BACTERIAL INFECTIONS DURING PREGNANCY.pptx

BACTERIAL INFECTIONS

1. BACTERIAL INFECTIONS DURING PREGNANCY Deeksha 7 th semester

2. UTI A UTI is an infection in any part of urinary system – kidneys , ureters , bladder and urethra . Most of the UTIs involve the lower urinary tract – the bladder and the urethra . Women are at greater risk . CAUSES : E.Coli ( most common ) . Others – klebsiella (10%) , enterobacter proteus .

3. RISK FACTORS : Female anatomy . Sexual activity . Menopause . Blockage in urinary tract . Hormonal changes .

4. TYPES : Asymptomatic bacteriuria (ASB) – bacteria in urine without symptoms . Lower UTI ( cystitis , urethritis ) – UTI affecting bladder and urethra . Upper UTI ( pyelonephritis ) – UTI affecting kidneys .

5. SYMPTOMS : Lower UTI – increased frequency of urination Increased urgency of urination . Bloody and cloudy urine . Urine that has strong odor . Burning micturition . Pelvic pain . Upper UTI – pain and tenderness in the upper back and sides . Nausea & vomiting . Fever & chills .

6. DIAGNOSTIC EVALUATION History collection . Physical examination – vital signs , abdominal examination ( suprapubic tenderness ) . CVA ( costovertebral angle ) tenderness – suggests pyelonephritis . Laboratory investigation : urine examination , blood examination , renal ultrasound .

7. URINE EXAMINATION – Urine screening : all the pregnant women should screened at first prenatal visit for asymptomatic bacteriuria . Urinalysis : dipstick test : leukocyte esterase – detects the presence of leukocytes in the urine , suggesting UTI . Nitrite indicator : suggests the presence of gram negative bacteria ( E.coli ) .

8. Urine culture more than or equals to 100,000 CFU/ml in asymptomatic women . More than or equals to 10,000 CFU/ml in symptomatic women . BLOOD EXAMINATION : elevated WBC count . Monitor for renal function test . RENAL ULTRASOUND : if pyelonephritis not improving after 48 -72 hrs of antibiotics . Suspected obstruction ( stones etc ) .

9. COMPLICATION : Maternal : acute pyelonephritis Septic shock . Anemia . Acute kidney injury . Preterm labor . Premature rupture of membranes . Increased risk of cesarean section .

10. Fetal complications : preterm birth . Premature rupture of membrane . IUGR . LBW . Perinatal morbidity and mortality .

11. Management of UTI in pregnancy General principles : Treat all bacteriuria in pregnancy even if asymptomatic . Choose safe antibiotic . Adequate hydration . Monitor for complication . Always do urineCS before treatment .

12. Asymptomatic bacteriuria : Routine urine CS . Antimicrobial / antibiotics – Nitrofurantoil 100 mg bid . Amoxicillin 500 mg tid . Cephalexin 500 mg tid . A course of 10-14 days will cure 70-100% of cases . Long term prophylaxis with nitrofurantoin 50 mg or amoxicillin 250 mg at night may have to be continued until delivery when the infection is recurrent .

13. Acute cystitis : nitrofurantoin 100 mg bid is effective . Acute pyelonephritis : the onset is acute and usually appears beyond 16 week . MANAGEMENT : hospitalization . IV fluid administration . evaluate complete hemogram , serum electrolytes etc . Acetaminophen for fever . Monitor urine output , vital signs .

14. IV administration for 48 hrs till culture report is availableand then change to oral therapy for another 10 to 14 days . Repeat urins culture after 2 weeks of antibiotic therapy and is repeated at each trimester of pregnancy . PREVENTION : Drink plenty of liquids especially water . Maintain perineal hygiene . Empty bladder soon after intercourse . Avoid potentially irritating feminine products .

15. METRITIS Metritis is the inflammation of the wall of the uterus , whereas endometritis is the inflammation of functional lining of the uterus , called the endometrium . Endometritis is caused by an infection in the uterus . It can be due to chlamydia , gonorrhea , tuberculosis. It is more likely to occur after miscarriage or childbirth .

16. The risk of endometritis is higher after having a pelvic procedure that is done through the cervix such as D&C , endometrial biopsy , hysteroscopy , placement of an IUCD . Sign & symptoms : Abdominal swelling Abnormal vaginal bleeding & discharge . Constipation . Fever , feeling of sickness . Pain in pelvis , lower abdominal area , rectal area .

17. COMPLICATION : Maternal – persistent postpartum fever , pelvic abscess , septic shock , preterm labor , PPH , subinvolution of uterus . Fetal and neonatal complications : During pregnancy – preterm delivery , PROM , still birth . Neonatal complication – neonatal sepsis , pneumonia , meningitis , LBW , IUGR , increased perinatal morbidity and mortality .

18. Diagnostic evaluation : Physical examination : general examination – vital signs , signs of dehydration . Abdominal examination – uterine tenderness , suprapubic pain , subinvoluted uterus postpartum . Pelvic examination : speculum exam – foul smelling purulent or blood stained vaginal discharge /lochia . May exclude retained products . Bimanual examination – uterus will be tender , soft , boggy , possibly enlarged .

19. Lab investigation : culture from the cervix for chlamydia , gonorrhea , and other organisms. Endometrial biopsy . CBC – leukocytosis with neutrophilia . Amniotic fluid studies ( if suspected intra amniotic infection ) :- amniocentesis – low glucose , high WBCs , positive gram stain / culture . Ultrasound – to rule out retained products , abscess . Wet prep

20. Management : General principles – hospitalization . Broad spectrum IV antibiotics . Supportive treatment ( IV fluid , antipyretics , maternal and fetal monitoring ) . Antibiotic therapy : Combination of clindamycin and gentamycin administered IV every 8 hourly . The combination of 2 nd or 3 rd generation cephalosporin with metronidazole is another popular choice . E.g. ampicillin + gentamicin + metronidazole .

21. PELVIC TUBERCULOSIS Pelvic TB is an infectious disease caused by mycobacterium tuberculi . Pelvic TB is often a silent disease . It is the most common cause of infertility especially in Asia . Cause – mycobacterium tuberculi . Risk factor – past or current pulmonary TB . Low socioeconomic condition . Malnutrition . Immunocompromised . Close contact with TB patient .

22. Sign & symptoms : Maternal symptoms – low grade fever , night sweats , malaise , weight loss . Chronic pelvic pain , cough / respiratory symptoms if pulmonary TB . Obstetric manifestation – infertility history before conception , recurrent pregnancy loss , antepartum hemorrhage , preterm labor . Fetal effect – IUGR , preterm birth , still birth , rarely congenital TB .

23. Examination and investigation : Hysterosalpingogram : X-ray of genital organ of a female . It is used to see tubal blocks . It also shows the peculiar lead to pipe appearance of fallopian tube . Endometrial biopsy : a piece of endometrial tissue is obtained in a laparoscopic procedure . Microscopic examination of the tissue might reveal tubercular bacteria . Culture of menstrual blood : a menstrual blood can be cultured to find out the presence of tubercular bacteria in the uterus . Blood test : increased differential blood count , ESR .

24. Management : antitubercular therapy – safe in pregnancy . First line regimen (6 months ) : Isoniazid (H) + rifampicin ( R) + ethambutol ( E) + pyrazinamide ( Z) . Streptomycin contraindicated – ototoxic to fetus . Nutritional support . Regular follow up .