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Pregnancy causes numerous changes in the womans is characterized by inflammation of the bladder as a
body. Hormonal and mechanical changes increase result of bacterial or nonbacterial causes (eg,
the risk of urinary stasis and vesicoureteral reflux. radiation or viral infection). Acute cystitis develops in
These changes, along with an already short urethra approximately 1% of pregnant patients, of whom
(approximately 3-4 cm in females) and difficulty with 60% have a negative result on initial screening. Signs
hygiene due to a distended pregnant belly, increase and symptoms include hematuria, dysuria,
the frequency of urinary tract infections (UTIs) in suprapubic discomfort, frequency, urgency, and
pregnant women. Indeed, UTIs are among the most nocturia. These symptoms are often difficult to
common bacterial infections during pregnancy. distinguish from those due to pregnancy itself.
In general, pregnant patients are considered Acute cystitis is complicated by upper urinary tract
immunocompromised UTI hosts because of the disease (ie, pyelonephritis) in 15-50% of cases.
physiologic changes associated with pregnancy (see Acute pyelonephritis
Pathophysiology). These changes increase the risk of Pyelonephritis is the most common urinary tract
serious infectious complications from symptomatic complication in pregnant women, occurring in
and asymptomatic urinary infections even in healthy approximately 2% of all pregnancies. Acute
pregnant women. (See Urinary Tract Infection in pyelonephritis is characterized by fever, flank pain,
Females.) and tenderness in addition to significant bacteriuria.
Oral antibiotics are the treatment of choice for Other symptoms may include nausea, vomiting,
asymptomatic bacteriuria and cystitis. The standard frequency, urgency, and dysuria. Furthermore,
course of treatment for pyelonephritis is hospital women with additional risk factors (eg,
admission and intravenous antibiotics. Antibiotic immunosuppression, diabetes, sickle cell
prophylaxis is indicated in some cases. (See anemia, neurogenic bladder, recurrent or persistent
Treatment of UTI in Pregnancy and Urethral UTIs before pregnancy) are at an increased risk for a
Catheterization in Women.) Patients treated for complicated UTI.
symptomatic UTI during pregnancy should be
continued on daily prophylactic antibiotics for the
duration of their pregnancy.
Pathophysiology
Annual health costs for UTI exceed $1 billion.
Although the condition-specific cost of asymptomatic
bacteriuria or UTI in pregnancy is unknown, Infections result from ascending colonization of the
screening for these conditions in pregnant women is urinary tract, primarily by existing vaginal, perineal,
cost-effective as compared with treating UTI and and fecal flora. Various maternal physiologic and
pyelonephritis without screening. Goals for future anatomic factors predispose to ascending infection.
research include targeting low-income groups and Such factors include urinary retention caused by the
women in developing countries for screening and
weight of the enlarging uterus and urinary stasis due
early treatment, as well as determining whether a
to progesterone-induced ureteral smooth muscle
causal relation exists between maternal UTI and
childhood neurologic consequences. relaxation. Blood-volume expansion is accompanied
For patient education information, see the Kidneys by increases in the glomerular filtration rate and
and Urinary System Center and Pregnancy and urinary output.
Reproduction Center, as well as Urinary Tract
Infections, Pregnancy, Bladder Control Problems, Loss of ureteral tone combined with increased
and Blood in the Urine. urinary tract volume results in urinary stasis, which
Definitions of key terms can lead to dilatation of the ureters, renal pelvis, and
calyces. Urinary stasis and the presence of
Urinary tract infection vesicoureteral reflux predispose some women to
UTI is defined as the presence of at least 100,000 upper urinary tract infections (UTIs) and acute
organisms per milliliter of urine in an asymptomatic pyelonephritis.
patient, or as more than 100 organisms/mL of urine
with accompanying pyuria (>7 white blood cells
[WBCs]/mL) in a symptomatic patient. A diagnosis of Calyceal and ureteral dilatation are more common on
UTI should be supported by a positive culture for a the right side; in 86% of cases, the dilatation is
uropathogen, particularly in patients with vague localized to the right. The degree of calyceal
symptoms. UTIs are associated with risks to both the dilatation is also more pronounced on the right than
fetus and the mother, including pyelonephritis, the left (average 15 mm vs 5 mm). This dilatation
preterm birth, low birth weight, and increased appears to begin by about 10 weeks gestation and
perinatal mortality. worsens throughout pregnancy. This is underscored
Asymptomatic bacteriuria by the distribution of cases of pyelonephritis during
Asymptomatic bacteriuria is commonly defined as pregnancy: 2% during the first trimester, 52% during
the presence of more than 100,000 organisms/mL in the second trimester, and 46% in the third trimester.
2 consecutive urine samples in the absence of
declared symptoms. Untreated asymptomatic
bacteriuria is a risk factor for acute cystitis (40%)
and pyelonephritis (25-30%) in pregnancy. These
cases account for 70% of all cases of symptomatic
UTI among unscreened pregnant women.
Acute cystitis
Although the influence of progesterone causes GBS colonization has important implications during
relative dilatation of the ureters, ureteral tone pregnancy. Intrapartum transmission that leads to
progressively increases above the pelvic brim during neonatal GBS infection can cause pneumonia,
pregnancy. However, whether bladder pressure meningitis, sepsis, and death. Current guidelines
increases or decreases during pregnancy is recommend universal vaginal and rectal screening in
controversial. all pregnant women at 35-37 weeks gestation rather
than treatment based on risk factors.
Glycosuria and an increase in levels of urinary amino
acids (aminoaciduria) during pregnancy are Preeclampsia
additional factors that lead to UTI. In many cases,
glucose excretion increases during pregnancy over The development of preeclampsia is associated with
nonpregnant values of 100 mg/day. Glycosuria is due maternal UTI (asymptomatic bacteriuria or
to impaired resorption by the collecting tubule and symptomatic infection) during pregnancy. A recent
loop of Henle of the 5% of the filtered glucose, which case-control study demonstrated an increased odds
escapes proximal convoluted tubular resorption. (1.22-fold) of preeclampsia in women with any UTI
during pregnancy versus those without
The fractional excretion of alanine, glycine, histidine, UTI. [2] Furthermore, a retrospective review of the
serine, and threonine is increased throughout perinatal database at a major tertiary center
pregnancy. levels of cystine, leucine, lysine, revealed a UTI rate of 16.2% in normotensive
phenylalanine, taurine, and tyrosine are elevated in patients, but this increased to 27.3% in women with
the first half of pregnancy but return to reference mild preeclampsia and 35.9% in women with severe
range levels by the second half. The mechanism of preeclampsia. The authors hypothesize that
selective aminoaciduria is unknown, although its underlying renal damage weakens patients systemic
presence has been postulated to affect the defense mechanisms against ascending infection.
adherence of Escherichia coli to the urothelium.
Cesarean delivery
Fosfomycin (Monurol)
Fosfomycin was given a "B, I" rating in the 1999 IDSA unchanged in the urine, and concentrations remain
guidelines for treating UTIs. Phosphonic acid is a high for 24-48 hours after a single dose. It is unique
bactericidal agent active against most UTI but quite expensive. Administer 3 g orally as single
pathogens, including Escherichia coli and dose with 3-4 oz of water
Enterobacter, Klebsiella, and Enterococcus species.
Little cross-resistance between fosfomycin and other
antibacterial agents exists. It is primarily excreted