UTI In Pregnancy

Question 1

Pregnancy and UTIs

Answer 1

 Recall pregnancy causes
hydronephrosis (dilation of renal
pelvis, calyces and ureters, this is
greater with the right than left
kidney) this is due to the fact
that:
 Pregnant uterus compresses
the lower ureter.
 Hormonal environment
decreases ureteral tone
(progesterone)
 Both these factors may cause
urinary stasis and increase
vesicoureteral reflux leading
to symptomatic upper urinary
tract infections (UTIs)

Question 2

The commonest organism for
UTI

Answer 2

Escherichia coli,
less commonly implicated are Streptococci, Proteus,
Pseudomonas and Klebsiella spp

Question 3

PREDISPOSING
FACTORS FOR UTI

Answer 3

 Pregnancy is a risk factor
 History of recurrent cystitis
 Renal tract abnormalities: duplex
system, scarred kidneys, ureteric
damage and stones
 Diabetes
 Bladder emptying problems e.g.
multiple sclerosis
 Sickle cell trait

Question 4

CLINICAL
FEATURES FOR UTI

Answer 4

 Symptoms may be different in
pregnancy, it occasionally
presents as low back pain and
general malaise with flu-like
symptoms.
 The classic presentation of
frequency, dysuria and hematuria
is not often seen.
 On examination:
 Tachycardia
 Pyrexia
 Dehydration
 Loin tenderness

Question 5

INVESTIGATIONS FOR UTI

Answer 5

 Should include:
 Midstream specimen of urine
(MSU) for microscopy,
culture and sensitivity.
 Full blood count

Question 6

PROPHYLAXIS TO
PREVENT FURUTE
UTIS

Answer 6

 Prophylaxis nitrofurantoin
100mg PO OD until 2 weeks
postnatal.
 Indications: acute cystitis,
pyelonephritis, recurrent or
persistent asymptomatic
bacteriuria.

Question 7

ASYMPTOMATIC
BACTERIURIA

Answer 7

 This is the most common UTI in
pregnancy.
 No symptoms although if not
treated it has the potential to
develop into acute
pyelonephritis

Question 8

ASYMPTOMATIC
BACTERIURIA DX

Answer 8

 Made with a positive urine
culture (midurine stream sample)
showing more than 105 colony
forming units/ml of a single
organism.

Question 9

ASYMPTOMATIC
BACTERIURIA TX

Answer 9

 Single-agent, outpatient oral
antibiotics (Nitrofurantoin)

Question 10

ACUTE CYSTITIS

Answer 10

 This is a UTI localized to the
bladder without systemic
findings

Question 11

ACUTE CYSTITIS C/F

Answer 11

 Urgency
 Frequency
 Burning
 Suprapubic pain
 It also has the propensity to
develop into acute pyelonephritis

Question 12

ACUTE CYSTITIS DX

Answer 12

 Positive urine culture (midurine
stream sample) showing more
than 105 colony forming units/ml
of a single organism.

Question 13

ACUTE CYSTITIS TX

Answer 13

 Single-agent, outpatient oral
antibiotics.
 Nitrofurantoin 100mg PO BD
x 7 days (second choice is
cefuroxime or cephalexin)
 Check urine culture and
sensitivities if available.
Adjust antibiotics as
indicated, especially if first
line treatment falls.
 If UTI recurs, the check urine
culture and sensitivities,
adjust antibiotics.
 Avoid Nitrofurantoin at term
as it may produce neonatal
hemolysis

Question 14

ACUTE
PYELONEPHRITIS

Answer 14

 This is a UTI involving the upper
urinary tract with systemic
findings. This is one of the most
common serious medical
complications of pregnancy.
 Acute pyelonephritis is unilateral
and affects the right side in more
than 50% of the cases.
 Escherichia coli is cultured in
80% of the time.
 Bacteremia is seen in 15-20% of
women with acute
pyelonephritis.

Question 15

ACUTE
PYELONEPHRITIS C/F

Answer 15

 Pain with urination, urgency and
frequency
 Shaking Chills and fever
(>38.5OC)
 Nausea and vomiting
 Anorexia
 Renal angle tenderness (Flank
pain)

Question 16

ACUTE
PYELONEPHRITIS DX

Answer 16

 Positive urine culture (midurine
stream sample) showing more
than 105 colony forming units/ml
of a single organism.
 Additional investigations for
baseline renal function should
include urea and electrolytes and
the baby must be monitored with
cardiotocography (CTG)

Question 17

ACUTE
PYELONEPHRITIS DDX

Answer 17

 Preterm labor
 Chorioamnionitis
 Appendicitis
 Placental abruption
 Infarcted myoma

Question 18

ACUTE
PYELONEPHRITIS MANAGEMENT

Answer 18

 Admit.
 IV hydration for adequate urinary
output.
 Opiate analgesia: Paracetamol
500mg PO for pain and fever
 Intravenous antibiotics such as
cephalosporins or gentamicin.
 Note: the most common cause
of persistent pyelonephritis
despite adequate therapy is
nephrolithiasis.
 Ceftriaxone 2g IV every 24
hours, if none, benzyl
penicillin 5 MU IV and then
2.5 MU every 6 hours and
gentamicin 5mg/kg x body
weight IV every 24 hours
 Check urine culture and
sensitivities if available prior
to starting antibiotics.
o Adjust treatment according
to results. If no clinical
response within 72 hours,
the re-evaluate results and
antibiotic coverage.
o If unavailable, then
antibiotics until afebrile for
48 hours. Change to cephalosporin if no clinical
response within 72 hours.
 Once afebrile, switch to oral
antibiotics for total of 14
days

Question 19

ACUTE
PYELONEPHRITIS COMPLICATIONS

Answer 19

 Renal dysfunction: increased
creatinine
 Pulmonary edema: endotoxininduce alveolar injury
 ARDS
 Hemolysis
 Preterm labor