Basic hallmark urinary tract diseases in pregnant women is the prevalence of erased, low-symptomatic forms with a minimum number of clinical manifestations and laboratory markers.
However, at the same time, the negative impact of the infectious process on the course of pregnancy is realized, the number of complications from both the mother and the fetus increases sharply. In this regard, the issues of timely diagnosis and full treatment of urinary tract infections at all stages of gestation should be given special attention.
It is customary to isolate infections of the upper and lower urinary tract. The first ones are
pyelonephritis (serous and purulent), the second - urethritis, cystitis and asymptomatic bacteriuria (BB). Uncomplicated UTIs are acute cystitis and acute pyelonephritis. The remaining diseases are considered complicated UTIs. Any form of urinary tract infection in pregnant women requires active therapy, including asymptomatic bacteriuria.
It has been shown that in the absence of antibacterial treatment, BD progresses to gestational pyelonephritis in 14-57% of cases.
Causes of urinary tract infection:
The main cause of urinary tract infection is considered to be an infectious agent. Among nonspecific pathogens, the most common (44%) are representatives of enterobacteria: Escherichia coli (leading in frequency), Klebsiella, Proteus, Enterobacter. The second place in frequency is occupied by gram-positive cocci (36%) - staphylococci, enterococci, streptococci. The share of fermenting and non-fermenting Gram-negative bacteria accounts for 19-20%. An essential role belongs to the non-spore-forming anaerobic flora (Peptostreptococcus, Veillonella, etc.). In 7% of patients, fungi of the genus Candida are a causally significant pathogen.Microbial associations are detected in 8% of cases. It is known that for last years significantly changed the sensitivity of microorganisms to antibacterial agents. In particular, the number of resistant strains of E. coli to semi-synthetic penicillins reaches 30-50%, to protected penicillins exceeds 20%. The same resistance is recorded in relation to most non-fluorinated quinolones, and nitroxaline is ineffective in more than 80% of cases.
The role of specific pathogens (chlamydia, representatives of the mycoplasma family, viruses) is determined by their special tropism for the tissues of the urinary tract, leading to the formation of long-term interstitial nephritis. Chlamydia, mycoplasmas and ureaplasmas are found in 45% of pregnant women with urinary tract infections, viruses (herpes simplex virus, cytomegalovirus, enteroviruses) - in 50%. As a rule, these microorganisms are associated with certain representatives of nonspecific flora - staphylococci, enterococci, Klebsiella, non-spore-forming anaerobes. At the same time, Escherichia coli is more often cultured in patients who do not have specific infections.
The source of urinary tract infection can be any infectious and inflammatory focus in the body, but in pregnant women highest value have pathogens localized in the genital tract and intestines, and not only inflammatory, but also dysbiotic processes play a role. In this regard, the risk group for the development of urinary tract infections in pregnant women includes patients with inflammatory processes of the genitals and bacterial vaginosis, women who have a partner with an inflammatory pathology of the genital apparatus, conducting intensive sexual life. Long-term use of COCs or spermicides on the eve of pregnancy matters. In addition, risk factors are intestinal dysbacteriosis and inflammatory processes in it. They indicate the role of the features of the anatomical structure of the pelvis, when the distance between the anus and the external opening of the urethra is less than 5 cm.
Ways of distribution of an infection are various. The ascending pathway predominates in infections of the lower urinary tract, as well as in conditions of disruption of normal urodynamics, the formation of a reflux system with a gradual reflux of urine from the vestibule of the vagina into the renal pelvis. However, with the development of pyelonephritis, the main route of infection is hematogenous.
It is believed that for the implementation of the infectious process, in addition to the microbial agent, the presence of predisposing pathogenetic factors is necessary, among which the most important are: a change in the immunoreactivity of the body, a violation of urodynamics (obstructive or dynamic), endocrine pathology (especially diabetes mellitus), an existing pathology of the urinary system, hereditary predisposition. As a rule, every pregnant woman has a combination of several factors.
The most natural of them is a dynamic violation of the outflow of urine. In the first trimester, it is associated mainly with hormonal changes in the body (increased progesterone levels), in the second and third trimesters, with a mechanical factor of compression of the kidneys and ureters due to the growth and rotation of the uterus. Compression events are typical for the following categories of women (risk groups for the development of pyelonephritis): with a large fetus, multiple pregnancy, polyhydramnios, narrow pelvis. Violation of carbohydrate metabolism in the form of reduced glucose tolerance is the most common variant of gestational diabetes, found in 3-10% of cases in relation to all pregnancies, is associated with UTI in 100% of cases. Among hereditary factors special meaning has a history of UTI in the mother, which increases the risk of recurrent urinary tract infections in a pregnant woman by 2-4 times.
Pyelonephritis:
Infectious-inflammatory disease with a primary lesion of the interstitial tissue of the kidney, its renal tubules, as well as cavities. From the point of view of the negative impact on the course of the gestational process, among various urinary tract infections, it is pyelonephritis that is of the greatest importance. Pyelonephritis during pregnancy may be a continuation of a chronic process that a woman had earlier. In this case, it is usually latent (in 75%) or is accompanied by exacerbations. If pyelonephritis is detected for the first time at any time, it is considered associated with pregnancy - gestational, while an acute, latent or recurrent variant of the course is possible. Clinical and laboratory manifestations and tactical principles are the same in both cases, but the chronic process determines the worst starting conditions and the complexity of treatment (for example, flora resistance).Types of pyelonephritis:
serous pyelonephritis (97%), in which a multifocal leukocyte infiltration of the connective tissue of the kidney is formed with compression and dysfunction of the renal tubules; Treatment is predominantly conservative.purulent pyelonephritis (3%) is non-destructive (apostematous) and destructive (subcapsular abscess and carbuncle of the kidney), always requires surgical treatment.
Pyelonephritis is more often found in nulliparous women (66%), usually manifests itself in the second or third trimesters of pregnancy (starting from 22-28 weeks). However, in Lately an earlier onset of the disease is increasingly observed - in the first trimester (in about 1/3 of cases). Kidney damage is often bilateral, but on the one hand (usually on the right) the process is more pronounced.
Symptoms of pyelonephritis in pregnant women
Acute pyelonephritis is an infectious and inflammatory disease with general and local symptoms. General symptoms appear first, they are associated with intoxication of the body. This is a general weakness, malaise, headaches, loss of appetite. Nausea and vomiting, loose stools are possible. There are muscle pains and aches all over the body. Temperature from subfebrile to hectic, chills, sweating. On the 2-3rd day of the disease, local symptoms appear. First of all, it is a pain syndrome. In pregnant women, as a rule, it is not pronounced even with a purulent process (otherwise, one should think about urolithiasis). The pains are localized in the lower back, are unilateral or girdle in nature, can radiate to the leg, intensify in the position on the contralateral side, as well as with deep inspiration, coughing, sneezing. Forced position in bed - on a sore side.
Pasternatsky's symptom may be positive, but negative does not indicate the absence of pyelonephritis. Pain is more reliable on palpation of the ureteral points located at the level of the navel, retreating from it in both directions by 3-4 cm (if the duration of pregnancy allows). With irritation of the parietal peritoneum, peritoneal signs may appear. Dysuric disorders are considered another typical manifestation. Diuresis is adequate or slightly increased, nocturia is characteristic. A decrease in diuresis is a symptom indicating a violation of the passage of urine due to blockage of the ureters by inflammatory detritus. This is a dangerous sign indicating a possible rapid transformation of the serous process into a purulent one and requiring immediate intervention in the form of ureteral catheterization. Exacerbations of chronic pyelonephritis, as well as recurrent gestational pyelonephritis, have clinical manifestations similar to the acute process, but the symptoms are usually more blurred, and sometimes minimal.
Latent pyelonephritis:
This condition is characterized by poor clinical symptoms, inconstancy and mosaic of deviations in urine tests. At the same time, some minimal activity of the pathological process is permanently present. It is far from always being assessed and treated in a timely manner.It is believed that one should think about latent PN in cases where a combination of three to four of the following signs is found:
a history of recurring cystitis;
periodic subfebrile condition;
complaints of weakness, night sweats, headaches;
pallor, grayish complexion, bags under the eyes;
pastosity of the face and hands;
aching pain in the lower back, appearing in connection with physical activity or hypothermia;
sudden onset and spontaneously disappearing episodes of dysuria;
a steady decrease in the specific gravity of urine;
periodic appearance of small proteinuria, leukocyturia, microhematuria, crystalluria, bacteriuria;
changes in the echostructure of the kidneys.
