UTI

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URINARY TRACT INFECTION IN PREGNANCY
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• S.P CHUWA

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OBJECTIVES .

• DEFINITION
• EPIDEMIOLOGY
• TYPES
• ASYMPTOMATIC BACTEURIA.
• INVESTIGATIONS
• TREATMENT.
• COMPLICATIONS

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• DEFINITION
• Urinary tract infection is an infection in any
  part of the urinary system ie kidneys, ureters
  bladder and urethra
• Also can be defined as presence of at least
  100,000 microorganism per ml of urine in an
  asymptomatic patient.
• Or as gt100 organisms/ml of urine with
  accompanying of pyuria(gt7WBCs/ml) in symptomatic
  patient

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• Other definitions
• Recurrent cystitis repeated infection with
  different organism with resolution of infection
  between clinical episode.
• Persistent cystitis an infection that never
  completely resolve and cultures remain positive
  for the same organism.
• Acute pyelonephritis clinical syndrome of fever,
  chills, low back or flank pain and tenderness,
  abdominal pain, nausea, vomiting and malaise
  combined with bacteriuria.

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ASYMPTOMATIC BACTERIURIA

• Bacteriuria - gt100,000 colonies of bacteria of
  the same species per mls of urine without
  symptoms of urinary tract infections
• Midstream urine sample
• 8 of women have Asymptomatic Bacteriuria
• 40 develop acute symptomatic UTI if left
  untreated.
• Increase the incidence , anaemia, low birth
  weight and fetal loss.
• Treat with antibiotics

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• Risk factors for urinary tract infection 
• Inability or failure to empty the bladder
  completely
• -Obstruction to the urinary flow congenital
  or acquired -calculi in the kidney or ureter
   -urethral strictures -compression of the
  ureters -neurological abnormalities
• Decreased natural host defenses or
  immunosuppression and chronic diseases
• Instrumentation catheters, cystoscope
• Inflammation or abrasion of the urethral mucosa
• Female anatomy short urethra and close
  proximity to the anus

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UTI IN PREGNANCY

• Pathophysiology
• Decreased Immunity
• Hormones decreasing peristalsis-dilated pelvis,
  ureters, urethra and Vesico-ureteric and Urethro
  vesical reflux
• compression of the ureters and bladder by gravid
  uterus
• Bladder emptying problemsrecurrent cystitis

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• Ascending infection Bacteria in perineal area
  ascends through the urethra, enters the urinary
  bladder and multiplies. This is the most common
  route of infection
• Hematogenic infection In a patient with
  bacteremia, bacteria may be implanted into the
  kidneys from the blood

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• Causative organisms
• Escherichia coli
• Proteus
• Pseudomonas
• Klebsiella and
• Staphylococcus (Diabetes)

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Which part of the urinary tract can get
infected? 

• Urethra - Urethritis  
• Urinary bladder Cystitis  
• Ureters Ureteritis  
• Kidneys - Pyelonephritis  

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Classification of UTI

• Lower urinary tract infections bladder and
  Urethra
• Upper urinary tract infections kidneys and
  ureters

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UTI Clinical Features

• Symptoms
• Fever 39-40 degrees
• Shivering
• Headache
• General malaise
• Blood in urine
• Vomiting
• Pain during urination
• Increased frequency

• Offensive smell- urine
• Lower Abdominal Pain
• Backache
• Pain in the groin

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On examination

• General examination
• Febrile, might be ill looking, tachycardic, not
  pale not jaundiced, /- signs of dehydration
• On per abdomen, suprapubic tenderness in
  cystitis, groin tenderness in ureteritis and
  pyelonephritis.

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UTI Differential Diagnosis

• Malaria
• Appendicitis
• Cholecystitis
• Septic Abortion
• Pelvic inflammatory disease (PID)
• Hyperemesis gravidarum
• Premature labour

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UTI Lab. Investigations

• Urinalysis cloudy urine, leucocyte gt1, nitrites
  
• full blood picture leukocytosis predominantly
  neutrophilia, anemia
• Urine for culture and sensitivity
• Renal Function test increased serum creatinine
• mRDT
• Renal Ultrasound in selected cases
• IVU or IVP-in selected cases
• Cystoscopy-in selected cases

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Management

• In Management of UTI choose one of the following
  depending on disease severity, Pregnancy, drug
  sensitivity, side effects, culture sensitivity,
  chronicity of the disease and economic status of
  the patient.

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UTI Management

• Prophylaxis
• Avoid Constipation
• Treat infection elsewhere
• Treat Asymptomatic Bacteriuria
• Treat Anaemia
• Emptying the bladder
• Proper hygiene
• Nutrition

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UTI Management

• General measures Hydration, Nutrition
• Analgesics, Anti-inflammatory and Antipyretics
• Antiemetics
• Antibiotics (According to C/S results)

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Pharmacological

• Nitrofurantoin tabs PO 100 mg 12 hourly for 5
  days OR
• Amoxicillin clavulanic acid (FDC) PO 40mg/kg/day
  (max 2000mg) in 3 divided doses for 7 days

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Management of the Pregnant Woman with Acute
Pyelonephritis

• Hospitalization
• Urine and blood cultures
• FBP, serum creatinine, and electrolytes
• Monitor vital signs frequently, including urinary
  output consider catheterization
• Intravenous crystalloid to establish urinary
  output to 30 mL/hr

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• Chest radiograph if there is dyspnea or tachypnea
• Repeat hematology and chemistry studies in 48
  hours
• Change to oral antimicrobials when afebrile
• Discharge when afebrile 24 hours consider
  antimicrobial therapy for 7 to 10 days
• Urine culture 1 to 2 weeks after antimicrobial
  therapy completed

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• IV antimicrobials
• IV ceftriaxone 1GM 24 hourly for 5 days

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UTI Complications

• Maternal
• Anemia, Septicemia, renal dysfunction and
  pulmonary insufficiency. ARDS may develop due to
  endotoxin induced alveolar capillary membrane
  damage following septicemia

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• Fetal increased fetal loss due to abortion,
  preterm labor, intrauterine fetal death caused by
  hyperpyrexia and low birth weight babies
  (prematurity and dysmaturity).

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Note

• Sulphonamides should not be used during the third
  trimester because they interfere with bilirubin
  binding and thus impose a risk of neonatal
  hyperbiliruninaemia and kernicterus
• Trimethoprime should also preferably be avoided
  particularly in the first trimester because of
  its antifolate effect leading to neural tube
  defects
• Tetracyclines (decolourisation of the teeth) and
  quinolones (fetal malformations) should be
  avoided during pregnancy

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• Gentamicin is advised to avoid during pregnancy.
• Whenever possible, Gentamicin treatment should
  not exceed 7 days due to side effects.
• Gentamicin should preferably not be given with
  pontentially ototoxic and nephrotoxic effects.

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References

• DC Duttas textbook of Obstetrics, seventh
  addition
• Dr Chuwas notes on UTI in pregnancy
• Tanzania Standard Treatment Guidelines, sixth
  edition 2021

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THE END

• THANK YOU!!!!!!