URINARY TRACT INFECTION

IN PREGNANCY
 Urinary Tract Infection
● Urinary tract infections (UTIs) are common in pregnant
women.
○ Asymptomatic bacteriuria occurs in 2 to 7 percent of
pregnant women
● Factors that have been associated with a higher risk of
bacteriuria include a history of prior urinary tract
infection, pre-existing diabetes mellitus, increased parity,
and low socioeconomic status
● Without treatment, as many as 30 to 40 percent of
pregnant women with asymptomatic bacteriuria will
develop a symptomatic urinary tract infection (UTI),
including pyelonephritis, during pregnancy
 Pregnancy Outcomes

● Untreated bacteriuria - associated increased

risk of preterm birth, low birth weight, and
perinatal mortality in most, but not all studies.
● Acute cystitis - no correlation has been clearly
established between acute cystitis of
pregnancy and increased risk of low birth
weight, preterm delivery, or pyelonephritis
● Pyelonephritis, however, has been associated
with adverse pregnancy outcomes – higher
rate of preterm birth
 Pathogenesis

● The organisms that cause bacteriuria and urinary tract infections (UTI) in
pregnant women are of the same species and have similar virulence factors as
in nonpregnant women.
● Mechanism of entry of bacteria into the urinary tract is likely to be the same
for both groups
● However, the smooth muscle relaxation and subsequent ureteral dilatation
○ Facilitate the ascent of bacteria from the bladder to the kidney, resulting
in the greater propensity for bacteriuria to progress to pyelonephritis
during pregnancy
● Pressure on the bladder from the enlarging uterus may also increase the risk
of progression to pyelonephritis.
● In addition, the immunosuppression of pregnancy may contribute.
○ As an example, mucosal interleukin-6 levels and serum antibody
responses to Escherichia coli antigens appear to be lower in pregnant
women
 Diagnosis

● For asymptomatic women, bacteriuria is formally defined

as:
○ Two consecutive voided urine specimens with isolation
of the same bacterial strain in quantitative counts of
≥105 colony forming units (cfu)/mL or a;
○ Single catheterized urine specimen with one bacterial
species isolated in a quantitative count of ≥102 cfu/mL
 Management

● Management of asymptomatic bacteriuria in pregnant women includes

antibiotic therapy tailored to culture results and follow-up cultures to confirm
sterilization of the urine.
● Potential options include beta-lactams, nitrofurantoin, and fosfomycin
● The optimal duration of antibiotics for asymptomatic bacteruria is uncertain.
● Short courses of antibiotics are preferred to minimize the antimicrobial
exposure to the fetus.
● Short course antibiotic therapy is usually effective in eradicating
asymptomatic bacteriuria of pregnancy, although single-dose regimens may
not be as effective as slightly longer regimens
 Management

● Because up to 30 percent of women fail to clear

asymptomatic bacteriuria following a short course of
therapy, a follow-up culture should be obtained as a test
of cure.
● Typically perform this a week after completion of therapy.
● In addition, we usually repeat urine cultures monthly until
completion of the pregnancy because of the risk of
persistent or recurrent bacteriuria.
 Persistent vs recurrent bacteriuria
● True persistent bacteriuria implies initial therapy was
inadequate and thus requires modification with a different
therapeutic approach in contrast to recurrent bacteriuria
○ Suppressive therapy may be appropriate for women with
bacteriuria that persists after two or more courses of therapy.
○ Nitrofurantoin (50 to 100 mg orally at bedtime) if susceptible for
the duration of pregnancy