Laboratory diagnosis of pyelonephritis:
Changes in urine tests1. Pyelonephritis is accompanied by a violation of the concentration function of the kidneys, a decrease in water reabsorption, therefore, the most constant sign is a decrease in the specific gravity of urine below 1015 against the background of a slight increase in diuresis and nocturia (Zimnitsky's test is required).
2. The acidity of urine, which is normally 6.2-6.8, often changes with pyelonephritis, shifting to the alkaline side.
3. Glycosuria is detected, as a rule, when the inflammatory process is activated and is associated with a violation of reabsorption processes in the tubules of the kidneys.
4. Proteinuria is often observed, but it does not reach high numbers and daily protein excretion does not exceed 1 g.
5. Leukocyturia usually corresponds to the severity of the inflammatory process. With a latent course of pyelonephritis, it is minimal. Normally, the number of leukocytes in one field of view during microscopy of a colored urine sediment does not exceed 4. Leukocytes are destroyed if several hours have passed before the start of the study (centrifugation), as well as with an alkaline urine reaction.
To detect latent leukocyturia, counting of formed elements in 1 ml of urine is used (there should not be more than 2000 leukocytes and 1000 erythrocytes). You can use a test with a prednisolone load (counting leukocytes in two portions of urine - before and after the introduction of 30 mg of prednisolone intramuscularly). This test is considered positive if in the second portion the number of leukocytes is at least 2 times higher than in the first and more than 4 (for example, it was 2-3 - it became 4-6).
6. With pyelonephritis, microhematuria is possible. In the absence of urolithiasis, glomerulonephritis, hydronephrosis or tuberculosis of the kidney, the persistent nature of microhematuria, which does not disappear after sanitation, indicates a high probability of interstitial nephritis caused by specific pathogens (chlamydia, mycoplasmas, viruses).
7. Cylinders - only hyaline are characteristic. Other variants of cylindruria are possible with severe kidney pathology.
8. Salt crystals indicate dysmetabolic nephropathy - a violation of the anti-crystallization stability of urine. The reasons for the latter are different, including the role of inflammatory processes. The significance of a non-random event is only persistent oxalate and urate crystalluria. A link has been established between oxaluria and chlamydial infection.
9. Bacteria in the urine may be present in a minimal amount, their content in 1 ml of urine should not exceed 104 CFU.
Besides:
Representatives of the intestinal group (E. coli, Klebsiella spp., Proteus spp., etc.), as well as Enterococcus in the urinary tract, are always considered pathogenic pathogens and, regardless of concentration, require mandatory elimination;
Staphylococcus epiderm. not allowed in a titer of more than 103 CFU;
In the presence of manifestations of process activity or against the background of antibiotic therapy, any monoculture of the pathogen in a titer of more than 102 CFU is considered causally significant.
To detect bacteriuria, methods of counting the number of bacteria by microscopy of a stained urine sediment, a nitrite test and the "gold standard" - sowing urine on media with the identification of microorganisms and counting CFU are used. When evaluating seeding results, consider the following:
The results of 2-3 consecutive cultures or one culture with provocation (furosemide at a dose of 20 mg) are informative;
Sterile cultures are not proof of the absence of infection, since a number of uropathogens (anaerobes, intracellular bacteria, viruses) do not grow on ordinary media;
Low (not true) bacteriuria may be associated with slow growth on the media of some uropathogenic strains;
False-positive results are observed in 20% of cases due to incorrect examination (the sample should be delivered to the laboratory within 1 hour or stored for up to a day at a temperature of + 2-4 °)
in all cases, the pathogen identified in the culture may not be causally significant in the pathogenesis of this inflammatory process.
Changes in blood tests:
Acute and exacerbation of chronic PI are accompanied by inflammatory blood changes (leukocytosis, shift to the left, lymphopenia, a significant increase in ESR) of varying severity, the appearance of C-reactive protein, anemia, hypo- and dysproteinemia. The negative dynamics of blood tests in the presence of clinical symptoms of PN should be alarming in terms of the risk of transformation of the serous process into a purulent one.With a latent process (chronic and gestational), a general blood test may show (not always) a slight lymphopenia, as well as signs of an iron deficiency state.
An increase in the content of nitrogenous slags (usually not residual nitrogen, but its fractions) is possible with a severe course of the disease, or with layering of PN on the initial pathology of the kidneys (glomerulonephritis, nephropathy of various origins, CRF). The study of the functions of filtration (Reberg's test) and re-absorption is carried out according to indications (required for a combination of PN and preeclampsia).
Additional research methods:
During pregnancy, there are significant limitations regarding additional, especially radiation, research methods. The following are allowed:1. Ultrasound of the urinary system. The criteria for the presence of pyelonephritis are:
asymmetric changes in the kidneys;
expansion and deformation of the renal pelvis;
coarsening of the contour of the cups, compaction of the papillae;
heterogeneity of the parenchyma;
shadows in the pelvis;
expansion of the upper ureters (indicates a violation of the passage of urine).
2. Chromocystoscopy and retrograde catheterization of the ureters. They allow to clarify the side of the lesion and, most importantly, to establish and eliminate the delay in the passage of urine. Shown up to 36 weeks of pregnancy.
3. Radioisotope renography with technetium. Allowed in the 2nd and 3rd trimesters. Radiation exposure is minimal.
Complications of pregnancy associated with urinary tract infection. The least negative impact on the course of pregnancy is provided by uncomplicated urinary tract infections - acute cystitis and pyelonephritis, provided they are properly treated. With inadequate therapy, there is a risk of developing infectious complications in the fetus. However, acute pyelonephritis in the 1st trimester of pregnancy is an indication for its termination due to the need for antibiotic therapy. Asymptomatic bacteriuria is dangerous, mainly due to the fact that very often (in more than half of cases) in the absence of treatment it is realized in pyelonephritis. Most often, complications of pregnancy are associated with recurrent and latent forms of gestational and especially chronic pyelonephritis.
The most typical complications in pregnant women:
1. Threat of abortion (30-60%); more often in the 1st and 2nd trimesters, has a persistent course, poorly responds to tocolytic therapy, usually stops against the background of antibacterial and anti-inflammatory treatment.2. Chronic feto-placental insufficiency against the background of morpho-functional rearrangement of the placenta (especially with a specific infection); taking into account compensated and subcompensated forms, the frequency reaches 100% of cases. May lead to IUGR, chronic and acute fetal hypoxia. Perinatal mortality ranges from 60 to 100%.
3. Infectious pathology of the placenta, membranes, fetus (placentitis, chorionamnionitis, polyhydramnios, IUI). Contamination by pathogens of the elements of the fetal egg is carried out predominantly by the hematogenous route.
4. Preeclampsia complicates up to 30% of pregnancies against the background of pyelonephritis, is characterized by an early onset and a tendency to progression.
5. Infectious pathology of the genitals - in 80% of cases, and almost half of the women have sexually transmitted infections. Almost in 100% of observations - dysbiotic processes.
6. Iron deficiency states (usually in the form of a latent deficiency) - in 80-90%; it should be remembered that the appointment of iron-containing drugs is permissible only after stopping the activity of the infectious-inflammatory process, due to their ability to provoke the inflammatory process.
7. Insufficient readiness (immaturity) of the cervix for childbirth (not less than 40%) - due to a violation of the processes of transformation of the connective tissue (in particular, collagen fibers), which ensures the elasticity and extensibility of this organ.
8. High frequency of untimely rupture of membranes, abnormal contractile activity of the uterus. The nature of SDM anomalies is different, and in case of a specific infection it is closely related to the type of pathogen.
In particular, for infection with representatives of the mycoplasma family, the formation of a pathological preliminary period, primary weakness and discoordination of SDM is typical (45%). With chlamydial infection, very often (about 25%) there is excessive contractile activity of the uterus, leading to rapid and rapid labor.
9. Acute urinary retention after childbirth is associated with a violation of the passage of urine due to a mechanical obstruction in the ureter (detritus). In such cases, catheterization of the bladder is ineffective. Requires intravenous administration of crystalloids, antispasmodics, saluretics, followed by ureteral catheterization (in the absence of effect).
