UTI in Pregnancy by Simpson Ahimbisibwe.pptx

Utis in pregnancy

1. UTI in Pregnancy A h i m b i s i b w e S i m p s o n 2 2 - 1 - 7 4 8

2. Overview Introduction Physiology renal changes during pregnancy Epidemiology of urinary tract infection during pregnancy Etiology Risk factors Types of UTI in pregnancy Clinical presentations of different types Diagnosis Management Complications 4/24/2025 7:32 AM 2

3. Introduction Disorders of the kidneys and urinary tract are commonly encountered in pregnancy. Some precede pregnancy—one example is nephrolithiasis. Pregnancy-induced changes may predispose to the development or worsening of urinary tract disorders—an example is the markedly increased risk for pyelonephritis. Last, renal pathology unique to pregnancy, such as preeclampsia, can develop. These infections are the most frequent bacterial infections complicating pregnancy.Although asymptomatic bacteriuria is the most common, symptomatic infection includes cystitis , or it may involve the renal calyces, pelvis, and parenchyma to cause pyelonephritis .Organisms that cause urinary infections are those from the normal perineal flora. Approximately 90 percent of Escherichia coli strains that cause nonobstructive pyelonephritis. 4/24/2025 7:32 AM 3

4. Physiology renal changes during pregnancy During normal pregnancy, significant changes o c c u r b o t h s t r u c t u r a l a n d f u n c t i o n a l . D i l a t a t i o n o f r e n a c a l y c e s a n d u r e t e r s d u e t o h o r m o n a l r e l a x a t i o n o f m u s c u l a r l a y e r s o f t h e u r i n a r y t r a c t , f u t h e r d i l a t a t i o n o c c u r s a t b e g i n i n g o f m i d p r e g n a n c y d u e t o u r e t e r a l c o m p r e s s i o n e s p e c i a l l y o n t h e r i g h t s i d e I n c r e a s e d v e s i c o u r e t e r a l r e f l u x P r o t e i n a n d g l u c o s e e x c r e t i o n i s i n c r e a s e d G l o m e r u l a r f i l t r a t i o n i s i n c r e a s e d b y 5 % - 7 5 % 4/24/2025 7:32 AM 4

5. Epidemiology of urinary tract infection during pregnancy The frequency of urinary tract infection in pregnant women about 0.3 to 1.3% is similar to that in non pregnant women. However, recurrent bacteriuria is more common in pregnant women than non pregnant women. I n one Australian study, kidney disorders had an incidence of 0.3 percent in 407,580 births (Fitzpatrick, 2019). Organisms from the normal perineal flora cause urinary infections. Escherichia coli strains most commonly cause nonobstructive pyelonephritis. 4/24/2025 7:32 AM 5

6. Etiology Organisms that cause urinary infections are those from the normal Perineal flora Escherichia coli strains – 90% Adhesins such as P- and S-fimbriae that enhance their virulence promote binding to vaginal and uroepithelial cells Others: Klebsiella-Enterobacter-Serratia group Staphylococcus aureus Enterococcus group B Streptococcus Proteus 4/24/2025 7:32 AM 6

7. Risk factors Urinary stasis and vesicoureteral reflux predispose to symptomatic upper urinary infections Diabetics are especially susceptible to developing pyelonephritis Increased bladder sensitivity to intravesical fluid tension ( → urine retention) due to: Labor trauma Analgesia Discomfort caused by an episiotomy, periurethral lacerations, or vaginal wall hematomas Catheterization to relieve retention and distension commonly leads to urinary infection 4/24/2025 7:32 AM 7

8. Risk factors Low socioeconomic status Parity Age Sexual practice Medical conditions such as diabetes and sickle cell trait. Second trimester Nulliparity Young age 4/24/2025 7:32 AM 8

9. Types of UTI in pregnancy Lower UTI Cystitis urethritis Upper UTI pyelonephritis 4/24/2025 7:32 AM 9

10. Clinical presentations of different types Asymptomatic bacteriuria : Refers to persistent, actively multiplying bacteria within the urinary tract in asymptomatic women Incidence during pregnancy is similar to nonpregnant women and varies from 2 - 7% Diagnostic criteria: clean-voided specimen containing >100,000 (colony count > 10 5 ) organisms per milliliter 4/24/2025 7:32 AM 10

11. Asymptomatic Bacteriuria Untreated cases – 25% → symptomatic infection during pregnancy 25–30% → acute pyelonephritis Asymptomatic bacteriuria has been associated with increased risks : Preterm delivery Fetal loss Low-birth weight infants Pregnancy-associated hypertension (PET) Anemia 4/24/2025 7:32 AM 11

12. Cystitis Lower UTI during pregnancy may develop without antecedent covert bacteriuria The bacteria causing cystitis are similar to those in asymptomatic bacteriuria Cystitis is usually uncomplicated → upper UTI due to ascending infection 40% of pregnant women with acute pyelonephritis have preceding symptoms of lower tract infection 4/24/2025 7:32 AM 12

13. Clinical Manifestations Clinically, the patient presents with symptoms of: urinary frequency urgency Dysuria suprapubic discomfort cloudy and malodorous urine / Pyuria and bacteriuria Microscopic hematuria is common / or gross hematuria from hemorrhagic cystitis 4/24/2025 7:32 AM 13

14. Acute Pyelonephritis Acute pyelonephritis occurs in 1–2% of all pregnant women Most common causes of hospitalization during pregnancy Is unilateral and > half of cases at right-side, and a fourth are bilateral 4/24/2025 7:32 AM 14

