsia Preterm delivery IUGR Vertical transmission
- 16. DIAGNOSIS Positive ELISAconfirmed by western blot or IF assay Or two positive ELISAs CD4 count for immunosuppression degree Viral load for disease progression
- 17. VERTICAL TRANSMISSION Antepartum 0-14weeks 1% 14-36 weeks 4% >36 12% Intrapartum 8 Postpartum with breast feeding Established infection 14 Primary infection 29 In India risk of vertical transmission is about 30%
- 18. FACTORS INCREASING VERTICAL TRANSMISSION DiseaseFactors Viral load Seroconversion Advanced mutant disease Low CD4 Obstetric Factors Vaginal delivery Prolonged rupture of membranes LBW Antepartum invasive procedure Breastfeeding
- 19. SCREENING All pregnantwomen should be offered screening early in pregnancy Pretest and posttest counselling mandatory ANTENATAL CARE Option of MTP should be discussed earliest HIV +ve mothers should be counselled about nutrition, hygiene, safe sex practices, etc Detailed anomaly scan should be a priority Prophylaxis for pneumocystis indicated when CD4 count is <200mm3
- 20. ANTI RETROVIRAL THERAPY RCOG GUIDELINES They recommend either zidovudine monotherapy or HAART(advanced disease, high viral load or low CD4 count) WHO GUIDELINES Option A- Zidovudine twice daily 14 weeks onwards, Neviparine single dose at labor onset, Zidovudine and lamivudine twice daily during labor and 1 week postpartum OPTION B triple drug prophylaxis from 14 weeks and during breast feeding NACO GUIDELINES Neviparine single dose 200mg onset of labor, single dose of 2mg/kg to neonate within three days of delivery
- 21. INTRAPARTUM MANAGEMENT Whenantiretroviral therapy was given in the prenatal, intrapartum, and neonatal periods along with cesarean delivery, the likelihood of neonatal transmission was reduced by 87 percent compared with vaginal delivery and without antiretroviral therapy Elective c section at 38 weeks for all women not taking HAART and viral load >50/ml is advised Planned vaginal if on HAART and viral load less than 50/ml In Zidovudine monotherapy c section reduces infection risk Universal Precautions should be followed stringently
- 22. BREAST FEEDING Theprobability of HIV transmission per liter of breast milk ingested is estimated to be similar in magnitude to heterosexual transmission with unsafe sex in adults Most transmission occurs in the first 6 months, and as many as two thirds of infections in breast-fed infants are from breast milk. In the Petra Study Team (2002) from Africa, the prophylactic benefits of shortcourse perinatal anti viral regimens were diminished considerably by 18 months of age due to breast feeding
- 23. POSTPARTUM MANAGEMENT otherwisehealthy women with normal CD4+ T-cell counts and low HIV RNA levels may discontinue treatment after delivery and be closely monitored according to adult guidelines The exception is the woman who plans another pregnancy in the near future
- 24. REFERENCES William’s Obstetrics24th edition Textbook of Obstetrics by Sheila Balakrishnan Uptodate.com
Editor's Notes
- #4 Cochrane metaanalyses- treatment of AUB decreases pyelonephritis by 75 pecent