10. Infectious and inflammatory complications in the postpartum period - endometritis, suture divergence.
Risk groups in pregnant women with urinary tract infections:
1 (minimum) - uncomplicated urinary tract infection, asymptomatic bacteriuria;2 (medium risk) - chronic pyelonephritis (any variant of the course), recurrent and latent gestational pyelonephritis;
3 (high risk) - chronic pyelonephritis of a single kidney, pyelonephritis with chronic renal failure; in these cases, pregnancy is contraindicated, however, with pyelonephritis of a single kidney, there is a positive experience in managing pregnant women in hospitals of the 1st level.
Observation of pregnant women with pyelonephritis:
1. When registering with a antenatal clinic, a pregnant woman with chronic kidney disease must be referred to a specialized hospital to clarify the diagnosis and choose a treatment method. Subsequent hospitalizations are indicated for:PN activation;
latent process, not amenable to outpatient sanitation;
occurrence of obstetric complications requiring inpatient treatment.
2. At all stages of observation - dynamic monitoring of urine tests with an emphasis on hypostenuria, leukocyturia, microhematuria and small bacteriuria. If signs of UTI appear, appropriate outpatient or inpatient treatment.
3. Identification of foci of infection (including specific) in the body, primarily in the genital tract, adequate sanitation, correction of dysbacteriosis.
4. Regular assessment of the condition of the fetus, carrying out activities aimed at the prevention and treatment of HFPI.
5. Timely diagnosis and treatment of pregnancy complications (threat of miscarriage, preeclampsia, etc.)
6. Antenatal hospitalization at 38-39 weeks (in order to clarify the activity of UTIs, find out the degree of maturity of the cervix, conduct appropriate preparation, sanitize the genital tract, calves, saluretic-aspasmolytics, salureticoa. It is required for veterinary childbirth and discoordination to assess the condition of the fetus, choose a method of delivery).
8. Delivery is carried out at full-term pregnancy. UTI, even often recurrent and requiring repeated antibiotic therapy, is not an indication for early delivery, unless there are special circumstances - progressive fetal suffering, severe obstetric complications (preeclampsia that cannot be corrected, placental abruption, etc.), diuresis drop during compression of the ureter of a pregnant woman uterus if ureteral catheterization fails.
Treatment for urinary tract infection:
1. Mode and diet. Bed rest is necessary only if you feel unwell and have symptoms of intoxication. The supine position should be avoided, as in this case the urine output drops by 20%. It is preferable to lie on your healthy side to decompress the damaged kidney. Several times a day it is useful to take the knee-elbow position.The exclusion of salt from the diet is not required, but too spicy and salty dishes are not recommended. There is no liquid restriction, the drink is neutral or alkaline, with the exception of cranberry (lingonberry) juice, which has a bactericidal effect in the kidneys. Persistent crystalluria requires dietary adjustments. In particular, it is not recommended for oxaluria frequent use milk, eggs, legumes, tea, broths, potatoes are limited. On the contrary, sour-milk products, cereals, vegetables, fruits (especially apples) are shown. Boiled meat and fish are allowed.
2. Antibacterial therapy is the most important link in the treatment of UTIs. The basic principles of a/b therapy are as follows:
adequate choice of drug for initial empiric therapy;
transition to monotherapy after identification of the pathogen;
timely monitoring of the effectiveness of treatment (initial assessment after 48-72 hours) with frequent and rapid change of drugs in the absence of clinical and laboratory signs of improvement;
compliance with the optimal duration of treatment.
1st trimester of pregnancy:
In the first trimester of pregnancy, antibiotic therapy should be minimized in order to protect the fetus from teratogenic and embryotoxic effects. In the case of BD or latent pyelonephritis (without signs of activity), phytotherapy (phytolysin, canephron, rensept) is allowed under the following conditions: the duration of therapy is at least 4-6 weeks, sanitation of the genital tract, the use of eubiotics. In the presence of clinical and laboratory markers of the activity of the inflammatory process, it is necessary to prescribe antibacterial drugs. The duration of treatment for acute cystitis is 3-5 days, for acute pyelonephritis - 7 days, for exacerbation of chronic pyelonephritis - 10 days, followed by a transition to herbal medicine. In the first trimester, semi-synthetic penicillins are allowed. Inhibitor-protected penicillins show the greatest efficiency. In particular, amoxicillin / clavulanate (amoxiclav, augmentin) - 0.625 every 8 hours or 1 g every 12 hours; in / venously 1.2-2.4 g every 8 hours.2nd and 3rd trimesters of pregnancy:
The functioning of the placenta determines slightly different principles for the treatment of urinary tract infections at this stage of pregnancy. For acute urethritis, cystitis, and BB, a short course of treatment (3 to 7 days) and only one antibacterial drug is used, followed by herbal medicine. Inhibitor-protected penicillins are used (amoxiclav 0.625 g 3 times a day), cephalosparins of 2-3 generations (cefuroxime 0.25-0.5 g 2-3 times a day, ceftibuten 0.4 g 1 time per day). Nitrofurans are also effective: furazidin (furagin) or nitrofurantoin (furadonin) 0.1 g 3-4 times a day. A 5-day course of treatment with B-lactam antibiotics is considered to be more effective than a 3-day course, and nitrofurans should be prescribed for a minimum of 7 days. A profitable alternative is a single (with uncomplicated cystitis and urethritis) or double (with BB) administration of fosfomycin (monural), which has a wide spectrum of action and is active against E. coli in 100% of cases. The drug is prescribed 3 g orally at night after emptying the bladder.Treatment for complicated forms of urinary tract infection:
duration of therapy for at least 14 days (otherwise, the probability of relapse is at least 60%);mandatory combination of two drugs (usually an antibiotic and a uroantiseptic or two antibiotics) in parallel or sequential mode;
in women with a high risk of recurrence of the process, use after the main antibacterial treatment of maintenance suppressive therapy (0.1 g of furagin daily at night after emptying the bladder for up to 3 months or 3 g of fosfamycin - 1 time in 10 days).
Drugs for the treatment of urinary tract infections in pregnant women:
The drugs recommended in the first trimester are used, as well as other groups of antibacterial agents.Cephalosporins (CS). When using these drugs for the treatment of UTIs, it should be taken into account that the 1st generation CAs are active mainly against gram-positive cocci, while the 2nd and 3rd generation CAs have predominant activity against gram-negative bacteria. IV generation CAs are more resistant to action (S-lactamase) and are active against both gram-positive and gram-negative microorganisms. However, all CAs do not act on MRSA, enterococci, and have low antianaerobic activity.
Aminoglycosides (AG). The main clinical significance of AGs is associated with their wide spectrum of action, special activity against gram-negative bacteria, high concentration in kidney tissues, and low allergenicity. Therefore, hypertension is indicated for initial empiric treatment of PN, especially in combination with CS. Of the adverse reactions, nephrotoxicity and ototoxicity are noted, which are most pronounced in first-generation drugs (not used in obstetrics), as well as with prolonged use (more than 7-10 days), rapid intravenous administration. The daily dose of AG (or 2/3 of it) can be used as a single injection.
Macrolides (ML). They mainly have a bacteriostatic effect against gram-positive cocci (enterococci are resistant) and intracellular pathogens. In the treatment of "PN ML, they are most often used as second-line drugs in patients with a specific infection.
As a rule, josamycin (vilprafen) is prescribed, it is excreted in the urine up to 20%, the dose is 1-2 g / day in 2-3 doses.
spiramycin (rovamycin) - 10-14% is excreted in the urine, the daily dose is 9 million IU / day (in 3 divided doses);
Lincosamides. They have a narrow spectrum of activity (gram-positive cocci, non-spore-forming anaerobes, mycoplasmas) and bacteriostatic action. They are excreted mainly in the urine. Relevant in cases where the significance of anaerobic flora is assumed or proven (lincomycin, lincocin - a daily dose of 1.2 to 2.4 g.
Uroantiseptics. They are second-line drugs, have a bactericidal or bacteriostatic effect. As monotherapy for complicated UTIs, it can be used to treat the latent process on an outpatient basis, as well as for suppressive treatment. Not prescribed after 38 weeks of pregnancy (risk of kernicterus in the fetus). Nitrofurans have a wide spectrum of activity, create high concentrations in the interstitium of the kidney - furazidin (furagin), nitrofurantoin (furadonin) are prescribed at 300-400 mg per day for at least 7 days. Preparations of 8-hydroxyquinolones (5-NOC, nitroxalin) are of little use, since the resistance of E. coli to them is 92%. Quinolones of the 1st generation (non-fluorinated) are active against gram-negative bacteria, the most effective drugs are pipemidic acid (palin, pimidel 0.8 g / day or urotractin 1 g / day).