● Recurrent bacteriuria: Treatment should be administered

with one of the regimens used for an initial bacteriuric
episode, tailored to antimicrobial susceptibility testing
 Acute Cystitis
● The typical symptoms of acute cystitis:
○ Sudden onset of dysuria and urinary urgency and frequency
○ Hematuria and pyuria are also frequently seen on urinalysis.
● Empiric therapy: cefpodoxime, amoxicillin-clavulanate, and
fosfomycin, given their safety in pregnancy and the somewhat
broader spectrum of activity compared with other agents (such as
amoxicillin or cephalexin).
● Nitrofurantoin is another option during the second or third trimester
or if the others cannot be used for some reason (eg, drug allergy).
● If recurrent: Daily or postcoital prophylaxis with low dose
nitrofurantoin (50 to 100 mg PO postcoitally or at bedtime) or
cephalexin (250 to 500 mg PO postcoitally or at bedtime) can be used.
 Acute pyelonephritis
● The typical symptoms of acute pyelonephritis:
○ Fever (>38ºC or 100.4ºF), flank pain, nausea, vomiting, and/or
costovertebral angle tenderness.
○ Symptoms of cystitis (eg, dysuria) are not always present.
○ Pyuria is a typical finding.
● Management of acute pyelonephritis in pregnant women includes
hospital admission for parenteral antibiotics.
● Parenteral, broad spectrum beta-lactams are the preferred
antibiotics for initial empiric therapy of pyelonephritis
● Pregnant women generally have definite improvement within 24 to
48 hours of appropriate antibiotic therapy.
● Once afebrile for 48 hours, pregnant patients can be switched to oral
therapy guided by culture susceptibility results and discharged to
complete 10 to 14 days of treatment
 Antibiotic Safety

● It is generally accepted that penicillins (with or

without beta-lactamase inhibitors),
cephalosporins, aztreonam, and fosfomycin are
safe in pregnancy.
● Because of possible but uncertain associations
with adverse birth outcomes, we generally
avoid nitrofurantoin during the first trimester
and trimethoprim-sulfamethoxazole during
the first trimester and near term unless no
other options are available.
UROSEPSIS
Urosepsis
 Sepsis in Pregnancy

● Obstetrical infections may require ICU admission,

particularly if they are complicated by severe sepsis or
septic shock, which has been reported to occur in 0.002 to
0.01 percent of all deliveries
● Such infections are a significant cause of maternal
morbidity and mortality
● The reported maternal mortality rate ranges from 20 to
28 percent in pregnant patients with septic shock and
multiple organ failure
● Women who are black, smoke, and are older the 35 years
may be more likely to be at risk of maternal sepsis
 Management

● Although there are no prospective studies of early goal-directed therapy

during pregnancy, the management of sepsis should be similar to that of the
nonpregnant patient and use the same targets.
 Targets

Goals during the first 6 hrs of resuscitation (grade 1C):

a. Central venous pressure 8–12 mm Hg

b. Mean arterial pressure (MAP) ≥ 65 mm Hg

c. Urine output ≥ 0.5 mL/kg/hr

d. Central venous (superior vena cava) O2 sat = 70% or mixed venous O2 sat =
65%
 Vasopressors

● The 2016 sepsis treatment guidelines published by the

Society of Critical Care Medicine do not specifically
address the care of pregnant patients.
● We consider norepinephrine as the first-line vasoactive
agent in pregnant patients who fail to respond to early
aggressive volume resuscitation.
● Although norepinephrine can reduce uterine blood flow,
there are no data to suggest that norepinephrine has an
adverse effect on the well-being of the fetus. Thus, we
consider this risk to be outweighed by the benefit of
maternal resuscitation
 Vasopressors

● For pregnant patients with refractory shock, the best second line agent is
unknown.
● Phenylephrine may a reasonable second-line agent
Sepsis in Pregnancy
 Monitoring

● All women should undergo conventional ICU monitoring.

● This usually includes continuous assessment of the heart
rate, cardiac rhythm, oxyhemoglobin saturation, and
respiratory rate, as well as frequent evaluation of the
blood pressure and temperature.
● Pregnant women should have fetal heart rate and uterine
monitoring, the frequency of which depends upon the
gestational age of the fetus and the clinical scenario.