15. Clinical manifestations Fever, chills, Flank pain Anorexia, nausea and vomiting → dehydration Tenderness elicited by percussion in one or both cost vertebral angles Increased urinary frequency Dysuria Headache Anemia Bacterial endotoxemia Endotoxic shock Renal insufficiency 4/24/2025 7:32 AM 15

16. Investigations Urine examination will reveal: MSU  Significant bacteriuria, pyuria, Proteinuria ,RBC cast WBC casts (in clumps contain numerous bacteria) in urinary sediment MSU count of 1–2 bacteria per high-power field or > 20 bacteria in the sediment of a centrifuged specimen is diagnostic Urine culture and sensitivity Associated hematuria may indicate urinary calculi 4/24/2025 7:32 AM 16

17. Investigation Blood – CBC - anemia, leukocytosis, thrombocytopenia Elevated fibrin split product levels Culture - bacteremia 15 to 20% cases RFT   GFR & Creatinine clearance (↑ cr ) - endotoxin-induced damage B/S for MPs to R/O malaria 4/24/2025 7:32 AM 17

18. Differential Diagnosis Labor Chorioamnionitis Acute abdomen ( Appendicitis, Ectopic pregnancy ) Placental abruption Infarcted leiomyoma Sepsis syndrome 4/24/2025 7:32 AM 18

19. Management Asymptomatic bacteriuria First choice drugs : Tabs Nitrofurantoin 50-100mg 6 hourly for 7 days or capsules amoxicillin 500mg 8 hourly for 7 days or second choice drug : tabs cefalexin 500mg 8 hourly for 7 days Cystitis Outpatient if mild, and admit if severe Tabs amoxicillin 500mg 8 hourly daily for 5 days or tab Nitrofurantoin 100mg 8 hourly for 5 days. Then follow up ANC, advise on prevention, early detection and early reporting to health facility. 4/24/2025 7:32 AM 19

20. Management Pyelonephritis Treat as inpatient, observe: temperature, pulse, respiration and blood pressure twice a day. Tepid sponge and give paracetamol if high temp Ensure adequate hydration by oral or IV route Give antibiotics; Ampicillin 2g IV every 6 hours plus IV metronidazole 500mg 8 hourly for 48 hours. Once the woman is fever free for 48 hours, give amoxicillin 1g by mouth three times per day to complete 14 days of treatment. Iv Ceftriaxone 2g once a day for 48 hours then Tabs cephixime 200mg 8 hourly for 14 days. Or Tabs cefloxime 250mg 8hourly for 14 days 4/24/2025 7:32 AM 20

21. A n t i b i o t i c s c o n t r a i n d i c a t e d i n p r e g n a n c y T e t r a c y c l i n e s . H a v e a d v e r s e e f f e c t o n f e t u s t e e t h a n d b o n e s a n d c o n g e n i t a l d e f e c t s T r i m e t h o p r i m i n 1 s t t r i m e s t e r . F a c i a l d e f e c t s a n d c a r d i a c a b n o r m a l i t i e s C h l o r a m p h e n i c o l . G r a y b a b y s y n d r o m e S u l p h o n a m i d e s i n 3 r d t r i m e s t e r c a u s e h a e m o l y t i c a n e a m i a i n m o t h e r s w i t h g l u c o s e - 6 - p h o s p h a t e d e h y d r o g e n a s e d e f i c i e n c y , j a u n d i c e a n d k e r n i c y e r u s 4/24/2025 7:32 AM 21

22. Prophylaxis for special cases ( Recurrent UTI ) Women whose recurrent UTIs are associated with sexual intercourse are offered postcoital antibiotic prophylaxis. This involves taking a single dose of nitrofurantoin 50mg or trimethoprim - sulfamethoxazole (40/200) mg or cephalexin 500 mg after sexual intercourse 4/24/2025 7:32 AM 22

23. P R E V E N T I V E M E A S U R E S A v o i d b a t h s W i p e f r o n t - t o - b a c k a f t e r u r i n a t i n g o r d e f i c a t i n g W a s h h a n d s b e f o r e u s i n g t h e t o i l e t U s e w a s h c l o t h s w h i l e c l e a n i n g p e r i n e u m U s e l i q u i d s o a p t o p r e v e n t c o l o n i s a t i o n f r o m b a r s o a p C l e a n t h e u r e t h r a l m e a t u s f i r s t w h e n b a t h i n g 4/24/2025 7:32 AM 23

24. Complications In severe cases : Preterm labor / prematurity Fetal death Small-for-gestational-age babies Teratogenic effects of hyperthermia in early pregnancy Risk factors for recurrent or severe disease are: History of pyelonephritis Urinary tract malformation Urinary calculi 4/24/2025 7:32 AM 24

25. Reference F.Gary Cunningham,Kenneth J. Leveno , Jodi S.Dashe , Barbara L Hoffman, Catherine Y, Spong , BrianM . Casey (2022) Williams OBSTETRICS 2 6 T H E D I T I O N. Raisa O platte, krystal reynolds (2021), urinary tract infections in pregnancy. Mediscape. The essential Maternal ,New Born clinical protocols ministry of health uganda. Uganda clinical guideline 202 3 . Grow Hill 4/24/2025 7:32 AM 25

26. End Thanks for listening 4/24/2025 7:32 AM 26