Evaluation of the effectiveness of treatment:
1. With properly selected treatment, improvement in well-being and a decrease in clinical symptoms occur quickly - in 2-3 days. The cessation of symptoms is achieved by 4-5 days.2. Normalization of urine tests and hemogram - by 5-7 days (do not stop treatment).
3. An obligatory component of the cure criterion is eradication of the pathogen; against the background of successful a/b therapy, urine should be sterile by 3-4 days.
4. Persistence of disease symptoms and changes in laboratory parameters requires a rapid change of antibiotics (taking into account sensitivity or empirical combination with a wide spectrum).
5. Deterioration of the condition, an increase in intoxication, signs of a violation of the passage of urine (decreased diuresis, dilation of the ureters) require a solution to the issue of ureteral catheterization (temporary or permanent self-retaining stent catheter) and do not exclude surgical treatment (nephrostomy, kidney decapsulation).
Urinary tract infections during pregnancy include infections of the kidneys, bladder, urethra, and other parts of the urinary tract. Infections of the genitourinary system in pregnant women pose a danger to the normal course of pregnancy and require mandatory timely treatment. Infectious diseases of the urogenital tract complicate pregnancy, childbirth and the postpartum period, therefore, if genitourinary infections are suspected, a screening examination of pregnant women for asymptomatic bacteriuria is carried out, bacterial diagnosis and sanitation of the genitourinary tract are carried out. If necessary, to maintain pregnancy, adequate treatment and preventive measures are prescribed against recurrence of urinary tract infections. The duration of treatment for uncomplicated urinary tract infections is 7-14 days.
Classification of infections of the genitourinary system:
- Asymptomatic bacteriuria is detected in 2-11% of pregnant women - persistent bacterial colonization of the organs of the urinary tract without the manifestation of dysuric symptoms.
- Acute cystitis of pregnant women is detected in 1.3% of pregnant women.
- Acute pyelonephritis is detected in 1-2.5%.
- Chronic pyelonephritis occurs in 10-18% of pregnant women.
Risk factors for urinary tract infections in women:
- short urethra;
- the outer third of the urethra constantly contains microorganisms from the vagina and rectum;
- women do not empty their bladder completely;
- the entry of bacteria into the bladder during sexual intercourse;
- the use of antimicrobial agents;
- pregnancy;
- low socioeconomic status;
- lactating women;
- chronic pyelonephritis.
Criteria for diagnosing urinary tract infections in women:
- Clinical picture (dysuric disorders, frequent urination, imperative urges, symptoms of intoxication).
- An increase in the number of leukocytes and protein in the urine, bacteriuria more than 100,000 microorganisms in one ml of urine.
- Cultural study of urine.
List of main diagnostic measures:
- research using test strips (blood, protein);
- bacterioscopic examination of urine at each visit to the clinic;
- study of urine sediment;
- culture of urine at the first visit to the clinic, and in the detection and treatment of bacteriuria and cystitis - every month before delivery and 4-6 weeks after it;
- cultural examination of urine after inpatient treatment of pyelonephritis - 2 times a month before delivery;
- the concentration of creatinine in the blood (according to indications);
- culture of blood for suspected pyelonephritis;
- serological testing for gonorrhea and chlamydia;
- Ultrasound of the kidneys.
List of additional diagnostic measures:
- Therapist's consultation.
- Urologist consultation.
Treatment of asymptomatic bacteriuria in pregnant women:
Asymptomatic bacteriuria. Pregnancy does not increase the incidence of bacteriuria, but if present, it contributes to the development of pyelonephritis. There is no scientific evidence that bacteriuria predisposes to the development of anemia, hypertension and preeclampsia, chronic kidney disease, amnionitis, endometritis.
Pregnant women with bacteriuria are at high risk for miscarriages, stillbirths, and intrauterine growth retardation. The level of neonatal mortality and prematurity increases by 2-3 times. The vast majority of pregnant women with bacteriuria can be detected at the first visit to the doctor in early pregnancy, in 1% - bacteriuria develops in later pregnancy.
All pregnant women with bacteriuria are subject to treatment. Treatment of bacteriuria in early pregnancy prevents the development of pyelonephritis in 70-80% of cases, as well as 5-10% of all cases of prematurity.
A short course of treatment (1-3 weeks) with ampicillin, cephalosporins or nitrofurans is as effective in eliminating bacteriuria (79-90%) as the constant use of antimicrobials. No drug has an advantage over others, and therefore, the choice of drug should be made empirically based on clinical and laboratory parameters. If bacteriuria is detected, treatment begins with a 3-day course of antibiotic therapy, followed by a monthly urine culture for control. If bacteriuria is detected again (16-33%), it is necessary to prescribe maintenance therapy before delivery and another 2 weeks after delivery (single dose of the drug in the evening after meals).
The danger of drugs for the fetus:
- Penicillins and cephalosporins do not pose a risk to the fetus.
- Sulfonamides can cause hyperbilirubinemia and kernicterus in newborns.
- Tetracyclines cause dysplasia of bones and teeth.
- Nitrofurans can cause hemolysis in fetuses with glucose-6-phosphate dehydrogenase deficiency.
- Aminoglycosides can cause damage to the 8th pair of cranial nerves in the fetus.
Treatment of acute cystitis during pregnancy:
Acute cystitis diagnosed by the clinical picture (frequent, painful urination, feeling of incomplete emptying of the bladder). Bacteriological confirmation of infection is possible only in 50% of pregnant women with dysuria.
Cases without bacteriuria are referred to as acute urethral syndrome associated with chlamydial infection.
The risk of developing acute pyelonephritis after cystitis is 6%. Pregnant women with cystitis are subject to the same treatment as pregnant women with bacteriuria.
Acute pyelonephritis during pregnancy:
Pregnant women with a clinic of acute pyelonephritis are shown mandatory hospitalization in a hospital. At the end of the treatment of pyelonephritis, the pregnant woman should be prescribed maintenance therapy until the end of pregnancy.
It is necessary to carry out a cultural study of urine 2 times a month and treat the detected bacteriuria.
Therapeutic tactics for the treatment of pregnant women:
1. Treatment of asymptomatic bacteriuria and acute cystitis in pregnant women is carried out for 3 days according to one of the following schemes:
- Amoxicillin 250-500 mg every 8 hours (3 times a day);
- Amoxicillin / clavulanate 375-625 mg every 8-12 hours (2-3 times a day);
- Cefazolin 1 mg twice a day);
- Furagin 50 mg every 6 hours.
2. If bacteriuria is detected again, it is necessary to prescribe maintenance therapy before delivery and another 2 weeks after delivery (a single dose of the drug in the evening after meals) according to one of the proposed schemes.
When you hear the phrase " urinary tract infection during pregnancy» (UTI), you most likely imagine bladder infections and their accompanying symptoms, such as frequent urination and burning during bladder emptying. Indeed, such a condition, called cystitis, is quite common among sexually active women from 18 to 45 years of age. However, this is not the whole list of infections of the urinary system!
In fact, an infection can develop anywhere in your urinary tract, which starts at the kidneys, where urine is made, continues with tubes called ureters that carry urine down to the bladder, and ends at the urethra, a short tube that carries urine out of the bladder. limits of the body.
UTIs are usually caused by bacteria brought from the skin, vagina, or rectum that travel up the entire length of the urinary tract through the urethra. Often the bacteria stop in the bladder and multiply there, causing inflammation (cystitis) and leading to the symptoms that almost everyone knows.
But bacteria can rise up from the bladder, all the way to the ureters, leading to infection of one or both kidneys. Kidney infection (pyelonephritis) is the most common serious complication of pregnancy. Such an infection can spread throughout the circulatory system and become life-threatening for the expectant mother.
A kidney infection can also have serious consequences for the baby. It increases the risk of preterm birth, low birth weight, and increases the risk of stillbirth and neonatal death.
It also happens that in the presence of infections urinary tract during pregnancy, that is, if there are bacteria in the urine test, the woman does not notice absolutely no symptoms. This condition is known as "asymptomatic bacteriuria". When you're not pregnant, this condition usually doesn't cause problems and often goes away on its own. But during pregnancy, undiagnosed and untreated asymptomatic bacteriuria significantly increases the risk of kidney infection and associated preterm birth, and can also lead to a woman having a low birth weight baby. It is for these reasons that a pregnant woman must be sure to give urine for analysis before each visit to her doctor.
Pregnancy itself greatly increases the risk of getting a kidney infection. And here's why: more high level the hormone progesterone reduces muscle tone ureters (tubules between the kidneys and the bladder), which leads to their expansion and slowing down the outflow of urine. In addition, an enlarged uterus can compress the ureters, making it difficult for urine to pass through them. Your bladder also loses tone during pregnancy. Therefore, emptying the bladder completely becomes difficult, and the bladder itself becomes more prone to reflux, a condition in which some urine is thrown back into the kidneys.
The result of these changes is that it takes longer for urine to pass through the urinary tract, thus giving bacteria more time to multiply and travel to the kidneys. Moreover, during pregnancy, your urine becomes less acidic and contains glucose, which creates the most favorable conditions for bacteria to thrive.
Symptoms of a urinary tract infection
Symptoms of all urinary tract infections during pregnancy almost the same, so we will give the most common symptoms of inflammation of the bladder (cystitis). Common symptoms of inflammatory processes in the bladder are as follows:
- discomfort, burning or pain during urination and intercourse (not always);
- pain in the pelvic region or lower abdomen (most often just above the pubic bone);
- an overwhelming or frequent urge to urinate, even if there is very little urine in the bladder.
You may also find that your urine has become bad smell or looks cloudy, or you may notice traces of blood in it. You may develop low-grade fever (about 37.2 degrees), but most often the temperature remains normal.
Since frequent urination is a fairly common occurrence during pregnancy, a woman may not notice in time that she has cystitis, especially if the symptoms of the infection are mild.
If you notice signs that indicate a possible kidney infection, you should immediately consult a doctor. Symptoms of a kidney infection often appear quite suddenly and usually include:
- high fever accompanied by fever, severe sweating, or chills;
- pain in the back, in the lumbar region;
- pain in the side, in the hypochondrium, which can be localized on one or both sides;
- abdominal pain;
- nausea and vomiting.
You may also notice blood or pus in your urine, and you may have some of the symptoms of cystitis.
Asymptomatic bacteriuria during pregnancy
Asymptomatic bacteriuria in pregnant women often leads to preterm labor and very small weight in a newborn child. If bacteriuria is not treated, then the likelihood of developing a kidney infection reaches 40%, however, with adequate treatment, the risk drops sharply and ranges from 1 to 4%.
To find out if there are bacteria in the urinary tract, your doctor will first prescribe a general urine test (OAM), but if abnormalities are found in it, then you will need to go through and. In addition, you may need an ultrasound of the renal pelvis to detect abnormalities in their structure and functioning.
If a urine test for the presence of bacteria gives a positive result, you are safe to take during pregnancy. Full course such antibiotic therapy lasts an average of about a week, and, as a rule, leads to the complete elimination of the infection.
After the end of treatment, you will need to repeat the tests in order to make sure that the infection has been cured. If suddenly the treatment is ineffective, you will be prescribed another course using a different antibiotic. If the bacteriuria persists, then you will most likely be given continuous antibiotics (at a low dose) for the remainder of your pregnancy.
Treatment of cystitis in pregnant women
If you develop a bladder infection (cystitis) during pregnancy, you will be treated similar to bacteriuria, but the course will be slightly shorter (usually up to five days). Antibiotics usually relieve symptoms within a day after the start of treatment, but it is still very important to complete the entire course to completely get rid of all bacteria in the urinary tract.
After completion of treatment (and periodically during pregnancy), you will be given a urine test to confirm the effectiveness of therapy. If cystitis does not respond to the prescribed treatment, or if you have relapses of the disease, then you may be prescribed a low dose of antibiotics daily (until the end of pregnancy) to prevent inflammation and complications from it.
Kidney infection in pregnant women
If you develop a kidney infection while you are pregnant, you will be hospitalized and given intravenous antibiotics. In addition, you and your baby's health will be closely monitored - doctors will evaluate many parameters, including temperature, blood pressure, pulse, respiration and daily urine output, your baby's heart rate, and watch for any signs of preterm labour.
The length of hospitalization varies depending on the specific situation. If after the first day of hospitalization it becomes clear that you have a mild form of the disease, that the prescribed treatment is effective and there is no threat of preterm labor, then you may be discharged home for outpatient treatment with oral antibiotics.
If you have a severe kidney infection, you will need to stay in the hospital for further treatment and monitoring. Such hospitalization will last until you have a normal temperature, which will remain so for two days, and you will no longer have any symptoms of infection.
Prevention of urinary tract infections
To prevent, you must adhere to the following recommendations:
- Drink plenty of water, at least eight glasses a day;
- Never ignore the urge to go to the toilet, and during urination, try to empty the bladder to the end (for this you need to lean forward slightly);
- After a bowel movement, wipe the anus area with movements from front to back - this way you will prevent bacteria from the rectum from entering the urethra;
- Observe the hygiene of the genitals, wash the genitals warm water with mild soap;
- Cleanse the genital area after urination, and before and after sexual intercourse;
- Drink cranberry or lingonberry juice. Studies show that cranberry and lingonberry juice reduce bacteria levels and prevent them from entering the urinary tract;
- Avoid feminine hygiene products (such as deodorants or lubricants) and avoid using non-private soaps. Such products can irritate the urethra and genitals, thereby creating a wonderful breeding ground for bacteria. And give up entirely contrast shower while you are pregnant.
Pregnant women often experience an exacerbation of existing infectious diseases or the appearance of new ones. The reasons for the development of urinary tract infections during pregnancy are associated with the peculiarities of the hormonal background, anatomical changes and rearrangements of the body aimed at bearing the fetus. But their treatment is mandatory, and ignoring it can lead to complications.
Features of the urinary tract in pregnant women
Urinary tract infections are a common complication of pregnancy. It can occur as an asymptomatic appearance in urine tests of the bacterial flora or with clinical manifestations of cystitis. The frequency of occurrence depends on the presence of pathology of the bladder or urethra before conception, as well as the presence of kidney stones or other pathological conditions.
Progesterone not only reduces the tone of the myometrium, but also affects the rest of the smooth muscles. This manifests itself:
- expansion of the renal-pelvic system;
- decrease in the tone of the ureters;
- slight relaxation of the sphincter of the bladder.
These changes lead to a slow passage of urine from the kidneys. The bladder does not empty completely. Decreased tone and presence of residual urine promotes reflux back into the ureters. This causes the penetration of pathogens into the kidneys in an ascending way.
Expanded renal pelvis lead to the development of physiological hydronephrosis of pregnant women, as an additional factor in infectious pathology.
Changes occur in the chemical properties of urine. Its pH increases, the concentration of estrogen increases. The presence in women of a tendency to increase blood sugar or is a provoking factor for the reproduction of microbes.
Changes in the composition of the vaginal microflora, a decrease in local immunological protection leads to the activation of an opportunistic infection in the genital tract. Pathogens can easily enter the urethra and then spread upward to the bladder and kidneys.
Main pathogens
Cystitis and pyelonephritis of a non-infectious nature in pregnant women rarely develop. Infectious diseases develop against the background of activation of opportunistic microflora. The most common causes are the following:
- coli;
- klebsiella;
- staphylococci;
- streptococci;
- enterococci;
- Proteus.
The cause of damage to the urinary tract can be the causative agents of sexually transmitted infections:
- chlamydia;
- ureaplasma;
- mycoplasmas;
- gonococci.
In rare cases, the causative agents are Mycobacterium tuberculosis or pale treponema.
The mechanism of development of pathology and complications of gestation
The spread of infection occurs in several ways:
- ascending;
- descending;
- hematogenous;
- lymphogenous;
- contact.
Most often in pregnant women, ascending infection is realized. The pathogens enter the urethra from the vagina. This is due to their close location, as well as the anatomical features of the urethra itself, which in women is short and wide.
Ascending infection
The mucous membrane of the bladder effectively resists the development of inflammation, but during pregnancy, the influence of additional risk factors increases:
- immunosuppression;
- hypovitaminosis;
- overwork;
- hormonal changes;
- hypothermia;
- promiscuity;
- non-compliance with personal hygiene;
- anatomical anomalies;
- surgical interventions and manipulations.
If a woman had chronic cystitis before pregnancy, then in most cases it will worsen during the gestation period. With increasing gestational age, the risk also increases. Mechanical compression of the bladder and ureters by the uterus interferes with the normal outflow of urine. Therefore, cystitis can acquire a relapsing course.
Any infection in the body increases the risk of developing complications of gestation. After infection of the lower urinary tract, pathogens easily penetrate higher. This is due to the natural lack of resistance of the renal medulla to microbial agents. This environment is characterized by a hypertonic state, which prevents the penetration of leukocytes, phagocytes, the action of the complement system is limited, which causes a lack of resistance to infection.
Against the background of inflammation of the urinary tract, the likelihood of spontaneous abortion and the birth of a premature baby increases. The risk is increased due to the local synthesis of prostaglandins, which are inflammatory mediators and increase uterine contractions.
Inflammation of the urinary tract can develop as a complication of the postpartum period. During childbirth, the bladder is compressed, its innervation and blood supply are disturbed. This is an additional factor in urinary retention. If there is an infection of the vestibule of the vagina, then pathogens can be introduced into the bladder during mandatory catheterization.
Asymptomatic bacteriuria
In 6% of pregnant women, depending on the social status, asymptomatic bacteriuria is recorded. At the same time, a large number of microbial cells are detected in the analysis of urine, and there are no clinical manifestations of inflammation of the urinary tract. This condition is directly related to sexual activity: the more often intimate contacts occur, the more violations in the analyzes are detected.
With a deep examination in such patients, nephrolithiasis or congenital malformations of the urinary tract can be detected.
Signs of the disease do not appear. Deviations in the analyzes are most often recorded already in the initial period of pregnancy, much less often in the later stages. Complications of gestation are the following pathological conditions:
- threat of interruption;
- placental insufficiency;
- delayed fetal development;
- intrauterine fetal death.
It is possible to reduce the risk of complications of gestation with the help of timely diagnosis and treatment.
Examination methods
Obligatory dispensary observation of pregnant women allows to diagnose this condition in a timely manner and choose a method of treatment.
History will help identify cases of acute urinary tract infection or the presence of predisposing factors. Diagnosis of urinary tract infection during pregnancy includes the following tests and examination methods:
- general and biochemical blood test;
- clinical analysis of urine;
- urine according to Nechiporenko;
- bacteriological examination of urine.
It is performed at the first admission of a woman to a consultation if she wishes to register. Urine is collected in compliance with the rules of asepsis in a sterile container purchased at a pharmacy. For sowing, an average portion of urine is needed. Asymptomatic bacteriuria is diagnosed if more than 100,000 CFU/ml of the same microorganism were detected in two consecutive crops with an interval of 3-7 days.
As a screening study, a reaction with trivinyltetrazolium chloride is used. This method in 90% of cases can show the presence of true bacteriuria.
For an in-depth study and exclusion of the organic cause of the appearance of bacteriuria, ultrasound of the kidneys with Dopplerography is used, which allows you to assess the state of renal blood flow. To monitor the condition of the fetus, ultrasound is also necessary.
According to indications, excretory or survey urography can be performed. Additionally, a consultation with a urologist or nephrologist is prescribed.
When is treatment needed?
If true asymptomatic bacteriuria is detected in pregnant women, treatment is mandatory. This is a risk factor for the development of a full-fledged infectious process in the urinary tract, which can manifest itself at any stage of gestation.
Methods of non-drug treatment aimed at increasing the passage of urine are used. For this, it is recommended to consume at least 2 liters of fluid per day. It is also necessary to acidify the urine by drinking. Cranberry juice helps a lot with this. It is useful to use decoctions of herbs with a diuretic effect. These include lingonberry leaves, corn stigmas.
But it is impossible to rely only on treatment without antibiotics. The principles of drug therapy are as follows:
- Treatment is with short courses of antibiotics.
- A single dose of a large dosage of the drug during pregnancy is not effective enough.
- The drug is selected empirically from the permitted list, none of them has advantages over others.
- If bacteriuria is detected, treatment is prescribed for three days, then monthly bacteriological control of urinalysis is necessary in order to detect a relapse in time.
- If bacteriuria is detected again, then maintenance treatment is prescribed in the form of a single dose of an antibiotic in the evening after a meal. This regimen is maintained until the moment of delivery and for another two weeks after them.
- How to treat pathology during the maintenance course is decided on the basis of determining the sensitivity of microorganisms to antibiotics.
- The course of treatment may include short doses of uroseptics.
Antibacterial therapy for infectious diseases of the urinary tract is carried out with the following drugs:
- Amoxicillin;
- Amoxiclav;
- Cefuroxime;
- Ceftibuten;
- Cephalexin;
- Nitrofurantoin.
For maintenance therapy, Amoxicillin or Cefalexin is used as a daily intake. It is allowed to take Fosfomycin once every 10 days.
Timely treatment of asymptomatic bacteriuria reduces the risk of development by 70-80%, and also reduces the likelihood of having a premature baby. With the development of complications of gestation, a method of therapy is chosen in accordance with the gestation period.
The effectiveness of treatment is assessed by conducting bacterial cultures:
- Recovery - if less than 10 CFU / ml is detected in the urine culture.
- Persistence - more than 10 CFU / ml of the same pathogen is determined in the analysis.
- Reinfection - more than 10 CFU / ml of any other microorganism is detected in bacopseve.
Bacteriuria is not an indication for delivery by caesarean section. Only the presence of obstetric complications requires a change in the tactics of conducting the birth process.
Cystitis
Inflammation of the bladder is one of the most common urinary tract infections in pregnant women. Classification can be carried out according to various signs of pathology.
According to the course, acute and chronic are distinguished. Depending on the location and prevalence, it can be:
- cervical;
- diffuse;
- trigonite.
Morphological classification is based on characteristic changes in the bladder wall. Cystitis may be:
- catarrhal;
- hemorrhagic;
- ulcerative;
- fibrinoulcerative;
- gangrenous;
- encrusting;
- tumor;
- interstitial.
Infectious lesions of the urinary tract can develop primary or secondary.
Clinical manifestations
During pregnancy, acute or exacerbated chronic cystitis may develop. Symptoms of an acute urinary tract infection develop suddenly. The first of these are painful and frequent urge to urinate. The pain is sharp, cutting, localized in the lower abdomen. Its intensity gradually increases.
Unpleasant sensations can accompany only the beginning of urination, appear throughout its entire length, or disturb constantly. Imperative urges and painful sensations lead to the appearance of urinary incontinence.
Sometimes the symptoms of cystitis may not be very pronounced and go away on their own after 2-3 days. But in most cases, it requires treatment, which can last 1-2 weeks. If the duration of therapy is prolonged and signs of the disease persist for a long time, this indicates the presence of a concomitant disease that helps maintain inflammation.
In severe cases of pathology, the main symptoms are added:
- increase in body temperature;
- fatigue and weakness;
- signs of intoxication;
- oliguria.
It is possible to judge the localization of inflammation by the time of occurrence of the pain syndrome. When the neck of the bladder is affected, intense sensations appear at the very end of the act of urination. This is due to the appearance of tenesmus and convulsive contractions of the sphincter.
Urine may become cloudy. Sometimes terminal hematuria joins. In most cases, it is not visible to the naked eye. The appearance of blood in the urine is associated with damage to the inflamed tissues of the bladder in the neck and Lieto's triangle at the end of urination.
In chronic cystitis, the clinical picture is not so bright. It depends on the general condition against which the exacerbation occurred, the etiological factor and the previous treatment. In most cases, the manifestations of the pathology are similar to the acute course, but are less pronounced. Sometimes chronic cystitis is accompanied by a constant detection of bacteria, leukocytes in the urine, but a poorly expressed pain syndrome.
Acute cystitis or exacerbation of a chronic one increases the chance of developing pyelonephritis when the pathogen spreads upward.
Diagnostic approaches
Examination with the appearance of signs of cystitis begins with the collection of anamnesis, where there may be indications of the appearance of signs of inflammation before pregnancy. Clinical practice guidelines for urinary tract infections in pregnancy suggest the following types diagnostics:
- general urine analysis;
- blood analysis;
- blood glucose;
- test according to Zimnitsky;
- urine according to Nechiporenko;
- urine culture;
- smear on the degree of purity of the vagina;
- PCR diagnostics for chlamydia, trichomonas, gonococci.
Laboratory diagnostics is supplemented by instrumental research methods. Ultrasound of the bladder, echography of the pelvic organs is mandatory.
If necessary, differential diagnosis is prescribed cystoscopy. It is not used during acute cystoscopy, so as not to contribute to the spread of infection and the appearance of an exacerbation. In a chronic course, during the study, edematous, hyperemic tissues of the bladder are determined, they can be locally thickened, covered with fibrin films, and have ulcerations.
For therapeutic and diagnostic purposes, bladder catheterization is performed. This facilitates the excretion of urine and allows the topical application of antiseptics and antibiotics. If you suspect the development of a tumor process, a biopsy from suspicious foci is necessary.
Choice of treatment method
Treatment of urinary tract infections in pregnant women is mandatory with the use of antibiotics. Herbal remedies recommended folk medicine, are not able to cope with a bacterial infection, which will lead to the transition of an acute process into a chronic one or the development of complications.
Drugs used to treat urinary tract infections in pregnant women
The main courses of the following drugs are used:
- Amoxicillin or in combination with clavulanic acid;
- Cefuroxime;
- Ceftibuten;
- Cephalexin;
- Nitrofurantoin.
After treatment of the acute phase, they switch to maintenance therapy with the same drugs, which are taken at night.
With catheterization, the use of local funds is possible. The use of herbal uroseptics, which are combined with antibiotics, helps. Assign courses for 7 days of the following drugs:
- Kanefron;
- Phytolysin;
- decoctions of diuretic herbs.
If there are signs or a sexually transmitted infection, they are treated. The choice of drug depends on the gestational age and the type of pathogen.
The effectiveness of treatment is determined by the disappearance of clinical signs of inflammation and the normalization of urine tests.
Forecasts and prevention
With timely treatment, the course of cystitis does not have a pronounced effect on pregnancy. Childbirth can be conducted through the natural birth canal in the absence of obstetric indications.
Prevention consists in timely examination and planning of pregnancy. If there are foci of chronic infection in the oral cavity in the form of tonsillitis, caries, in the vagina, then they must be sanitized before conception.
Constipation predisposes to the development of cystitis. Therefore, pregnant women who are prone to bowel disorders must follow a diet or take additional mild laxatives in the form of Lactulose.
It is better for women with chronic cystitis to limit spicy, sour foods, marinades, spicy, fried foods in the diet. Alcohol consumption is also not allowed. In the postpartum period, these recommendations are preserved.
A broad-spectrum antibiotic that creates high concentrations in the bladder only.
The effectiveness of Monural is confirmed by numerous studies conducted in Russia and EU countries. The experience of using Monural has hundreds of thousands of patients.
Urinary tract infections in pregnant women. Modern approaches to treatment
Published in the magazine:Effective pharmacotherapy in obstetrics and gynecology. No. 1 January 2008
L.A. SINYAKOVA Doctor of Medical Sciences, Professor
I.V. KOSOVA
RMAPO, Moscow
In the first Russian manual on obstetrics, compiled by N.M. Maksimovich-Ambodik, "The Art of Fiddling, or the Science of Womanhood" (1784), there were indications of close anatomical connections between the genital and urinary organs in women. What is the tactics for nephroureterolithiasis, nephroptosis, and other diseases that require surgical correction in pregnant women? The answer is unequivocal: it is desirable to eliminate urological diseases before pregnancy. Pregnancy is a risk factor for the development of both uncomplicated (in 4-10% of cases) and complicated urinary tract infections.
Urinary tract infections in pregnancy may present as asymptomatic bacteriuria, uncomplicated lower urinary tract infections (acute cystitis, recurrent cystitis), and upper urinary tract infections (acute pyelonephritis).
The prevalence of asymptomatic bacteriuria in the population of pregnant women averages 6%. Acute cystitis and acute pyelonephritis are somewhat less common - in 1-2.5%. However, 20-40% of pregnant women with asymptomatic bacteriuria develop acute pyelonephritis in the second and third trimesters (13). Acute pyelonephritis develops in the third trimester in 60-75% of cases (7). Approximately 1/3 of patients with chronic pyelonephritis develop an exacerbation during pregnancy (8).
Table 1. Prevalence of asymptomatic bacteriuria in the population
| Population groups | Prevalence, % |
| Healthy premenopausal women | 1,0-5,0 |
| pregnant | 1,9-9,5 |
| Postmenopausal women over 50-70 | 2,8-8,6 |
| Patients with diabetes | |
| women | 9,0-27 |
| men | 0,7-11 |
| Elderly patients living in the community, 70 years | |
| women | 10,8-16 |
| men | 3,6-19 |
| Elderly patients living in nursing homes | |
| women | 25-50 |
| men | 15-40 |
| Patients with spinal cord injury | |
| with intermittently withdrawn catheter | 23-89 |
| with sphincterotomy and condom catheter | 57 |
| Patients on hemodialysis | 28 |
| Patients with an indwelling catheter | |
| short | 9-23 |
| long-term | 100 |
Urinary tract infections can cause a number of serious complications of pregnancy and childbirth: anemia, hypertension, premature birth, premature rupture of amniotic fluid, low birth weight babies (<2500 г), что в свою очередь приводит к повышению перинатальной смертности в 3 раза (1).
Indications for termination of pregnancy, regardless of the term, are as follows.
1. Progressive renal failure, established on the basis of the following criteria:
- the value of creatinine is more than 265 µmol/l (3 mg%);
- glomerular filtration below 30 ml/min.
2. An increase in the severity of hypertension, especially in malignant forms of its course. The high prevalence of urinary tract infections in pregnant women is explained by the following factors: a short wide urethra, its proximity to natural reservoirs of infection (vagina, anus), mechanical compression of the ureters by the uterus, decreased tone of the urinary tract, glucosuria, immunosuppression, changes in urine pH, etc.
The most common etiological factor in the development of urinary tract infections in pregnant women is Escherichia coli. The data are shown in Figure 1.
Figure 1. Etiology of urinary tract infections in pregnant women (AP1/IB 2003)
* - Paeruginosa - 2.2%, S. agalactiae - 2.2%, Candida spp. - 0.5% and others - 1%
However, in his work on urinary tract infections during pregnancy, A.P. Nikonov (2007) cites higher incidence of E. coli as the causative agent of urinary tract infections - up to 80%.
DIAGNOSTICS
According to the guidelines of the European Association of Urology from 2001, severe bacteriuria in adults:
1. ≥ 10 3 pathogens / ml in the average portion of urine in acute uncomplicated cystitis in women;
2. ≥ 10 4 pathogens / ml in the middle portion of urine in acute uncomplicated pyelonephritis in women;
3. 10 5 pathogens / ml in the average portion of urine in men (or in urine taken from women with a direct catheter) with complicated UTI;
4. In a urine sample obtained by suprapubic puncture of the bladder, any number of bacteria indicates bacteriuria.
Asymptomatic bacteriuria in pregnancy- This is a microbiological diagnosis based on the study of urine collected with the maximum observance of sterility and delivered to the laboratory in the shortest possible time, which allows the growth of bacteria to be most limited. The diagnosis of asymptomatic bacteriuria can be established by detecting 10 5 CFU / ml (B-II) of one strain of bacteria in two urine samples taken more than 24 hours apart in the absence of clinical manifestations of urinary tract infections.
Considering the high probability of developing an ascending urinary tract infection in pregnant women with asymptomatic bacteriuria, the possibility of developing complications during pregnancy with a risk of death for the mother and fetus, screening and treatment of asymptomatic bacteriuria of pregnant women is indicated for all patients. The algorithm is shown in Figure 2.
Figure 2. Screening examination of pregnant women for detection of asymptomatic bacteriuria
Clinical symptoms of acute cystitis in pregnant women are manifested by dysuria, frequent imperative urge to urinate, pain over the womb. When conducting laboratory tests, pyuria is detected (10 or more leukocytes in 1 μl of centrifuged urine) and bacteriuria: 10 2 CFU / ml for coliform microorganisms and 10 5 CFU / ml for other uropathogens.
In acute pyelonephritis, fever, chills, nausea, vomiting, pain in the lumbar region appear. Pyuria and bacteriuria over 10 4 CFU/ml persist. At the same time, in 75% - the right kidney is affected, in 10-15% - the left kidney, in 10-15% there is a bilateral process (1).
Particular attention should be paid to the diagnosis of frequently recurrent cystitis, since they can occur against the background of urogenital infections, and in such cases, no changes can be detected in the urine culture or in the clinical analysis of the urine. Such patients need to be examined to exclude sexually transmitted infections: scraping from the urethra for STIs by PCR, ELISA, if necessary, the use of serological diagnostic methods.
The algorithm for diagnosing urinary tract infections in pregnant women is presented in Table 2.
Table 2. Diagnosis of UTI in pregnant women
TREATMENT
When choosing an antimicrobial drug (AMP) for the treatment of UTI in pregnant women, in addition to microbiological activity, level of resistance, pharmacokinetic profile, proven efficacy of the drug, we must take into account its safety and tolerability.
Rational and effective use of antimicrobials during pregnancy involves the following conditions:
- it is necessary to use drugs (MP) only with established safety in pregnancy, with known metabolic pathways (FDA criteria);
- when prescribing drugs, the duration of pregnancy should be taken into account: early or late. Since it is impossible to determine the final completion of embryogenesis, it is necessary to be especially careful when prescribing an antimicrobial drug up to 5 months. pregnancy;
- in the process of treatment, careful monitoring of the condition of the mother and fetus is necessary.
If there is no objective information confirming the safety of the use of the drug, including antimicrobials, during pregnancy or breastfeeding, they should not be prescribed to these categories of patients.
The following risk categories for the use of drugs during pregnancy, developed by the American Food and Drug Administration - FDA (Food and Drug Administration) are widely used all over the world:
A- as a result of adequate strictly controlled studies, there was no risk of adverse effects on the fetus in the first trimester of pregnancy (and there is no evidence of a similar risk in subsequent trimesters).
B- Animal reproduction studies have shown no risk of adverse effects on the fetus, and there are no adequate and well-controlled studies in pregnant women.
C- Animal reproduction studies have shown adverse effects on the fetus, and adequate and well-controlled studies in pregnant women have not been conducted, however, the potential benefits associated with the use of drugs in pregnant women may justify its use, despite the possible risk.
D- there is evidence of the risk of adverse effects of drugs on the human fetus, obtained from research or practice, however, the potential benefits associated with the use of drugs in pregnant women may justify its use despite the possible risk.
Treatment of asymptomatic bacteriuria in early pregnancy reduces the risk of developing acute pyelonephritis in later pregnancy from 28% to less than 3% (9). Given that pregnancy is a risk factor for the development of complicated infections, the use of short courses of antimicrobial therapy for the treatment of asymptomatic bacteriuria and acute cystitis is ineffective. An exception is fosfomycin trometamol (Monural) in a standard dosage of 3 g once, since at concentrations close to the average and maximum levels, Monural leads to the death of all pathogens that cause acute cystitis within 5 hours, the activity of Monural against E. coli exceeds the activity of norfloxacin and co-trimoxazole (4). In addition, the concentration of the drug in the urine in doses exceeding the MIC is maintained for 24-80 hours.
Fosfomycin trometamol is an ideal first-line drug in the treatment of acute cystitis of pregnancy. It has the necessary spectrum of antimicrobial activity, minimal resistance of primary uropathogens, resistant clones of microbes are damaged. It overcomes the acquired resistance to antibacterial drugs of other groups, has bactericidal activity. According to Zinner, when using fosfomycin trometamol (n=153) 3 g once, the cure rate for asymptomatic bacteriuria after 1 month was 93%.
Thus, for the treatment of lower urinary tract infections and asymptomatic bacteriuria in pregnant women, the use of monodose therapy is indicated - fosfomycin trometamol at a dose of 3 g; cephalosporins for 3 days - cefuroxime axetil 250-500 mg 2-3 r / day, aminopenicillins / BLI for 7-10 days (amoxicillin \ clavulanate 375-625 mg 2-3 r / day; nitrofurans - nitrofurantoin 100 mg 4 r / day - 7 days (only II trimester).
In Russia, a study was conducted on the use of various drugs for the treatment of uncomplicated lower urinary tract infections in pregnant women, the data are presented in Table 4. At the same time, the frequency of incorrect prescriptions was 48% !!!
Table 4. Antibacterial therapy for infections of the lower urinary tract in pregnant women in Russia (Chilova R.A., 2006)
Table 5 presents the main adverse events in the appointment of a number of drugs during pregnancy.
Table 5. Risk of drug use during pregnancy
When atypical pathogens (urea-mycoplasma infection, chlamydial infection) are detected in patients with frequently recurrent cystitis, the use of macrolides (josamycin, azithromycin in standard dosages) in the trimester of pregnancy is indicated.
Patients with acute pyelonephritis require emergency hospitalization. The complex of laboratory diagnostic methods should include: general analysis of urine, blood, bacteriological examination of urine; Ultrasound of the kidneys, bladder. Monitor vital signs. The cornerstone of the treatment of patients with gestational pyelonephritis is the decision on the need for drainage of the urinary tract and the choice of drainage method.
An indication for drainage of the urinary tract during pregnancy is the presence of acute pyelonephritis in a patient against the background of impaired urodynamics.
The choice of the method of drainage of the urinary tract during pregnancy depends on: the causes of urodynamic disorders (ICD, decreased tone of the urinary tract, uterine compression, reflux); terms of pregnancy; stages of pyelonephritis (serous, purulent).
In Table 6 we present the methods of drainage of the urinary tract depending on the stage of pyelonephritis.
Table 6. Methods of drainage of the urinary tract during pregnancy in acute pyelonephritis (5)
| Acute serous pyelonephritis | Acute purulent pyelonephritis |
| Position therapy: sleep on the "healthy" side, knee-elbow position for 10-15 minutes 3-4 times a day | Percutaneous puncture nephrostomy |
| Catheterization of the ureter - in the early stages with the serous phase of pyelonephritis | Open surgery: nephrostomy, decapsulation, revision of the kidney, dissection or excision of carbuncles, opening of abscesses |
| Ureteral stenting: | |
| Percutaneous puncture nephrostomy: with the ineffectiveness of retrograde drainage of the kidneys and the progression of the infectious and inflammatory process | |
| Operational nephrostomy in the absence of technical capabilities to perform PNNS |
Antibacterial therapy is carried out only parenterally with subsequent monitoring of the effectiveness of treatment after 48-72 hours. Subsequently, the correction of antibiotic therapy is carried out according to the results of bacteriological examination. The duration of therapy for the serous stage of inflammation is 14 days: 5 days - parenterally, then the transition to the oral regimen. Drugs approved for use in pregnant women for the treatment of acute pyelonephritis include:
A similar study of the use of antimicrobial drugs was conducted for the treatment of patients with acute pyelonephritis during pregnancy and found that the frequency of incorrect prescriptions of antibacterial drugs was 78%. The data are presented in table 7.
Table 7. Antibacterial therapy for pyelonephritis in pregnant women in Russia (Chilova R.A., 2006)
In Russia, a high level of resistance of Escherichia coli to ampicillin, amoxicillin and co-trimoxazole has been identified, and therefore it is not advisable to use these drugs. Data on the level of E. coli resistance in Russia are presented in Table 8.
Table 8. Resistance of E. coli isolated from patients with outpatient UTIs in Russia to oral antibiotics, % Rafalsky V.V., 2005
Table 9. Infectious Diseases Society of America and US Health Service Grading System for Evaluating Clinical Guideline Recommendations
| Category, degree | Definition |
| Degree of justification for use | |
| A | Convincing data for application; should always be taken into account |
| B | Data of average degree of persuasiveness; should generally be taken into account |
| C | Inconclusive evidence for application; at the discretion of |
| D | Data of moderate degree of persuasiveness against application; generally should not be taken into account. |
| E | Convincing data against application; should never be considered |
| Evidence category | |
| I | Data from 1 or more properly randomized controlled trials |
| II | Data obtained from 1 or more well-designed non-randomized clinical trials; cohort or case-control study (preferably more than 1 center); multiple studies at certain intervals; impressive results obtained in uncontrolled experiments |
| III | Data based on the opinion of respected experts, clinical experience, presented in publications or reports of expert commissions |
Currently, infectious diseases of the genitourinary system in women are distinguished by their polyetiology, blurred clinical picture, high frequency of mixed infection and a tendency to recur, which requires an integrated approach to diagnosis and treatment. The solution of the problem of antibiotic therapy in obstetrics and gynecology can be facilitated by: the creation of state standards and their strict observance; creation of an expert council for the revision of standards; physicians' awareness of the principles of evidence-based medicine (1).
